Large investments are currently made in community–based complementary food supplement  programs to improve nutrition of young children in rural areas in China. However, there is a lack of knowledge about the experience and challenges of implementing YYB programs in China. We aimed to: 1) monitor distribution of YYB; 2) assess children’s adherence to and acceptability of YYB; and 3) evaluate community–based strategies to improve the program.This mixed methods evaluation study combined data from surveys and focus groups that took place during a controlled interventional evaluation trial. The trial aimed to evaluate the effectiveness of community–based YYB distribution on improving children's health status in rural areas in China. We conducted five cross–sectional surveys with caregivers of children aged 6–23 months (baseline survey (N = 1804) in August 2012 and four follow–up cross–sectional surveys: 1) N = 494 in January 2013; 2) N = 2187 in August 2013; 3) N = 504 in January 2014; and 4) N = 2186 in August 2014) in one rural county in Qinghai Province. We used a two–stage cluster sampling technique to select mothers with eligible children for each survey. Information was collected from caregivers on household characteristics, YYB consumption and acceptability in the surveys. High adherence in each survey was defined as children who consumed at least four YYB sachets during the previous week. A logistic regression model was developed to obtain odds ratios (OR) with 95% confidence intervals of factors associated with high adherence. Also, we conducted 10 focus groups with73 caregivers and health workers involved in the YYB distribution. Content analysis was used to explore qualitative findings, which were used to gain deeper insight into the quantitative results.P < 0.0001). Repeated training sessions with village doctors could increase adherence. However, due to unplanned YYB stock–out, caregivers did not receive YYB for six months, which may have led to a decrease of high adherence from 64.1% in the second follow–up survey (August 2013) to 53.6% in the third follow–up survey . Self–reported acceptability increased from 43.2% to 71.8%, partly due to improving the taste of YYB, which was the main reason that children disliked taking YYB. Unfortunately, more than 60% of caregivers did not perceive positive health improvement in their children after taking YYB. Multivariate analysis showed that children with diarrhea , cough or fever  during the past two weeks had significantly lower adherence.Around 90% of caregivers had ever received YYB and more than 80% of children ever took YYB. Caregivers mainly knew about YYB through their village doctors. High adherence to YYB increased from 49.4% in the first follow–up survey (January 2013) to 81.4% in the last follow–up survey (August 2014; This evaluation study showed that program monitoring in rural West China was critically important for understanding program implementation and adherence trends. This led to strategic changes to the intervention over time: improving the taste of YYB; strengthening health education of village doctors and caregivers; and ensuring continuity of YYB supply. Future programs need to monitor program implementation in other settings in China and elsewhere. Although China has made great achievements in improving children's health during the past two decades, malnutrition of children is still a prominent problem, particularly in poor rural areas . The preDuring the last decade, multi–nutrient powders (MNPs), which are home nutrition fortification products, were developed and have been proposed as an important intervention for addressing undernutrition and micronutrient deficiencies among children younger than two years . The eff3 (5 μg), vitamin B1 (0.5 mg), vitamin B2 (0.5 mg), vitamin B12 (0.5 μg), folic acid (75 mg), elemental iron (7.5 mg), zinc (5 mg), and calcium (200mg). A small–scale efficacy study carried out in Gansu from 2001 to 2004 showed YYB can reduce anemia .” “MCH workers from township hospitals in the intervention county generally agreed that more than half of the village doctors in their townships had a positive attitude toward YYB distribution; however, some village doctors also made complaints.“We are very busy, and still have to distribute YYB.”“Although we work very hard on YYB distribution, caregivers are ungrateful.” Village doctors indicated that several caregivers in the villages were uncooperative and reluctant to feed their children YYB or some children disliked taking YYB.There is a grandmother in my village who did not feed YYB to her grandchild. I called her for three times to encourage her to feed, but she still told me her child disliked taking YYB.”