Arachis hypogaea) is mainly grown for oil extraction and the remaining oil-free seed referred as peanut meal (PM) leaves with high protein content which can be a possible substitute for fishmeal in aqua-diets. This study evaluates the suitability of three types of processed peanut seeds, namely untreated PM (UPM), fermented PM (FPM), and germinated PM (GPM) from peanut seeds to replace fishmeal in barramundi  diets cultured under a commercial production environment. Nine formulated diets having 3 inclusion levels from the 3 different peanuts  were evaluated against a control without PM. The performance of various types and levels of PMs was assessed by examining the growth, gut and liver condition and survival of fish after eight weeks of feeding the test diets. The immunological responses of juvenile barramundi were assessed by exposing the fish to the hypoxic conditions for 4 hours. The results showed that fermentation and germination significantly (P<0.05) reduced the tannins and alkaloid contents in the PMs. The fish fed 15% GPM diet grew faster and had higher survival than fish fed control diet, while fish fed diet including 60% GPM showed a significant reduction in growth and survival, and an increase in food conversion rate (FCR). FPM and UPM at any inclusion levels did not alter the growth, survival and FCR. Histology analysis revealed that fish fed 60% GPM and UPM showed higher amount of lipid droplets in liver, myodigeneration in fish muscle and a decrease number of acidic mucins in distal gut compare to all other test diets. Stress caused by reduced dissolved oxygen did not change the sodium, potassium, chlorides and alanine aminotransferase concentrations of plasma of fish fed any diet. However, the stress did increase plasma cortisol significantly (P<0.05) in fish fed 60% GPM, 30% and 60% UPM diets. These results suggest that the PMs can partly replace the fishmeal in juvenile barramundi diet and the processing further improves the PMs quality by reducing its antinutritional factors which in turn can increase either its inclusion level in the barramundi diets or improved growth and health status of the species.Peanut ( Oncorhynchus mykiss) [Argyrosomus regius) [The increase in fish production through aquaculture has been accompanied by rapid growth of aquafeed production. While fishmeal, a primary protein source in aquafeed, has become limited and expensive, the plant-derived protein ingredients as potential alternatives to fishmeal have gained recognition , 2. A wi mykiss)  or incre regius) .Lates calcarifer), a carnivore fish is an important cultured species in Australia and Southeast Asia [Barramundi   that advArachis hypogaea), a worldwide important crop, ranks second in term of cropped area after rapeseed (FAS USDA web 2013). Most peanuts are used for oil extraction for human consumption [Peanut  as a potential protein source to replace fishmeal in juvenile barramundi diets by evaluating growth, gut and liver health, and immunological indices of fish challenging to an acute hypoxic condition.The study protocols and design were approved by the Ethics Committee of Curtin University, Australia . Fish handling activities and all samples were extracted based on the Australian code for the care and use of animals for scientific purposes.Whole peeled peanut seeds of 40 kg were purchased from a local store in Hungloc-Nghean, Vietnam and were divided into two equivalent portions. One portion was used for germination while the other for oil extraction. The extraction of oil was performed by steaming the seed at 90°C for 2 hours before grinding to about 50 μm; then the grounded seed was expressed mechanically  until most of the oil was extracted. Oil extracted product was then ground again to 200μm size that was ready to be used as an alternative ingredient to fishmeal. This oil free peanut was termed as untreated peanut meal (UPM).Lactobacilli spp. as described in previous study using lupin [L. acidophilus, L. aporogenes and L. kefir, were obtained from a commercial product BIOLAC, BIOPHARCO, Vietnam, and mass incubated in MRS broth medium (Merck KgaA Germany) containing polysorbate, acetate, magnesium and manganese. To each 1000 ml of distilled water was added 55 g MRS broth and 250 ml soy extract. The combination was autoclaved at 121°C for 15 minutes prior to culturing of Lactobacilli spp. The incubation was carried out in a black glass jar with minimum oxygen at 37°C for 24 hours in a refrigerated incubator . After incubation samples were collected to check if bacterial density was reached to > 107 CFU ml-1, while the remaining part was mixed with autoclaved UPM in a plastic bag where commercial N2 gas from Hai Duong Gas Company, Vietnam, was filled to enhance anaerobic conditions. The UPM fermentation was conducted at 37°C for 72 hours. The final fermented UPM product was term as fermented peanut meal (FPM)Half of the UPM was further fermented by ng lupin . CultureGermination was performed at room temperature of 25–27°C and 90% humidity. The whole peanut seed was rinsed under dark conditions in a 70-L aluminium container by fresh 37°C warm water for 12 hours. After that, the water in the container was drained out. Germination took place in the same container where the seed were soaked with water at 33–37°C in every 6 hours. After germination, seed with about 2 mm sprouts were selected for oil extraction. The oil extraction and grinding were performed as outlined earlier in this section to become germinated peanut meal (GPM). Finally, the 200g samples from UPM, FPM and GPM were collected to analyse the tannins and alkaloids levels in them.-1 fishmeal was used as a control diet. Diets were processed by addition of water to about 35% mash dry weight with well mixing to form the dough. This dough was then screw pelleted by a laboratory pelletiser to 1.2–2 mm pellets. These moist pellets were oven dried at 60°C for 12 hours followed by cooling to room temperature before storing at– 20°C till further use.Diets were formulated based on the nutritional composition of the raw ingredients to meet 45% protein and 13% lipid levels . All ing3 each. The flow-through culture systems were set up in an open outdoor shed with a roof to protect from rain and direct sunlight. The natural temperature and photoperiod ranged between 28–31°C and 12 hours light respectively. After acclimation the experimental fish were fed for eight weeks with the ten different pre-designed diets  and 3 types of PM . Juvenile barramundi were obtained from Northern National Marine Broodstock Centre, Vietnam and shipped to National Freshwater Breeding Centre (NBC), Vietnam where the juveniles were raised until they were adapted to salinity of 0 ppt. The fish were then acclimated for two weeks and fed Uni-President-Vietnam feed . These fish were then graded, and those within the weight range of 6.0–6.5 g each were selected randomly into thirty tanks of 3.5 med diets . Every d-1 to 2 ± 0.2 mg L-1 for 4 hours. The water used to DO exhaust was taken from the same tank that the fish were collected. The reduction of DO was carried out by pumping continuously pure N2 gas, purchased from Hai Duong Gas Company (Vietnam) into the water. DO was measured by HI9146 Portable Dissolved Oxygen Meter (HANNA Instruments).The challenge test to depict acute exposure to reduced dissolved oxygen (DO) was performed to the fish after eight weeks of feeding with 10 test diets. To perform the acute challenge test, five fish were randomly collected from every tanks and kept in closed 5-L plastic bags of freshwater where DO was reduced from 5 mg L-1; fish were killed with a dose of 0.4 ml L-1 after blood sampling [Blood samples were carried out under an application of 2-phenoxyethanol with a dose of 0.2 ml Lsampling . Fish blTannins and alkaloids in all types of PM were analysed in National Institute for Food Control, Hanoi, Vietnam. All blood samples were analysed at Laboratory of Melatec Hospital, Hanoi, Vietnam. Blood chemical parameters consisted of sodium, potassium, chloride, alanine aminotransferase (ALT), cortisol, and glucose were analysed as described by Suski, Killen . The plaFor hepatic, muscle and intestine histological evaluation, three fish in each treatment were randomly euthanized with AQUI-S at 175 mg/L and dissected to excise liver. Liver and muscle tissues were immediately fixed in 10% buffered formalin prior to dehydrate in series of ethanol and equilibrate in xylene. Then the tissues were embedded in paraffin wax, sectioned at approximately 5 μm using a rotary microtome machine and stained with hematoxylin and eosin (H&E) according to standard histological procedures. Photographs of histological slides were scanned under a light microscope . Intestinal sections were stained with Alcian Blue (AB) pH 2.5 to visualize acidic mucins which were counted from ten highest intact villi under a light microscope , following the methods of Sewaka, Trullas  and ChakThe data were analysed using IBM SPSS for Windows version 25 at Curtin University, Australia and Stata SE 12, USA with the results expressed as the means and standard errors of the mean (SEM). One-way ANOVA was performed to compare ANFs between processed peanut samples and growth performance