“In addition, there was no allowance on YYB distribution for health workers. Several village doctors said that the YYB distribution increased their work load. Every month, they had to use two to four working days to inform of caregivers and distribute YYB. Sometimes they had to bring YYB door to door if caregivers did not come to village clinics. Village doctors had to pay all the fees for calls and transportation during the YYB distribution. Both MCH workers and village doctors asked whether village doctors could be given allowance.We initially developed a leaflet called “a letter to caregivers”, which contained a detailed description of YYB benefit and usage. However, at the baseline survey (August 2012) we found that more than 40% of main caregivers were illiterate. Therefore, we encouraged village doctors to deliver YYB information through face–to–face counseling and we modified the leaflet by adding more pictures to replace the text description. However, only less than 10% of caregivers reported that they got information of YYB from the leaflets in four follow–up surveys , we found that 61.3% of caregivers temporarily skipped sachets of YYB to their children when they were sick (cold or diarrhea) , no new program problems were identified (August 2013).However, caregivers who forgot to give YYB and children who disliked YYB significantly increased to 22.0% , the percentage of children who took YYB within the last 24 hours and high adherence significantly decreased as a result of the YYB stock–out ” to “Fu Ge Sen (福格森)” and YYB was re–supplied from March 2014 onward. In June 2014, we carried out a three–day training sessions to retrain all the village doctors in the intervention county to strengthen their YYB related knowledge, health education and complementary feeding skills. Most village doctors in the training sessions said that the taste of the new YYB was much better than before and that children in their village liked YYB more which was reflected by a decrease in the proportion of children who disliked YYB at the time of the endline survey in August 2014 (23 months later survey)  yearly to implement the community–based complementary food supplement program (YYB program) to improve children’s health in rural counties in China since 2014 . HoweverProgram monitoring is critical for understanding program implementation and enabling more strategic implementation ,29. In oInterventions like MNP that aim to reduce anemia prevalence in rural communities will only work when high levels of acceptance and adherence are reached ,30. PrevWe found in our study that children who got cough/fever or diarrhea during the past two weeks had significant lower adherence, which consist with most caregivers’ report that they would skip sachets of YYB when their children got cold or diarrhea. Mirak et al. also found in Bangladesh that around 19% of the mothers reported that they skipped a sachet of MMNP because of any children’s illness in the past 60 days, and nearly half of those who skipped a sachet of YYB had fever in the past 15 days .In addition, our study suggested that one of the main reasons for poor acceptability and adherence was that children disliked or even refused to eat YYB, which implied that the taste of YYB needed to be improved. A study in Lao People’s Democratic Republic also report sprinkles had unpleasant smell and taste . DiffereReal–life program implementation challenges can be hard to predict. It is known that effectiveness of MNP depends on caregivers to be motivated to offer sachets MNP for children properly and without interruption . ExperieA strength of this evaluation study is that we collected data from four follow–up cross-sectional surveys which showed the trends over time in program implementation. Our evaluation study also has several limitations. First, the main indicator “high adherence to YYB (children who consumed at least four YYB sachets during the previous week)” in this paper was based the caregivers’ recalled data during the previous week, which may have recall bias. Previous studies defined “high adherence to MNP” on weekly basis  that is Monitoring YYB distribution and consumption promoted the YYB program implementation, which could reveal issues affecting adherence to and acceptability of YYB, and direct more strategic implementation. Village doctors were critical to the success of the Chinese community–based YYB programs as they distribute the supplements and educate caregivers; quality training conducted among village doctors could improve the caregivers’ awareness of YYB, thus improve children adherence to YYB. Efforts to improve adherence in the community–based complementary food supplements include: improving the taste of the food supplement, strengthening health education of village doctors and caregivers, and ensuring continuity of food supplement supply. Future programs also need to monitor program implementation in other settings in China and elsewhere.