indices. Two-way ANOVA using general linear model was performed to compare effects of various inclusion levels and peanut types as well as their interaction. Levels of significance were set at P<0.05.There were significant differences in ANFs profiles among FPM, GPM and UPM . FermentThe growth performance of juvenile barramundi fed various levels of untreated, fermented and germinated PMs are presented in Survival of fish in all dietary treatments was greater than 90% except for the fish fed diet containing 60% GPM and UPM, where survival rates were 82.8% and 85.7%, respectively. Feeding FPM and UPM diets at different inclusion levels did not result in the different survival rates and were similar to the fish fed the control diet. The diet contained 60% GPM showed significantly higher mortality (11.20% in average) than fish fed diets containing 15% and 30% inclusion levels . No mort-1, 18–20 mmol L-1, and 135–145 mmol L-1, respectively. Before exposing fish to hypoxic stress, no interaction was observed both in inclusion levels and types of PMs relating biochemical responses of fish. After low DO stress was induced, the plasma sodium and chloride concentrations decreased  while plasma potassium increased (19–26 mmol L-1). However, these changes in immunological parameters were not significant due to feeding different diets or when exposed to DO reduction. Interaction of DO reduction and diets on the change of these immunological parameters were also not observed.The biochemical responses of juvenile barramundi fed untreated, fermented and germinated peanut meals at various inclusion levels are presented in -1 and 83–154 U L-1. Average levels of ALT concentrations had a trend to decrease for the fish fed diets 15FPM, 30FPM, 60FPM, 60GPM, 15UPM, 30UPM and control while increased for the fish fed diets 15GPM and 30GPM. However, these changes were not significant among fish groups fed with various diets without or with DO reduction. There was also not a significant interaction between diets and the DO reduction induced stress in the change of plasma ALT concentration.The ALT concentrations of plasma of fish groups fed different diets before and after DO reduction were respectively in the range of 78–159 U L-1 with the highest level in fish fed 30GPM diet and the lowest in fish fed 60GPM diet. Exposure to reduced DO significantly increased plasma cortisol level in fish fed diets contained 60% of GPM and UPM, and 30% of UPM. Irrespective of this increase, reduced DO failed to influence any plasma cortisol levels of fish among any feeding groups.Before juvenile barramundi were subjected to DO reduction, the concentration of cortisol in the plasma was 68–177 mmol L-1. Under DO reduction stress the fish fed all diets resulted in the significantly four-fold increase in plasma glucose concentration (19–31 mmol L-1) than the fish without stress in 60GPM and 60UPMP diets. However, DO reduction had no influence in plasma glucose levels of fish among the feeding groups. Interaction between DO reduction and the test diets on physiological parameters were not observed.The level of glucose concentrations in plasma of fish fed test diets after 8 weeks was in the range of 4.9–8.4 mmol LThe hepatic lipid content showed a gradual increase from lower to higher replacement levels of fishmeal by PMs and a significant (P<0.05) increase was found in fish fed 60GPM and 60UPM when compared to control . In accoLactobacilli is able to reduce phytic acids and tannins in sweet lupin (Lupinus angustifolius) by 87.04% and 17.64%, respectively [Oryza sativa.There are several ANFs such as phytic acids tannins, alkaloids, trypsin and amylase inhibitors present in protein rich plants  includinectively . Liang, ectively  reportedSenecio jacobaea) when included in rainbow trout  diet at a concentration of 100mg/kg resulted in severe reduction in growth and survival [Cyprinus carpio) [Labeo rohita), catla (Catla catla), and mrigala  [Pyrrilizidine alkaloids extracted from tansy ragwort   as they mrigala) . In thisLupinus angustifolius) could increase fishmeal replaced proportion in juvenile barramundi diets which is similar to the current study where 60% fermented peanut inclusion diets resulted in no changes in growth rate and FCR than the control diet.After 8 weeks of feeding, the barramundi juveniles fed all diets gained greater than 29 g from an initial average of 6.2g at FCR of 1.0 or less, except in fish fed 60GPM diets that resulted in reduced growth of 27 g and increased FCR of 1.44. The reduced growth performance in fish fed higher fishmeal replacement diet of 60GPM may be associated with the deficiency and/or imbalanced rations of certain essential amino acids and fatty acids, and higher variability in biochemical composition in the supplied diet compared to lower fishmeal substitute diet by various PMs. However, there is no published research available that can be used to compare our results with the literature on using PMs as fishmeal replacement diet in aquaculture production. FPM and GPM are also never tested as a diet ingredient for barramundi or any other marine species. In comparison to other plant-derived protein ingredient tested for the same species, our previous investigation  reportedGPM inclusion in diet seemed to have an effect on palatability of juvenile barramundi. At low inclusion levels of 15% and 30%, fish had a higher feed intake and unchanged FCR than the control diet; but at higher inclusion level of 60%, fish rejected the feed, leading to a very high FCR, as 1.5 fold higher than other test diets. FPM and UPM included in diets did not influence the feed intake or FCR at any inclusion level of PM in diet, the FCR was as low as in control diet.Supplementary immunological stimulants contained in a feed are believed to increase the fish health and the survival . It is kDietary compositions can influence the biochemical responses of the target species . The incThe monovalent sodium, potassium and chloride ions are involved in neuromuscular excitability, acid-base balance and osmotic pressure . Potassi-1, higher than that in saline ground water (13–14 mmol L-1) [-1 [Concentrations of sodium and chloride in plasma in this study were similar to those found by Glencross, Rutherford , where smol L-1) , 46 and L-1) [-1 . This de-1 can improved phagocytic activities, respiratory burst activities and reduced the level of cortisol when exposure to and challenged by air exposure and bacterial pathogen [The hypothalamus of the stressed fish releases corticotropin-releasing factor and other chemicals in blood circulation which finally activate the release of cortisol by the interrenal tissue. Additionally, the increase in plasma glucose is to cope with the demand of energy as the response of the fish fight against the stressor. Barton, Schreck  reportedpathogen . In thisTo reduce feed production cost, proportion of fishmeal should be decreased in diets while ensuring a balanced nutritional formulation that provides the fish with good growth performance and health. Protein concentration in processed peanuts is lower than in fishmeal thus high protein ingredients, blood meal and wheat gluten have been used in accordance with levels of the peanuts included into the diets. Meanwhile the cassava meal and wheat flour portions were changed to keep the diets with isonitrogenous and isocaloric. Barramundi used efficiently blood meal and the Inclusion of this ingredient did not affect to the fish growth and FCR , but theSalmo gairdneri [Epinephelus lanceolatus ♂ × Epinephelus fuscoguttatus ♀) [Lates calcarifer fed selenium deficient lupin meal showed necrotic muscle, characterized by myodigeneration, while selenium supplemented lupin meal showed no obvious change in muscle and liver. Also, vitamin E deficiency generated myodigeneration in Atlantic salmon, Salmo salar [Histological observation of liver has been considered as a good indicator to evaluate the nutritional condition of fish, and the most common changes in the liver of fish is the accumulation of fat, which results from impaired protein synthesis or excessive amount of dietary lipid or energy being stored in the hepatic cells unable to oxidise fatty acids . In the airdneri . Similartatus ♀) , 54. In tatus ♀) , 56, whimo salar . HistopaScophthalmus maximus L. [Salmo salar and Rainbow trout, Oncorhynchus mykiss [The complexity of internal architecture of fish intestine is induced by quality and quantity of feed . The numximus L. , Atlantis mykiss , 65 whens mykiss  and othes mykiss , 68, hows mykiss , 70, whiIn conclusion, fermentation of peanut resulted in significant reduction in tannins and alkaloid by 60% and 40% while germination resulted in decline of 86% and 45% of tannins and alkaloids, respectively. The inclusion level of fermented peanut meal in the diet could be increased up to 60%, without compromising the growth performance. However, a reduced growth and higher cortisol level were reported in fish fed 60% germinated peanut meal or untreated peanut. The depressed growth performance in 60% GPM and UPM was further supported by histopathological changes in liver, myodigeneration in muscle and a decrease number of acidic mucins in intestine of juvenile barramundi.


Recently there has been a continuing worldwide decrease in the quality of human spermatozoa, especially in spermatozoa motility and concentration. Many factors are involved in this decline, and great efforts have been made to rescue spermatogenesis; however, there has been little progress in the improvement of sperm quality. Chestnuts are used in traditional Chinese medicine; their major active components are chestnut polysaccharides (CPs). CPs have many biological activities but their effects on spermatogenesis are unknown. The current investigation was designed to explore the impact of CPs on spermatogenesis and the underlying mechanisms. We demonstrated that CPs significantly increased sperm motility and concentration , and improved seminiferous tubule development by increasing the number of germ cells after busulfan treatment. CPs dramatically rescued the expression of important genes and proteins  in spermatogenesis. Furthermore, CPs increased the levels of hormone synthesis proteins such as CYP17A1 and HSD17β1. All the data suggested that CPs improved the testicular microenvironment to rescue spermatogenesis. With CPs being natural products, they may be an attractive alternative for treating infertile patients in the future. At the same time, the deep underlying mechanisms of their action need to be explored. During the past three decades, a growing number of people have been suffering from reproductive health issues leading to infertility. Many factors are involved in infertility, but in the male, a decrease in the quality of spermatozoa is a key factor. Many studies have revealed that environmental pollution and ionizing radiation played vital roles in the deterioration of spermatozoa quality (spermatozoa motility and concentration) –4. ThereRecently, it has been found that polysaccharides have many biological functions. They pose anti-oxidative and anti-inflammatory functions through promoting the expression of antioxidant enzymes and decreasing the expression levels of inflammation factors –8, immunVASA, DAZL, and DMC1. VASA is a germ cell marker important for germ cell proliferation and differentiation, and VASA mutation results in the cessation of germ cell differentiation [DAZL serves as a gateway in oogenesis and spermatogenesis, and the abnormal expression of DAZL will affect the initiation of gametogenesis [DMC1 plays an important role in spermatogenesis, and its mutation leads to obstacles in male sterility [Spermatogenesis takes place in the seminiferous tubules of the testis; it includes spermatocyte proliferation, spermatogonial differentiation into spermatocytes, spermatid production, and sperm maturation. Many factors are involved in regulating spermatogenesis such as genes, hormones, and epigenetic regulators –24. The ntiation . DAZL seogenesis . DMC1 plterility .Hormones such as testosterone and estrogen play essential roles in regulating spermatogenesis . Many prAlthough CPs have been shown to be beneficial for human health, the effects on spermatogenesis and the underlying mechanisms are not understood. The aim of this study was to explore the means of CPs improve spermatogenesis and the underlying mechanisms.CPs alone did not change murine sperm motility , howeverFirst, testicular tissue transcriptomes were determined after busulfan and/or CPs treatments to search for gene expression patterns. Principal components analysis (PCA) showed that the busulfan and control groups were well separated, which suggested that the busulfan treatment produced profound effects on gene expression . The B+CVASA, CREM, SYCP3, DAZL, REC8, PGK2, DMC1, SYCP1, STRA8, and ZFP42. Most of the DEGs that were decreased in Control-vs-B while being increased in B-vs-B+CPs 0.10, were involved in spermatogenesis or reproduction, including STRA8, DAZL, SYCP1, SYCP3, TNP1, etc.  are involved in the production of these hormones. We determined these proteins by IHC and found that the levels of CYP17A1, and HSD17β1 were decreased by busulfan while elevated by B+CPs 0.10 –6C. The Chestnuts have been used as a traditional food and medicine for millennia in China due to their health advantages . CPs, keSubsequently, we explored the underlying mechanisms of CPs in rescuing mouse spermatogenesis. Gene expression within testicular samples was determined by RNA-seq analysis. It was interesting to notice that 9043 DEGs were decreased by busulfan while increased by CPs, and 4248 DEGs were increased by busulfan while decreased by CPs. GO enrichment analysis revealed that these 9043 DEGs, that were decreased by busulfan while being increased by CPs, were enriched in spermatogenesis related functional pathways. But the 4248 DEGs, those were increased by busulfan while decreased by CPs, were enriched in other functional pathways (non-sperm related groups). The data indicated that CPs may regulate gene expression machinery to improve spermatogenesis.Moreover, we explored the effect of CPs on hormone production pathways in mouse testes, because of the critical role that hormones play in spermatogenesis , 36, 37.In conclusion, the results of this study suggested that CPs improved spermatogenesis by increasing sperm motility and concentration. The underlying mechanisms involved CPs regulation of gene expression machinery to increase the expression levels of genes and proteins involved in spermatogenesis and to improve the testicular microenvironment to rescue spermatogenesis. A decrease in the quality of spermatozoa is a key factor that caused infertility. Therefore, looking for a feasible approach to protect fertilization capacity or to reverse any damage in testes is necessary. CPs being as natural products, they may be an attractive alternative method for treating infertile patients in the future.Male ICR mice were purchased from the Beijing Vital River Laboratory Animal Technology Co., Ltd . The mice were fed in constant temperature (22-23°C) rooms with a 12 h light: 12 h dark photoperiod and had free access to food (chow diet) and water throughout the period of study. All procedures used in this study were in accordance with the guidance of the Ethics Committee of Qingdao Agricultural University.Busulfan was used as a model compound to create an infertile animal model as it has been frequently used in recent published articles , 39. CPsSperm motility was analyzed during sample collection. Sperm were collected from the epididymis then cultured in DMEM/F12  with 10% FBS  medium and incubated at 37.5°C on a heated stage for 5 min, counting boards were prepared in advanced. Then samples were placed in a counting chamber  and sperTotal RNA was extracted from collected testis samples using a kit  and according to the manual instructions . SequencTotal RNA was reverse transcribed using the TransScript One-Step gDNA Removal Kit and cDNA Synthesis Kit . To evaluate the changes in mRNA level, we conducted quantitative real-time PCR (qRT-PCR) using transcribed cDNA. qRT-PCR was conducted using a Light Cycler real-time PCR instrument  using Light Cycler SYBR Green I Master Mix according to the manufacturer’s instructions. A reaction system volume of 24 μl was used in this study containing 2 μl cDNA, 12 μl of SYBR green master mix, 1.2 μl of primer mix including forward and reverse primer genes, and 8.8 μl of RNAase-free water. The PCR conditions of a previous study were followed . We quanCollected testes were fixed in 4% paraformaldehyde and kept in a refrigerator at 4°C overnight, then subsequently stored in different concentrations of dehydrating solutions. The dehydrated testicular samples were then embedded in paraffin and the resulting paraffin blocks were sectioned at 5 μm thickness following standard histological procedures. Sections were stained with H&E, following the procedure of a previous study , 50. TesTesticular proteins were extracted using the process described below. Samples were submerged in cold RIPA buffer and a crusher was used to treat the samples twice at a cold temperature. The protein lysates were centrifuged at 10000 rcf/min for 10 min then the supernatant was collected and added to SDS-loading buffer, and boiled for 5 min in water till the protein was completely denatured. Protein samples were mixed evenly before loading onto 10% SDS polyacrylamide electrophoresis gels and processed at 100V for 1.5 h; the specific time depended on the electrophoresis situation. The proteins on the gels were transferred to a polyvinylidene fluoride membrane. Subsequently, membranes were blocked with skimmed milk or 5% bovine serum albumin at a cold temperature for at least an hour, followed by 3 washes with Tris-buffered saline, 0.1% Tween 20 (TBST). We then used primary antibodies to incubate membranes in the refrigerator overnight at 4°C. On the second day, membranes were washed 3 times with TBST and incubated with the HRP-labeled secondary antibody  for 1 h at room temperature. After 3 washes with TBST, the membranes were imaged . The imaP < 0.05 as a significant difference, while P < 0.01 was a highly significant difference.All experiments were repeated at least 3 times and results were expressed as the mean ± SEM. SPSS software one-way analysis of variance (ANOVA) following by LSD multiple comparison test was used for data analysis and we defined Supplementary Figure 1Supplementary Tables