One of the most effective means of preventing the transduction and transmission of acute and perioperative pain is through the use of local anaesthetics. However, local anaesthetics currently available have a relatively short duration of action. Although there are several tools available to treat perioperative pain in companion animals, overall, there is an unmet need for products that can be administered in the clinic, and provide pain relief for the crucial first few days following surgery in the home environment. Specifically, in relation to local anaesthetics, there is a clear unmet need for a long‐acting local anaesthetic that can be added to the multimodal analgesic protocol to provide pain relief to patients in the home environment or during extended hospitalization. Bupivacaine liposomal injectable suspension recently became available for use in humans, and has proven efficacious and safe. This paper will review the use of local anaesthetics, particularly bupivacaine, in dogs and cats, and introduce a new formulation of prolonged release bupivacaine that is in development for dogs and cats. All surgical procedures result in some degree of tissue trauma and associated pain. Over the last two decades in veterinary medicine, there has been a dramatic shift in the approach to perioperative pain, with an increased recognition of pain and increased use of analgesics to control perioperative pain  provide pre‐emptive analgesia, (ii) utilize multimodal pain management, (iii) deliver overlapping/ continuous analgesia and (iv) match the analgesic plan to the degree of surgery. The pain transmission system is complex, with a lot of redundancy, and therefore in order to minimize postoperative pain and any long‐term sequelae of unrelieved pain, an effective multimodal approach should be employed that interrupts the pain transmission and detection system at multiple levels Fig. . Veterinet al. ™, Elanco) have been approved for post‐surgical analgesia in dogs, and injectable buprenorphine  and the cyclooxygenase inhibiting NSAID robenicoxib  in cats. Meloxicam  is approved for use in cats preoperatively, but only for a single dose. Beyond these options, there are unapproved fentanyl patches manufactured for human use, which have been suggested to be efficacious . This paper will review the use of local anaesthetics, particularly bupivacaine, in dogs and cats, introduce a new formulation of prolonged release bupivacaine and review the published literature on this product.Overall, there is a clear unmet need for effective analgesic products that can be given in the clinic and continued in the home environment, or products that can be administered in the clinic and provide pain relief for the crucial first few days following surgery in the home environment. Specifically, in relation to local anaesthetics, there is a clear unmet need for a long‐acting local anaesthetic that can be added to the multimodal analgesic protocol to provide pain relief to patients in the home environment or during extended hospitalization. Bupivacaine liposomal injectable suspension is currently being developed for dogs and cats, with a target indication of 72 h of local analgesic efficacy following intra‐operative tissue infiltration  reported the average dose and arterial plasma concentration at seizure onset for several local anaesthetics  strongly recommends the routine use of local anaesthetic .Local anaesthetics are also frequently used for regional nerve blocks and these techniques have demonstrated significant enhancement of postoperative analgesia in dogs and cats  for use as a single‐dose infiltration into the surgical site to effect post‐surgical analgesia in human surgical patients. The prolonged‐release technology used in this product consists of multi‐vesicular liposomes encapsulating aqueous bupivacaine. The liposomes are microscopic structures made of non‐concentric lipid bilayers designed such that bupivacaine is gradually released from vesicles over 96 h as the lipid bilayers break down. The lipids making up the bilayer structures consist of phospholipids, cholesterol and triglycerides, and importantly do not contain lecithin which has been associated with tissue necrosis and toxicity. The technique for instilling bupivacaine liposomal injectable suspension into a wound differs slightly from using traditional bupivacaine formulation because the liposomes do not readily diffuse into tissues. This is due to the size of the liposomes – each liposome is approximately 10–30 μm in diameter . A moving needle technique is used to inject the solution into all tissue layers within the surgical field . The 30% reduction in pain compared to placebo over the 72 h was considered clinically meaningful. Furthermore, bupivacaine liposome injectable suspension‐treated patients required significantly less opioid medication (P < 0.0008) during the first 72 h and had significantly greater overall satisfaction with postoperative analgesia (P = 0.0007)  in favour of bupivacaine liposome injectable suspension, and there were significantly more treatment successes (reduction