Do Medicare Advantage beneficiaries experience different care services and outcomes from inpatient rehabilitation facilities than traditional Medicare beneficiaries do?In this multiyear cross-sectional study of more than 1 million inpatient rehabilitation facility admissions , Medicare Advantage beneficiaries had a shorter mean length of stay (1.15% shorter for stroke and 0.85% shorter for hip fracture) and a greater likelihood of returning to the community (3.0% for stroke and 5.0% for hip fracture) than did traditional Medicare beneficiaries, without substantially compromising their functional improvements.These findings suggest that policy makers may consider using strategies in managed care to further improve care quality and control costs. This cross-sectional study measures the differences in length of stay at inpatient rehabilitation services and health outcomes between traditional Medicare and Medicare Advantage beneficiaries. Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types.To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US.This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019.Medicare insurance plan type, TM or MA.Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge.The sample included a total of 1 028 470 patients : 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries  and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke  and hip fracture . The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0%  for stroke and 5.0%  for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type  and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types.This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics. Compared with other PAC sectors, such as SNFs and home health agencies, which experienced a more pronounced decline in annual spending growth than total Medicare spending (−2.8% and −1.8% vs 0.6%), the mean annual spending growth for IRFs was fairly stable at a higher rate (1.8%) between 2008 and 2015.3In the US, approximately 42% of all hospitalized Medicare beneficiaries receive postacute care (PAC) after discharge; among those, 5.5% go to inpatient rehabilitation facilities (IRFs).5Medicare Advantage (MA), the managed care version of Medicare, controls care costs via management of network , utilization , and incentives . The percentage of Medicare beneficiaries enrolled in MA plans has almost doubled over the past decade, from approximately 16% in 2006 to 31% in 2015, and continues to grow.6 and MA in terms of PAC delivery and outcomes are very scarce, with only a few exceptions, such as the study by Huckfeldt et al7 on hospital discharge patterns to alternative PAC facilities, including IRFs, SNFs, and home health agencies. Even less is known about the differences in utilization, costs, and health outcomes between TM and MA. The present study seeks to answer these questions and to contribute to health services research on PAC in several ways.As a result of limitations on data availability, direct comparisons between TM9 and patient health outcomes.11 Second, we sought to fill the knowledge gaps by understanding functional outcomes among Medicare beneficiaries who receive inpatient rehabilitation services. Because of data limitations and different measurement requirements across reporting and administrative systems, rehabilitation sector–specific care outcomes  have rarely been available for both TM and MA beneficiaries.13 Third, this study is also closely related to the general literature on the scientific inquiry of the mechanisms that contribute to the differences in care delivery and outcomes between TM and MA.16 This study attempted to disentangle and quantify the relative strength of patient-level, facility-level, and regional care system–level variations that contribute to the differences between TM and MA in inpatient rehabilitation services.First, we measured the differences between TM and MA with respect to inpatient rehabilitation services on care utilization17 as well as the recently proposed Medicare reforms that shift the traditional fee-for-service payment model to capitated plans with payment incentives similar to those in MA.20 Equally important is the identification of patient, facility, and regional characteristics associated with poor care quality and outcomes, which will inform future implementation, quality improvement, and policy reform.23Understanding the differences between TM and MA in terms of PAC quality, cost, and outcomes is critical given the current growth of alternative payment models and accountable care organizations,24 Data from the Inpatient Rehabilitation Patient Assessment Instrument, a tool for patient assessment used at both admission and at discharge mandated by the Centers for Medicare & Medicaid Services for payment reimbursement,25 was obtained from the UDSMR data repository. The Inpatient Rehabilitation Patient Assessment Instrument includes patient-level sociodemographic variables, prehospital living arrangement, marital status, predisability employment status, discharge disposition, diagnoses , facility characteristics, and cost factors such as length of stay (LOS) and source of payment. In addition, the Functional Independence Measure (FIM) instrument is also included in the Inpatient Rehabilitation Patient Assessment Instrument, which includes items on patient level of physical and cognitive functioning assessed by a clinician from an IRF.The Uniform Data System for Medical Rehabilitation (UDSMR) is the world’s largest nongovernment data repository for inpatient medical rehabilitation in the US since 1987.STROBE) reporting guideline. The study was approved by the institutional review board of University at Buffalo, which also waived the need to obtain informed consent from the participants because the data were anonymous. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (2This study focused on elderly (aged >65 years) adult Medicare beneficiaries who received initial rehabilitation services (readmission and facility transfers excluded) between 2007 and 2016 from more than 1100 Medicare-reimbursable IRFs across the US. Three common reasons for IRF stays were selected in this study according to UDSMR Impairment Group Codes: 2 acute conditions  and 1 elective condition , which accounted for approximately 19.8%, 11.5%, and 6.8% of all inpatient rehabilitation services delivered to the aging population, respectively.Comparing care delivery in IRFs between TM and MA beneficiaries faces the challenges of endogeneity and selection, because patients could self-select to enroll in TM or MA plans ; furthermore, MA plans could affect the probability that a patient is admitted to a hospital and then to an IRF. Such selection concerns were less of an issue for acute conditions than elective conditions. As a result, this study focuses on the results for the 2 acute conditions, and the results for the elective condition (joint replacement) are shown in eTable 1 and eTable 2 in the The sample started with 1 199 229 patient records that passed the aforementioned inclusion criteria. We excluded patients whose prehospital living settings were nonhome , patients who died during the rehabilitation stays , patients whose inpatient stay for rehabilitation was longer than 30 days  or shorter than 3 days , and those with key variables missing . Beneficiaries with dual Medicare and Medicaid coverage  were also excluded because dual eligibility was not equally distributed between TM and MA beneficiaries, and the exclusion can mitigate the problem of unobserved heterogeneity. The 12Rehabilitation LOS was calculated as the total number of days spent in the inpatient rehabilitation facility excluding the interrupted periods. The LOS was used as a proxy of resource utilization.A patient’s motor and cognitive function were assessed within 72 hours of admission and discharge using the FIM instrument. The FIM instrument consists of 18 items covering 6 domains: self-care or activities of daily living (6 items), bladder and bowel control (2 items), mobility (3 transfer items), locomotion , communication (2 items on comprehension and expression), and social cognition . The first 4 domains measure motor function and the last 2 domains measure cognitive function.26All 18 items are measured on a 7-point scale from 1  to 7 (complete independence). The motor function score ranges from 13 to 91 and the cognitive function score ranges from 5 to 35, with the total FIM score ranging from 8 to 126.The FIM score at admission indicated the severity of a patient’s acute condition before treatment, and its mean value of a subpopulation reflected the inpatient admission requirement. The FIM admission score was used as one of the clinical factor control variables in the analysis.26The change in FIM, which was obtained by subtracting a patient’s FIM at admission from the FIM at discharge, was used to assess the effectiveness of an inpatient stay. A larger FIM score improvement indicated higher treatment effectiveness. The total FIM score change divided by total LOS represented the mean daily efficiency of treatment.The discharge setting was collapsed into a dichotomized variable. The variable was return to the community  as opposed to discharge to another level of PAC, readmission to acute care, or discharge to residence in an institutional setting.25 Facility characteristics included number of certified beds and facility type . These variables were selected according to the availability of the UDSMR data set and other studies on rehabilitation outcomes.28Control variables in the study included patient demographic characteristics, clinical factors, and facility characteristics. Demographic characteristics included age, sex, race/ethnicity, marital status, and secondary payer source (having other sources of payment vs none), year, and region of inpatient stay as fixed effects. Clinical factors included FIM score at admission, comorbidity tiers, and case-mix group defined by Centers for Medicare & Medicaid Services.I(MA)∙θ + Xβ + Zδ + λ + τ + ϵ, where I(MA) is a dummy indicator , the estimated coefficient θ captures the impact of Medicare insurance type (MA vs TM) on outcomes of interest, Xβ represents patient-level demographic characteristics and clinical conditions, Zδ represents facility-level variations, λ denotes the regional fixed effects, τ denotes the year fixed effects, and ϵ is the error term.The study adopted a retrospective study design to compile multiyear admissions to IRFs between 2007 and 2016. The unit of observation is 1 patient-episode. The main area of interest was whether and by how much the inpatient rehabilitation care delivery and outcomes were different between beneficiaries who enrolled in MA and TM after controlling for other patient-level, facility-level, and regional-level differences. The model specification is outcome = 29A generalized linear model was used to estimate the outcome variables. All outcome variables were treated as continuous such that the estimated coefficients were directly interpreted as the marginal effects. To capture the heterogeneous associations and to provide insights on the potential mechanisms through which insurance-associated differences happened, models were also estimated without controlling for facility type, alternative payment sources, or both.Sensitivity analysis was performed by excluding the patient records with program interruption or discharge against medical advice and including those records that indicated Medicare as a secondary payer (<1% of the sample). Analysis was also stratified by major subgroups of population . The seemingly unrelated estimation method was used to compare the estimated differences (TM vs MA) between the stratified groups. SAS statistical software version 9.4 (SAS Institute) was used to conduct data analysis. Data were analyzed from September 2018 to August 2019.5 eFigure 1 and eFigure 2 in the The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. In contrast, according to the Centers for Medicare & Medicaid Services, approximately 31% of beneficiaries were enrolled in MA plans in 2015.Our results show that MA beneficiaries had a shorter mean LOS for stroke by 0.17 day   and for The likelihood of returning to the community after discharge was higher for MA beneficiaries than TM beneficiaries by 3.0%  for stroke  and 5.0%For LOS, fixed effects of facility type and alternative payment sources only minimally absorbed  the differences between TM and MA, by 0.01 (change in mean [SE] estimated coefficients from −0.19 [0.02] to −0.18 [0.02]) for stroke. For hip fracture, including fixed effects of alternative payment sources decreased the LOS difference between TM and MA by 25% (change in mean [SE] estimated coefficients from −0.16 [0.02] without control to −0.12 [0.02] with control). Including the facility type further decreased the differences. For FIM score improvements, including the fixed effects of facility type in the model almost fully absorbed the differences between TM and MA for stroke (change in mean [SE] estimated coefficients from −0.20 [0.05] to −0.01 [0.06]); in contrast, for hip fracture, including the fixed effects made the insurance differences more salient (change in mean [SE] estimated coefficients from −0.10 [0.07] to 0.16 [0.08]) . DiffereMA beneficiaries admitted to IRFs had shorter LOSs than did TM beneficiaries without compromising their functional improvements. Facility type and alternative payment sources were shown to partially explain the differences in rehabilitation treatment and care outcomes.5 The sample in this study showed a dynamic pattern in terms of the percentage of MA beneficiaries receiving treatment in IRFs that is consistent with plan enrollment percentages over the years  between TM and MA beneficiaries and differences in the resulting health outcomes on hospital readmission and mortality rates, but results for more direct clinical outcomes such as functional status and recovery are still scarce. This study instead showed that conditional on IRF admission and after controlling for patient and facility characteristics, MA beneficiaries did not experience lower functional improvements than TM beneficiaries did.Second, studiesThird, although there were differences in LOS and functional improvements between TM and MA beneficiaries, the absolute values were small. The implications are still practically meaningful. On the one hand, a 1.15% shorter LOS for stroke and 0.85% shorter LOS for hip fracture were associated with 3.0% and 5.0% increases, respectively, in the likelihood of returning to the community. On the other hand, because of the large population base of Medicare and the high costs of daily inpatient stay in the US, a 1.15% or 0.85% difference per patient in LOS can yield huge cost savings in total.15 The study showed that shorter LOS and better functional improvements among MA beneficiaries were more likely to happen in freestanding IRFs than in those within the same acute care hospitals, which implies the potential power of care coordination across facilities within managed care networks. These findings were also in line with those of previous studies22 claiming that facility attributes contributed substantially to care delivery and outcomes. Furthermore, the study shows that shorter LOS and lower functional improvements among MA beneficiaries can be partially explained by the existence of alternative payment sources, implying that the additional payment sources mitigated the differences in care outcomes by Medicare insurance type.Finally, this study provides insights on the potential reasons to explain the differences in care and outcomes between TM and MA beneficiaries.10 have shown, differences in PAC between the 2 insurance types are also reflected in discharge patterns to alternative facilities beyond IRFs, such as SNFs and home health agencies. Second, only facility and regional attributes that were available in the UDSMR without restrictions were controlled in the analysis . Including more comprehensive and better refined facility and regional attributes will provide additional insights into the relative strength of patient, facility, and regional factors in driving the differences in care between TM and MA. Third, patient characteristics in the study were limited to basic demographic characteristics and clinical diagnosis. The inclusion of additional patient-level information, such as family history, caregiving structure, and patient perceptions, will help to further explore the channels and mechanisms that contribute to the differences in care between TM and MA.This study has limitations. First, the study sample only included Medicare beneficiaries who were admitted to IRFs for PAC after their hospital inpatient stay. As a result, the differences in care delivery and outcomes between TM and MA enrollees were limited to IRFs. As other studiesThis study investigated the differences in inpatient rehabilitation services between TM and MA beneficiaries. The results show that proportionately fewer MA beneficiaries than TM beneficiaries received PAC in IRFs. The MA plan holders experienced shorter LOS, but not worse functional improvements. The possibility of returning to the community was also higher for MA beneficiaries. Freestanding facility type and alternative payment sources were found to be associated with these differences between insurance types.


Furthermore, structural connectivity was reduced in the right perisylvian regions but enhanced in the perifocal areas (p < 0.05). The vulnerability of the left supramarginal gyrus was significantly increased , and the bilateral putamina were added as hubs in the AVM patients. These alterations provide evidence for the long-range effects of AVMs on brain white matter networks. Our preliminary findings contribute extra insights into the understanding of brain plasticity and pathological state in patients with AVMs.Focal brain lesions, such as stroke and tumors, can lead to remote structural alterations across the whole-brain networks. Brain arteriovenous malformations (AVMs), usually presumed to be congenital, often result in tissue degeneration and functional displacement of the perifocal areas, but it remains unclear whether AVMs may produce long-range effects upon the whole-brain white matter organization. In this study, we used diffusion tensor imaging and graph theory methods to investigate the alterations of brain structural networks in 14 patients with AVMs in the presumed Broca's area, compared to 27 normal controls. Weighted brain structural networks were constructed based on deterministic tractography. We compared the topological properties and network connectivity between patients and normal controls. Functional magnetic resonance imaging revealed contralateral reorganization of Broca's area in five (35.7%) patients. Compared to normal controls, the patients exhibited preserved small-worldness of brain structural networks. However, AVM patients exhibited significantly decreased global efficiency ( Brain arteriovenous malformations (AVMs) are commonly presumed to be congenital lesions with the pathology of direct connection between arteries and veins, resulting in arteriovenous shunting of blood , 2. The The graph theory analysis provides an outstanding framework for studying the complex brain networks , 16. RecWe hypothesized that AVMs not only cause brain reorganization of the perifocal areas but also have long-range effects on the whole-brain white matter organization. In this study, we selectively included patients with AVMs located in the presumed Broca's area, in order to investigate the alterations in topological properties and network connectivity of brain structural networks.NCT02868008). The inclusion criteria were as follows: (1) patients with lesions located in the left frontal lobe, wholly or partially overlying the presumed Broca's area ; (2) patients with no history of AVM rupture; (3) patients with no apparent perifocal edema on T2-weighted images; (4) patients with no apparent space-occupying effect ; and (5) patients with no other neurological or psychiatric disorders.This study was approved by the institutional review board of Beijing Tiantan Hospital, Capital Medical University. The participants provided their written informed consent to participate in the study. From January 2015 to June 2019, patients with AVMs in the left