in pain scores) in the bupivacaine liposome injectable suspension group compared to placebo over each 24‐h period  up to 72 h postoperatively. No significant adverse events were seen (unpublished data). Recently, the top‐line results from the subsequently performed larger pivotal study were announced, with similar efficacy seen. Pilot studies using this product are also in progress in cats.Bupivacaine liposome injectable suspension is currently being investigated for use in dogs and cats. At the time of writing, a multi‐centre, placebo‐controlled pilot trial in dogs undergoing orthopaedic surgery has been completed and the results presented. In dogs undergoing lateral retinacular suture stabilization of cruciate deficient stifles, 46 dogs were enrolled in a blinded, placebo‐controlled study and evaluated postoperatively using subjective assessments. Bupivacaine liposome injectable suspension was injected intra‐incisionally at the time of closure of the wound to provide postoperative analgesia. There was a significant overall treatment effect of pain reduction (Local anaesthetics are potentially the most effective analgesic class available to veterinarians for use in the perioperative period because they have the potential to completely block nociceptive signals from reaching the CNS. However, their clinical effectiveness is limited by the relatively short duration of action. The recent development and approval for use in humans of a prolonged duration of action liposome formulation of bupivacaine appears to be having a dramatic and positive impact in human postoperative pain control. The development of this product for the veterinary market shows promise to be an effective tool for practitioners, and would help address a significant unmet need – the ability to provide prolonged postoperative analgesia using the most effective class of perioperative analgesic available.NoneThe authors are both paid consultants of Aratana Therapeutics.KKS and BDXL both planned, drafted and finalized the manuscript


The great need for more sustainable alternatives to fossil fuels has increased our research interests in algal biofuels. Microalgal cells, characterized by high photosynthetic efficiency and rapid cell division, are an excellent source of neutral lipids as potential fuel stocks. Various stress factors, especially nutrient‐starvation conditions, induce an increased formation of lipid bodies filled with triacylglycerol in these cells. Here we review our knowledge base on glycerolipid synthesis in the green algae with an emphasis on recent studies on carbon flux, redistribution of lipids under nutrient‐limiting conditions and its regulation. We discuss the contributions and limitations of classical and novel approaches used to elucidate the algal triacylglycerol biosynthetic pathway and its regulatory network in green algae. Also discussed are gaps in knowledge and suggestions for much needed research both on the biology of triacylglycerol accumulation and possible avenues to engineer improved algal strains. Bile acid:Na+ symporter) were induced compared to N‐replete cultures. This suggested that an enhanced CO2 assimilation rate could increase carbon flux towards fatty acid synthesis , the rate‐limiting enzyme in fatty acid biosynthesis  can be directly used for the sequential acylation of glycerol‐3‐phosphate in the chloroplast, which leads to the production of diacylglycerol (DAG). In the chloroplast, DAG mainly serves as a precursor for photosynthetic membrane lipids, such as galactoglycerolipids, which contribute to more than 50% of the total glycerolipids in normal growth conditions , which contains a catalytic lipase motif, suggested that increased TAG synthesis is a protection mechanism against free fatty acid‐induced cell death in fast‐growing tissues of plants . While AtDGAT catalyses the direct acylation of DAG, AtPDAT is involved in the acyl‐editing pathway, catalysing the transfer of an acyl group from the sn‐2 position of phosphatidylcholine (PC) to the sn‐3 position of DAG  was detected on purified lipid droplets through a proteomics study , a putative repressor of cellular quiescence, was also impaired in TAG turnover following N resupply  might act as nitrate sensors in addition to their transport function , a putative transcription factor with a regulatory role in N assimilation and TAG accumulation in N‐depleted Chlamydomonas , which was previously implied in the control of circadian rhythmicity in Chlamydomonas , a tyrosine phosphorylation‐regulated kinase implicated in the control of TAG accumulation upon both N and sulphur (S) deficiencies  and acetate assimilation , despite the severe phenotype under N‐starvation conditions  might be a result of its phosphorylation activity upon transcription factors controlling downstream reactions. However, the targets of TAR1 remain unknown to date  have been used in an effort to better understand the mechanisms underlying N‐starvation‐induced lipid accumulation in green algae  permitted in‐depth investigations of the early regulatory networks responding to N deficiency in Chlamydomonas, few studies have pinpointed the function of specific genes in TAG accumulation in green algae using multiple lines of evidence including biochemical pathway analyses in mutants and engineered strains , temporarily alleviating internal P deficiency  and abiotic stress conditions (different light intensities) have also been reported to trigger lipid accumulation in green algae  and N deficiency responses in et al., et al., Cryptomonas rufescens demonstrated that high light intensity leads to the accumulation of both intracellular starch and lipids and eventual cyst formation, while lipid synthesis alone is induced by N deficiency in this species  starvation is as critical for inducing lipid accumulation in diatoms as N starvation is in green algae  as feed  was isolated in a screen for mutants impaired in the recovery after N resupply to N‐deprived cultures (Tsai et al., et al., The effects of N starvation can be easily reversed by adding N to the medium, which has been useful for investigating the algal recovery responses after N resupply in the oleaginous microalgae Chlamydomonas genome (Blaby et al., et al., et al., Chlamydomonas will be a great resource to solve scientific questions, efforts into technology transfer targeting robust oil‐producing strains that can grow outdoors, in different environments, without being outcompeted by other algae, and resist predators, will be fundamental for the development of the algal biodiesel industry.Despite major insights provided by recent gene function and systems biology studies, further research will be fundamental to identify the regulatory cascades controlling TAG accumulation under stress conditions in green algae. Recent improvements in genomic data, such as high‐quality gene models, have been made because of the initial efforts put into sequencing the


The main objectives were to investigate whether cortical activity can be (1) detected using functional fNIRS, and (2) if it is possible to distinguish between painful and nonpainful pressure as well as a tactile brushing stimulus based on relative changes in oxy‐ and deoxyhemoglobin ([O2Hb] and [HHb]).This study aimed at investigating the feasibility of functional near‐infrared spectroscopy  and primary somatosensory cortex (S1) were measured bilaterally using a multichannel continuous‐wave fNIRS imaging system.Twenty right‐handed subjects  participated in the study. Painful and nonpainful pressure stimulation was exerted with a thumb grip perpendicularly to the 2Hb] in the SMA and S1 after both pressure stimulations (corrected for multiple comparison) were observed. [HHb] showed only much weaker changes (uncorrected). The brushing stimulus did not reveal any significant changes in [O2Hb] or [HHb].Characteristic relative changes in [OfNIRS is sensitive enough to detect varying hemodynamic responses to different types of mechanosensory stimulation. The acquired data will serve as a foundation for further investigations in patients with chronic lower back pain. The future aim is to disentangle possible maladaptive neuroplastic changes in sensorimotor areas during painful and nonpainful lower back stimulations based on fNIRS neuroimaging.The results indicate that  For each subject the age‐dependent Differential Pathlength Factor (DPF) was calculated according to the equation given by Scholkmann and Wolf  data were first uploaded to the nirsLAB analysis software , together with the probe information. By applying the modified Beer‐Lambert Law . Furthermore, the grand averages per condition and group were calculated by taking again the median (from the middle 2.5 s of the 5 s lasting stimuli) of all the subjects. In order to assess variance of the datasets, the standard error of the median (SEMed) was calculated as well.2.5.2q < 0.05). To test whether the three different conditions elicited characteristic hemodynamic responses per condition, grand averages (averaged medians) were calculated per each condition. Subsequently, Wilcoxon signed‐rank tests were applied per channel in order to compare the hemodynamic response against zero. Data were again corrected for multiple comparisons . Finally, post hoc paired Wilcoxon rank‐sum tests were computed to assess significant differences in the hemodynamic response among the three different conditions .As the data were generally not normally distributed the whole statistical analyses of the hemodynamic changes was conducted by using nonparametric tests. To test for statistical significance at single‐subject level, a Wilcoxon signed‐rank test was applied per channel to check for the null hypothesis that the median values have a distribution not different from zero. For the group‐level analyses, two different approaches were applied. The first (classic) approach  comprised all channels of all subjects, independently of which channels showed statistical significance in the previously calculated Wilcoxon signed‐rank test (at single‐subject level). The second approach  comprised only those channels into the group analysis which were classified being ‘responders’. Therefore, all channels exhibiting