frontal lobe were screened out from our clinical trial database  were female and six (42.9%) were male, with ages ranging from 15 to 38 years . All patients were native Chinese speakers and right-handed, and no patient showed language deficits before the participation. Meanwhile, 27 right-handed normal controls with no history of neurological or psychiatric disorders were recruited, of whom 15 (55.6%) were female, with ages ranging from 19 to 40 years .T1-weighted anatomical images were acquired with a 3D MP-RAGE sequence, with TR = 2300 ms, TE = 2.98 ms, flip angle = 9°, voxel size = 1 × 1 × 1 mm, slice thickness = 1 mm, FOV = 240 × 256 mm, matrix size = 240 × 256, and sagittal slices = 176b‐value = 1000 along 30 diffusion directions, TR = 6800 ms, TE = 93 ms, flip angle = 120°, voxel size = 1.8 × 1.8 × 2.8 mm, slice thickness = 2.8 mm, FOV = 230 × 230 mm, matrix size = 128 × 128, slice number = 50, double averaging, and parallel acquisition (GRAPPA factor = 2)Diffusion tensor images were acquired with an EPI sequence, with Functional images were acquired with an EPI sequence, with TR = 3000 ms, TE = 30 ms, flip angle = 90°, voxel size = 3.3 × 3.3 × 4 mm, slice thickness = 4 mm, FOV = 210 × 210 mm, matrix size = 64 × 64, and slice number = 30All subjects had undergone T1-weighted and T2-weighted imaging. Furthermore, the AVM patients went through DTI and language fMRI examination, while the normal controls only underwent DTI scanning. MRI data was acquired with a 3.0 T system  with the following parameters:https://people.cas.sc.edu/rorden/mricron/). Next, using the clinical toolbox  on SPM12, the lesion masks were normalized with the individual's T1-weighted images into the Montreal Neurological Institute (MNI) space and were then overlapped on an MNI template for display.The boundaries of the AVMs were manually drawn on the anatomical T1-weighted images slice by slice with the MRIcron software (http://surfer.nmr.mgh.harvard.edu/). In order to overcome the possible signal loss and structural distortions of the lesioned brain, we employed the enantiomorphic filling method using the clinical toolbox on SPM12 [All processes were following the accepted pipeline. Structural segmentation was performed with the FreeSurfer software package  and the PANDA pipeline toolbox (https://www.nitrc.org/projects/panda/). Eddy currents and head motion artifacts were corrected. A whole-brain deterministic tractography was performed by using the Fiber Assignment by Continuous Tracking (FACT) algorithm. Fiber tracking was stopped at voxels with FA less than 0.15, and the curvature angle threshold was set to 45°.Diffusion images were processed by using the FSL diffusion toolbox (wij) between a pair of nodes i and j was the number of streamlines with a correction with the distance travelled by the fibers and the volumes of ROI i and j. Thus, a weighted 82 × 82 structural connectivity matrix was generated for each subject.The whole-brain structural networks were represented as an adjacent matrix. The parcellated 82 gray matter ROIs were used as nodes, and the edges were defined as the white matter fibers connecting each pair of nodes. If the number of streamlines between two nodes was less than three, the connection would be set to zero in order to reduce possible spurious connections. The connectivity strength (https://github.com/cwatson/brainGraph). The nodal topological properties computed included the connectivity strength, nodal efficiency, local clustering coefficient, betweenness centrality, and vulnerability. The global topological properties computed included the global efficiency, local efficiency, clustering coefficient, characteristic path length, and small-worldness.Based on graph theory, the topological properties of the weighted networks were analyzed at global and nodal level using the brainGraph toolbox available in R (Si) of node i is the sum of the weights of all its connections:wij is the connectivity weight between nodes i and j and N is the set of all 82 nodes of the network.The connectivity strength (Enod) measures the ability of node i to exchange information with the remaining nodes in the network:N is the number of nodes within the network and Lij was the length of the shortest weighted path between nodes i and j.The nodal efficiency (Ci) of node i describes how strong the node and its neighbors tend to cluster as a local network:ki is the number of edges connected to node i and wij, wih, and wjh are the weights between node i and its neighbor nodes j and h and the weight between j and h.The local clustering coefficient (Bi) quantifies the centrality of node i, which is the fraction of all the shortest paths in the network that contain i:δjh(i) is number of the shortest paths between nodes j and h that pass through node i. In this study, node i was defined as a hub, if Bi was at least one standard deviation (SD) greater than the average betweenness centrality of the network.The betweenness centrality (Vi) reflects the influence of node i on the network efficiency, which is defined as the proportional drop in global efficiency when i and its connections are removed from the network:Eglobi is the global efficiency after removing node i.The vulnerability (Eglob) measures how efficient the information is exchanged across the whole network, which is the average of the nodal efficiency values of all nodes in the network:The global efficiency (loc) measures the average capacity for information transfer within a local network:Eiglob, is the global efficiency of the subgraph consisting of the neighbors of node i.The local efficiency (ECp) measures the degree to which the nodes in the network tend to cluster, which is the average of the local clustering coefficient values of all nodes:The global clustering coefficient (Lp) is the harmonic mean of the shortest path between each pair of nodes in the network, which reflects how well the entire network is connected for information exchange. Lp equals to the inverse of Eglob:The characteristic path length (σ) is defined as the ratio between the normalized clustering coefficient (γ) and the normalized characteristic path length (λ):Cprand and Lprand represent the average of the global clustering coefficient and characteristic path length of 100 matched random networks with the same numbers of nodes, edges, and degree distributions as the real network. A network is considered a small-world network if σ > 1.The small-worldness  on MATLAB 2017b . We employed the enantiomorphic filling and unified segmentation approach for normalization in image preprocessing [p < 0.001 with cluster size ≥ 10 voxels. The frontal ROI was defined as the pars opercularis and pars triangularis of the inferior frontal gyrus and the dorsolateral prefrontal cortex . The laterality index  was calculated as LI = (L − R)/(L + R), where L and R represented the number of voxels activated in the ROIs of the left and right hemisphere. A patient was classified as typically left-lateralized if LI ≥ 0.2 and atypically lateralized if LI < 0.2.Functional images were processed with the widely accepted pipeline of SPM12  was used to visualize the results. The difference in global topological properties  between patients and normal controls was tested using permutation inference for a general linear model (GLM), with age and sex as covariates. The one-tailed p values were computed using 10000 permutations, and the significance threshold was set at p < 0.05. Between-group comparisons of the nodal topological properties  of each region were also performed using permutation inference for GLM with age and sex as covariates and were corrected for multiple comparisons with the family-wise error (FWE). The one-tailed p values were computed using 10000 permutations, and a corrected p value less than 0.05 was considered significant.Statistical analysis was performed with the brainGraph toolbox in R . BrainNet Viewer  was used to identify the altered structural connectivity between the patients and normal controls . BrieflyThe demographics and the number of whole-brain streamlines of normal controls and AVM patients are presented in σ > 1) in brain structural networks. No significant between-group difference was found in the small-worldness (p = 0.744) or in the local efficiency (p = 0.731). However, AVM patients showed significantly greater characteristic path length (p = 0.007) and lower clustering coefficient (p = 0.014). In addition, the global efficiency was significantly decreased in the patients (p = 0.004).The global topological properties of brain structural networks of the normal controls and patients are presented in p < 0.05) in nodal properties were identified. A number of regions were found with significantly lower nodal strength, nodal efficiency, and local clustering coefficient in AVM patients relative to normal controls . No significant difference was found in the nodal betweenness centrality.Brain regions with significant between-group difference  in atypically lateralized patients than in typically lateralized patients. However, no significant difference was found in other topological properties or in structural connectivity.Functional lateralization of the frontal language area was evaluated for each patient. We found contralateral language reorganization in five (35.7%) patients with a mean LI of −0.50 ± 0.50, who were classified as atypically lateralized. The remaining nine (64.3%) patients had a mean LI of 0.87 ± 0.16 and were classified as typically lateralized. The global and nodal topological properties were compared between the two groups. We found that the clustering coefficient was significantly lower (The lacking capillary bed of an AVM causes a low-resistance condition and results in arteriovenous shunting of blood. The high-flow shunting diverts blood away from the surrounding brain tissue, leading to “arterial steal,” as well as raising the