a task‐related hemodynamic change were included, while all channels not exhibiting any task‐related response were excluded from the group analyses. This approach decreases the rate of false negatives in the group analysis and takes into account that single subjects do not show significant hemodynamic responses. Both approaches were applied throughout this work for several statistical tests. First, the main effect of group was calculated by using a Friedman test. Results were corrected for multiple comparisons by the false discovery rate (FDR) correction following the Benjamini and Hochberg  procedur2.5.3Finally, a habituation and/or sensitization analysis was performed by using individual linear regressions. For each single subject, condition, and channel, one linear regression model was calculated to assess whether subjects show a sensitization  or habituation  over time.2.5.4HRmean) and maximal values (HRmax) per stimulus (5 s) and per ISI (15 s) were extracted from the Garmin Edge500 device and exported to Excel . In the case of the ISI there is a need for differentiating between pre‐ISI (the one before a specific stimulus) and the post‐ISI (the one after a specific stimulus). Moreover, for each condition  the mean, the standard deviation (SD), and the standard error of the mean (SEM) of HRmean as well as HRmax were calculated for all subjects. Three paired Wilcoxon‐tests were used to calculate whether there was a significant difference between HRmax during the stimulus and HRmax during the post‐ISI  . To answer the question whether there was a significant difference regarding heart rate between the different stimuli, the difference between the HRmax for the post‐ISI and HRmax during the stimulus was calculated and used for a paired Friedman test .For the heart rate analysis, averaged  for [O2Hb], whereas for [HHb] only uncorrected results  showed significant differences for the three conditions in a few channels. These channels corresponded to the significant channels for [O2Hb], with the exception of channel 1.At the group level, the Friedman test yielded at least three or more channels that significantly distinguished between the three conditions .Grand averages per condition are shown in Figs 2Hb] changes in contrast to the brushing condition . Eight subjects showed positive correlations in maximally 1–3 channels per subject. Five subjects showed negative correlations in maximally 1–3 channels. Therefore, both cortical habituation and sensitization could be detected in a few channels in some subjects, however, no group correlation or at least specific correlations for specific channels could be found.Individual linear regression models at the single‐subject level revealed several significant correlations in a couple of [O3.3HRmax analysis revealed on the one hand a clear effect of condition as the post‐ISI HRmax was found to be significantly higher than the HRmax during the stimulus itself in all three conditions   by capnography in order to quantify the effect of respiration on cortical hemodynamics. Even though they did not find characteristic [O2Hb] and [HHb] changes due to the different stimulations, they were able to reveal a strongly confounding effect of “respiration‐related‐changes in the partial pressure of CO2 in arterial blood (PaCO2) on fNIRS‐derived parameters”  have been also observed during stimulations of sensorimotor areas due to nonpainful and painful electrical muscle stimulations . The study from Holper et al. , who havIn addition, we conducted heart rate measurements over the course of the experiment in order to monitor related physiologic responses. This parameter will be discussed in a later section below.4.22Hb] in several channels within both ROIs, whereas changes in [HHb] remained constant or decreased, although this decrease failed to reach significance after FDR correction. The bilateral S1 activation was located near by the midline, corresponding to the representation of the trunk in the human somatosensory homunculus  and the Analysis_Responders. These two approaches are representing distinct intentions. The classic Analyses_All approach, which is disregarding the single‐subject level, is including subjects and channels which are not showing any task‐related changes. Therefore, in this approach we include randomly noisy channels. This factor does influence the results, by allowing for more false‐negative results. Meanwhile, the Analysis_Responders approach is able to decrease the false‐negative rate by already excluding channels on single‐subject level which are showing random noise. Although this approach is not preselecting the data regarding quality, as, for example, systemic changes (large increases in both [O2Hb] and [HHb]) would also reach significance at single‐subject level and would be included into further group analyses.The statistical analyses in this work comprised two different approaches, the Here, we are showing both analyses approaches, as in our opinion it adds value having both approaches of the same dataset. As it can be seen in Tables There are advantages and disadvantages of both methods and we propose to implement both approaches in further fNIRS and probably also fMRI investigations in order to take into account the individual physiological response to a stimulus or task  within the superficial layers. Second, the missing difference between the three stimulations might indicate that the PPT was too ‘low’, in order to induce significantly different changes regarding heart rate than the other stimulations.52 in combination with fNIRS.This investigation reports on results about cortical hemodynamic changes in sensorimotor areas after painful and nonpainful stimuli. Nevertheless, there are some limitations to mention. Although the PA‐pressure stimulation technique is frequently applied in the clinical setting, its application in research is novel. Therefore, its use in neuroscience research is a big advantage over other pain modalities. Nevertheless, these manually applied stimulations cannot be as specifically administered as, for example, stimulations by laser optodes or electrodes. Therefore, a certain imprecision has to be taken into account, which should be improved by further development of this stimulus modality for research applications. A further limitation of the study is related to the method to remove extracerebral hemodynamic effects. Although the short‐separation regression was applied in order to remove hemodynamic changes in the superficial layer, thereby interfering with the cerebral responses, this could be improved by increasing the number of short‐distance channels. However, due to technical restrictions of our fNIRS imaging device, we were confined to implement only two short‐distance channels, one per ROI. By applying multiple short‐distance channels per ROI, the SNR could be further improved, allowing for a more exact insight into solely cerebral hemodynamics. Also the impact of systemic changes on the cerebral hemodynamics itself should be assessed by future studies in this area. This could be done, for example, by measuring PetCO62Hb] in both SMA and S1, whereas the brushing stimulation failed to elicit characteristic hemodynamic changes. Moreover, [HHb] did not reveal significant (corrected) changes for all three stimulations. However, as fNIRS proved to be a feasible and reproducible optical imaging method, this investigation will serve as a foundation for further measurements in LBP patients in order to provide an insight to their neuronal processing of LBP.To conclude, this investigation shows the feasibility of using fNIRS for the measurement of hemodynamic responses due to painful pressure stimulation on the lower back. Painful and nonpainful pressure yielded similar characteristic changes in mainly [OAll authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article. Click here for additional data file.


Platelet activating factor (PAF) is an important mediator of vascular leak in acute dengue. Phospholipase A2s (PLA2) are inflammatory lipid enzymes that generate and regulate PAF and other mediators associated with mast cells. We sought to investigate if mast cell activation and increases in secretory sPLA2s are associated with an increase in PAF and occurrence of dengue haemorrhagic fever (DHF).The changes in the levels of mast cell tryptase, PAF and the activity of sPLA2 were determined throughout the course of illness in 13 adult patients with DHF, and 30 patients with dengue fever (DF).We found that sPLA2 activity was significantly higher in patients with DHF when compared to those with DF, during the first 120 h of clinical illness. sPLA2 activity was significantly associated with PAF levels, which were also significantly higher in patients with DHF. Although levels of mast cell tryptase were higher in patients with DHF, the difference was not significant, and the levels were not above the reference ranges. sPLA2 activity significantly correlated with the degree of viraemia in patients with DHF but not in those with DF.sPLA2 appears to play an important role in the pathogenesis of dengue. Since its activity is significantly increased during the early phase of infection in patients with DHF, this suggests that understanding the underlying mechanisms may provide opportunities for early intervention. Dengue is one of the most important mosquito borne virus infections in the world, affecting approximately 390 million individuals annually Typical dengue is characterised by fever, myalgia, arthralgia and gastrointestinal symptoms such as abdominal pain and vomiting Many inflammatory mediators have been implicated in the vascular leak seen in acute dengue 2) and cytoplasmic phospholipase A2 are known to generate and regulate PAF and both are produced by mast cells, endothelial cells, hepatocytes, monocytes and many types of epithelial cells PAF is an inflammatory lipid mediator that is produced by mast cells, monocytes, macrophages, neutrophils, endothelial cells and platelets Mast cells are activated occurs in acute dengue and mast cell mediators have been associated with vascular leak in mouse models of this disease 2 activity in these patients.Since mast cells are