venous pressures, causing venous congestion , 4. It hThe small-world network organization of the human brain has been revealed in previous studies –36. A smThus, we suggest that the integrity and efficiency of the whole-brain structural networks are compromised in AVM patients, though there may be a degree of compensatory reorganization. In the current patient series, no one had presented with language dysfunction, and strict linguistic testing was not performed, so we failed to determine whether the disrupted topological organization is associated with declined language ability or occasional speech difficulties. Researches have proposed the disruption of structural network topology as a potential biomarker for a cognitive decline in several diseases –41. PrevIn comparison with normal controls, AVM patients exhibited significantly reduced nodal connections in several regions. Most of the regions exhibiting decreased nodal strength coincided with those exhibiting decreased nodal efficiency, mainly located in the right perisylvian regions and the left occipital lobe. Furthermore, the local clustering coefficient was reduced in several right temporoparietal regions close to those regions with decreased nodal strength, suggesting weakened structural segregation of information processing within these neighboring regions. Interestingly, the brain regions with altered nodal properties were remote from the lesion sites, indicating the remote effects produced by AVMs. In a network analysis of stroke patients, the authors demonstrated reduced communicability not only in the lesioned hemisphere but also in the contralesional hemisphere, and they interpreted this remote alteration as the result of secondary white matter tract degeneration from the lesioned hemisphere . We suppThe vulnerability and betweenness centrality characterize the critical role of nodes from different aspects . A higheWe used the level of betweenness centrality to identify the hubs of the structural networks. The betweenness centrality quantifies the role of nodes that act as bridges between the other nodes. Although there were no regions showing remarkable between-group difference in betweenness centrality, we found that the patients exhibited altered hub distribution compared to normal controls. Coinciding with the results of previous studies , 35, theAlthough no significant difference of nodal properties was found in the brain regions near AVMs, we identified a subnetwork with enhanced structural connectivity involving the perifocal regions, which might reflect compensatory reorganization of the structural networks for maintaining language function in these patients. Additionally, we found another subnetwork with enhanced connectivity, mainly composed of the left amygdala and insulo-orbito-temporopolar component , suggestFurthermore, we identified an extensive subnetwork with decreased structural connectivity in AVM patients compared with normal controls, which demonstrated weakened intraregional connectivity in the right perisylvian regions and weakened interhemispheric connectivity between Broca's area and the homologous regions of the right hemisphere. It is currently thought that the structural networks can predict and constrain the functional activity across the brain, and conversely, the functional activity can produce an effect on the structural networks , 50. In Functional reorganization has been frequently reported in AVM patients with eloquent areas involved , 7, 8, aThis is an exploratory study focusing on the whole-brain structural networks in patients with AVMs. Some issues should be addressed when interpreting the results: firstly, methodological issues. In this study, we used deterministic tractography to construct the structural network, but this algorithm failed to resolve the crossing fibers, which may result in a loss of existing fibers. The probabilistic tractography algorithm has been proposed to improve the network sensitivity, but it often has low specificity due to false positives . In thisIn conclusion, patients with AVMs had preserved small-worldness in brain structural networks, indicating brain resilience against pathologies. However, compared with the normal controls, AVM patients exhibited significantly decreased global efficiency and clustering coefficient, along with decreased corresponding nodal properties in some remote brain regions, such as the left occipital lobe and the right perisylvian regions. Furthermore, structural connectivity was reduced in the right perisylvian regions but was enhanced in the perifocal areas. The vulnerability of the left supramarginal gyrus was significantly increased, and the bilateral putamina were added as hubs in the AVM patients. The current study is the first to demonstrate the altered organization of brain structural networks in AVM patients, and the results provide evidence for the long-range effects of AVMs upon the whole-brain white matter networks. Our preliminary findings may contribute extra insights into the understanding of brain plasticity and pathological state in patients with AVMs.


This article presents analytical observations on physicochemical parameters and major and trace element concentrations of water, ice, and sediment samples from the lake systems of Clearwater Mesa (CWM), northeast Antarctic Peninsula. Geochemical analyses include inductively coupled plasma mass spectrometry (ICP-MS) for cations and trace elements and ion chromatography for anions. Some figures are included (i.e. Piper and Gibbs diagrams) which indicate water classification type and rock-water interactions in CWM, respectively. It also contains PHREEQC software output, listing the chemical speciation for dissolved elements, Saturation Indexes (SI), and modelling outputs. Each lake SI are also illustrated in a figure. Finally, total organic and inorganic carbon  were determined for bottom lake sediments and marginal salt samples. This information will be useful for future research assessing the impacts of anthropogenic pollution and the effects of climate change, providing insights into naturally occurring geochemical processes in a pristine environment, and evaluating geochemical behaviour of dissolved elements in high-latitude hydrological systems. These data correspond to the research article “Dissolved major and trace geochemical dynamics in Antarctic Lacustrine Systems” [1]. Specifications table•Given the logistical constraints associated with collecting information from this unique and scarcely known high latitude environment, these observations present an opportunity for hydrological and geochemical research without the need for resampling.•This information can be helpful for multidisciplinary researchers, such as environmentalists, biologists, physics, and geologists, and can be readily incorporated into meta-analyses.•This information can be used to identify and analyse processes controlling high latitude lake chemistry through geochemical diagrams and models, and compare them with other environments.•The present information contributes to a growing database that can serve as a baseline in environmental change and pollution studies  for Antarctic systems.1Water, ice, and sediment samples from 35 different lakes and ponds were collected during the austral summer (15–29 January 2015) on Clearwater Mesa (CWM), located on James Ross Island, northeast Antarctic Peninsula 2+/Ca2+ and Na+/(Na++Ca2+) ratios; and sediment TOC and TIC. +/(Na++Ca2+) ratios in a Gibbs diagram Physico-chemical parameters and major ion concentrations were determined for 37 lake and ice samples, and are presented in Supplementary Material. It comprises ion speciation, Saturation Indexes, and geochemical models (i.e. mixing modelling between Blancmange Glacier and Cecilia samples and inverse modelling between Blancmange Glacier and Florencia samples). Finally, PHREEQC models are presented in the Software Output, which is included in the 22.1Water and sediment samples were collected from 35 different lakes and ponds on Clearwater Mesa during the 2015 Antarctic summer field campaign following standard protocols in situ. Redox potential and pH were measured with a Hach digital detector, while temperature, TDS, and electrical conductivity were measured using a digital Hach conductivimeter. Alkalinity was measured as CaCO3 by end point titration in the field, and using a 0.16 N H2SO4 solution until pH = 4.5. For the determination of anions, major cations, and trace elements, samples were vacuum-filtered in the field with 0.22 µm pore size cellulose filters . An aliquot was stored in polyethylene bottles at 4 °C for the determination of chloride and sulphate by chemically suppressed ion chromatography with conductivity detection. The other aliquot was acidified (pH< 2) with concentrated, redistilled and ultrapure HNO3 (Sigma-Aldrich) for the analytical determination of major and trace elements by inductively coupled plasma-mass spectrometry . Major and trace elements concentrations were validated using NIST  1640 and Riverine Water Reference Materials for Trace Metals certified by the National Research Council of Canada (SRLS-4), and detection limits are reported in the corresponding tables. Statistical parameters (i.e. mean and median) were calculated for each hydrogeological system's trace elements and physical and chemical characteristics.Water temperature, pH, redox potential, electrical conductivity, TDS, and alkalinity were measured at each waterbody 2.2Bottom lake sediment samples were collected from 32 shallow lakes using a standard scoop sampler. Lake Katerina was sampled 3 times in order to characterize spatial variability in this large lake. Particular attention was paid to collect the sediment/water interface. Samples were skimmed from the benthic surface (top 2–3 cm), stored in plastic bags, and refrigerated until analysis.TOC and TIC was determined in sediment samples using the loss on ignition method LOI; . Prior t2.3Supplementary Material. The SI is the ratio between the ion activity product for the given material and the reaction constant at a given temperature. When SI > 0, it means that the solution is supersaturated with respect to the mineral phase and may therefore precipitate, whereas when SI < 0 the solution is below saturation of the specified mineral.Chemical information was processed with PHREEQC 2 (g) given that these are surficial hydrological systems. Finally, three mixing models with different proportions of Blancmange Glacier and Lake Cecilia solutions  were made to verify eventual mixing processes.Geochemical modelling uses the interaction of cations and anions as a function of temperature, redox potential, pH, and ionic strength. Inverse modelling was performed to quantify weathering processes occurring, first between connected lakes Esther and Tatana, and second between Blancmange Glacier and Lake Florencia. Inverse modelling begins with known initial and final solutions, and available mineral phases which attempts to quantify the processes that lead to the final solution chemistry e.g., . In the


Principal component analysis and the membership function value (MFV) method was used to analyze the physiological and phenotypic characters, including abscission rate, amino acids content, net photosynthetic rate (Pn), etc. Finally, we developed a mathematical evaluation model, selected 100 mg L−1 TDZ as the optimal concentration and identified reliable characters net photosynthetic rate (Pn), stomatal conductance (Gs), and transpiration rate (Tr) to evaluate cotton leaf abscission sensitivity. These results also confirmed that CRI 12 was more sensitive to TDZ than CRI 49. This is the first time using a mathematical evaluation method to evaluate the cotton leaf abscission sensitivity triggered by TDZ at the seedling stage and the results were also confirmed in the field experiment. Furthermore, it will be valuable that MFV method is applied to stress sensitivity evaluation in other crop species under stress environment.Chemical defoliation is an essential agricultural practice in cotton production for mechanic harvesting. Thidiazuron (TDZ) is the active ingredient of the chemical defoliant used on cotton. So far, few studies havefocused on the method of identifying the sensitivity of cotton cultivars to TDZ. Therefore, a greenhouse soil culture experiment was performed by using two widely cultivatedupland cotton cultivars CRI 49 and CRI 12 treated with seven different concentrations (0, 100, 200, 300, 400, 500, and 1000 mg L Abscission of plant parts, such as leaves, flowers, or fruit, is a fundamental biological process of plants sin owing to biotic or/and abiotic stress ,2,3, natBrassica napus [Gossypium hirsutum L [Sorghum bicolor (L.) [Triticum aestivum L. [Panicum miliaceum and Setaria italica) [So far, there is a lack of quantitative evaluation method for abscission sensitivity in cotton against TDZ treatment.The fuzzy comprehensive evaluation method has been applied to plant stress researches ,19, and ca napus , Gossypirsutum L , and Sorlor (L.) . MFV anativum L.  and MillThe comprehensive evaluation analysis of cotton leaf abscission sensitivity is dependent on environmental factors and cotton growth stages. To avoid the influence of aging and other environmental factors, TDZ treatment was applied to cotton plants at the seedling stage in the greenhouse. Subsequently, a field experiment was carried out to verify the reliability of the results obtained from the seedling stage experiment. We investigated leaf phenotype characteristics, amino acids, soluble sugar, photosynthetic pigment, and photosynthetic parameters under different concentrations of TDZ in the greenhouse and leaf abscission rate in the field. Our previous study proved that these indicators are mirrored to leaf abscission to some extent. The overall objectives of the current study were to (1) screen the optimum TDZ concentration at the seedling stage; (2) identify evaluation indexes of leaf abscission sensitivity; and (3) evaluate the leaf abscission sensitivity of CRI 49 and CRI 12 under both greenhouse and field conditionn. Our research provided a reference method to evaluate abscission sensitivity and an available system to study the mechanism of leaf abscission, as well as othertissue abscission.To understand the contribution degree of leaf abscission sensitivity evaluation indexes, principal component analysis (PCA) was used to weight the selected indicators for the first time. PCA clustering analysis showed that the TDZ treatments were significantly distinguished from the control treatment . Tr, net2 concentration (Ci), other indicators have a higher weight in 21 indexes, which are an important indicator of cotton leaf abscission after TDZ treatment.Five principal components  could be utilized to explain the difference between genotypes and treatments in 21 indexes, and the cumulative contribution rate reached 91% . The PC In this study, two cotton genotypes (CRI 49 and CRI 12) were studied under seven different TDZ concentrations. Based on the selected indexes, a comprehensive evaluation of the genotypes sensitivity and leaf abscission under different concentrations was conducted by MFV method. The results showed the values of fuzzy membership functions and final membership functions (MV) of the two cultivars under different concentrations . Accordi−1 TDZ, respectively , however, no significant correlation was found between Chl a, Chl b, T Chl, Chl a/b, LRWC, NWSD, AA, and leaf ARs . Similar−1 TDZ caused leaf abscission in CRI 12 at 2 DAT (days after treatment)  . Howevereatment) . The pheeatment) . Both CReatment) . The absultivars . At the r CRI 12 . Additior CRI 12 . TherefoIn order to ascertain the reliability of screening at the seedling stage, field experiments were also carried out. Leaf abscission rate showed higher after defoliant treatment in both cultivars and regions in the field . There w−1 TDZ treatments have the lowest net photosynthetic rate for both cultivars.Through the measurement of photosynthetic characteristics 1 day after TDZ treatment, it was found that Pn, Tr, and Gs of leaves all decreased to close to zero values under the treatment of different concentrations of TDZ , indicatThe abscission of leaves, flowers and fruit is a natural seasonal phenomenon in plants in the world. Cotton plants show leaf abscission phenomenon due to physiological senescence in the late growth stage and defoliant, in which its major ingredient is TDZ, is applied to cotton production to accelerate leaf shedding process to facilitate mechanical harvesting ,10. In t−1 have a higher value of MV  cultivars and are widely planted in Xinjiang cotton-growing areas in China. CRI 12 and CRI 49 were also cultivated under normal agricultural conditions in the field in Kuitun  and Anyang  to investigate leaf abscission rate for field verification. Thidiazuron was sprayed using an automatic backpack sprayer when 20 to 40% of cotton bolls were opened (on 16 September 2019 and 5 September 2019).The experiment was carried out in the greenhouse of the cotton research institute of the Chinese academy of agricultural sciences . The concentration screening and physiological response experiment of leaf abscission induced by TDZ  were performed on CRI 12 and CRI 49, which are excellent cotton  filled with nutritive soil: vermiculite (1:1), 1 plant/basin. The conditions of the greenhouse were set as 16 h light/8 h dark cycles with a temperature of 28 ± 2 °C, 150–250 μmol mLeaves wilting (Lw), leaves with purple spots (Lp), and the total (Lt) were counted and leaf wilting incidence (WI) and purple spot incidence (PSI) were calculated 3 days after treatment (DAT). The remaining leaf number (N) was recorded and the abscission rate  was calculated at 3, 4, 5, 8, 9, 10 DAT. The plants had been artificially topped, and no new leaves grew. The calculation formula is as follows:Leaf relative water content (LRWC)  and natuThe contents of soluble sugar and amino acid in the fourth leaves were determined at 3 DAT Soluble sugar and amino acid was extracted by the ethanol-soluble extraction method, as described by Hu . SolublePhotosynthetic pigments (chlorophyll a (Chl a), chlorophyll b (Chl b), total chlorophyll (T Chl), and carotenoid (Car)) were determined using a spectrophotometer  . In shor2 concentration (Ci) of the fourth true leaf were determined by portable photosynthetic apparatus . Photosynthetic parameters were set as follows: humidity, 55 ± 5%; CO2, 400 ± 5 μmol mol−1; photosynthetic intensity, 180–200 μmol m−2 s−1.The net photosynthetic rate (Pn), transpiration rate (Tr), stomatal conductance (Gs) and intercellular CO(1)Weight of indexes by PCA:(2)MFV calculation in fuzzy mathematics:The method of principal component weighting was firstly used to carry out a comprehensive evaluation analysis of MFV.The final membership function value (MV) of comprehensive evaluation:Leaf abscission sensitivity was assessed by the value of the final membership function (MV). The higher the MV, the stronger the leaf abscission sensitivity is.(1)The Pearson correlation between 13 physiological indexes and the MV was analyzed.(2)The correlation of all morpho-physiological characters was analyzed by Pearson correlation analysis.Origin Pro2018 was used for data analysis and plotting.−1 TDZ could be used as the optimal concentration for the shedding of cotton leaves. Photosynthetic parameters  were reliable indexes to evaluate the cotton leaf shedding sensitivity. Furthermore, we proposed a mathematical evaluation model to assess the cotton leaf abscission sensitivity that could be potentially used to evaluate various stress responses of plants.In conclusion, CRI 12 was more sensitive than CRI 49 to leaf abscission induced by TDZ. The concentration of 100 mg L