an important source of PAF and mast cell activation and degranulation have been shown to contribute to vascular leak and disease severity, we investigated the relationship between PAF and mast cell tryptase during the course of illness in patients with DHF and DF and also in those with primary and secondary dengue. In addition, since PLA2 is known to regulate PAF and since mast cells are also a known source of certain subgroups of this lipid enzyme, we also evaluated the kinetics of sPLA2 activity was significantly higher in patients with DHF, when compared to those with DF. Although, mast cell tryptase levels were higher in patients with DHF, this increase was not statistically significant. In addition, both the activity of sPLA2 and mast cell tryptase levels were significantly associated with the degree of viraemia in patients with DHF. Therefore, events that occur in early in DENV infection are likely to contribute to subsequent disease severity, and this suggests that these could be a focus of therapeutic targeting.We found that during the first five days (120 h) of clinical illness, serum sPLAWe enrolled 43 adult patients with clinical features of dengue, admitted to a general medical ward in a tertiary care hospital  in Colombo during the year 2015. Following informed written consent, serial blood samples were obtained in the morning (5.00 a.m.) and afternoon (3.00 p.m.), from the time of admission to the time of discharge from hospital, throughout the course of their illness. Only those whose duration from onset of illness was ≤ 5 days were recruited. The day in which the patient first developed fever was considered as day one of illness. Those who were known to have chronic liver disease, chronic renal disease, pregnant individuals, those on a steroid dose of > 40 mg/day for over seven days were excluded from the study.Clinical features including fever, blood pressure, pulse pressure and the urine output were measured at least four times a day. The severity of acute dengue was classified according to the 2011 WHO dengue guidelines The ethical approval was granted from the Ethical Review Committee of the University of Sri Jayawardanapura.Levels of PAF and mast cell tryptase were determined in all serial blood samples which were obtained twice a day. All the assays were done in duplicate. The PAF  and mast cell tryptase assays  were carried out using a quantitative ELISA according to manufacturers’ instructions. These assays have been used previously to quantify levels of serum PAF 2in patients with dengue infections were measured using a commercial sPLA2 kit , according to manufacturer's instructions. Briefly in a flat‐bottom 96‐well plate, 10 μl DTNB and 15 μl of the assay buffer were added to the blank wells and 10 μl DTNB, 10 μl Bee Venom PLA2, and 5 μl assay buffer added to the positive control wells. Ten micro litres DTNB, and 5 μl assay buffer along with 10 μl of the serum sample were added to each sample well. The reaction was initiated by adding 200 μl Substrate Solution to each well. All the samples were tested in duplicate. The absorbance was read every min at 414 (or 405) nm using an ELISA plate reader to obtain at least five time points. The reaction rate was determined using a DTNB extinction coefficient of 10.66 mM‐1 according to the recommended formula for calculating the sPLA2 activity.The activity of sPLARNA was extracted from all serial serum samples using QIAamp Viral RNA Mini Kit  according to the manufacturer's protocol. The RNA was reverse transcribed into cDNA in GeneAmp PCR system 9,700 using High Capacity cDNA reverse transcription kit  according to the manufacturer's instructions. Reaction conditions were 10 min at 25°C, 120 min at 37°C, 5 min at 85°C and final hold at 4°C.Multiplex quantitative real‐time PCR was performed as previously described using the CDC real time PCR assay for detection of the DENV 2 incubator, the plaques were developed and counted. Virus concentrations were calculated as pfu/mL. Following quantification of the viruses, the standard curves were generated as serial dilutions from 106 to 101 of pfu/mL for each virus serotype. In order to quantify the virus in clinical samples the unknowns were compared to known values in the standard curves of each virus. The viral loads were expressed as pfu/mL.To generate standard curves, the four DENVs were grown in C6/36 cell lines supplemented with L15 media at 28°C. Virus supernatants were harvested seven following infection and immediately used to infect vero81 cell lines. To determine the infective virus particles by plaque assays, virus culture supernatants were serially diluted and inoculated in triplicate. Undiluted sample from the virus culture supernatant was used as the positive control and culture media as the negative control. After 5 days of incubation at 37°C in 5% COAcute dengue infection was confirmed in the serum samples using the NS1 early dengue ELISA . All assays were done in duplicate. Dengue antibody response was also confirmed in these patients with a commercial capture‐IgM and IgG enzyme‐linked immunosorbent assay (ELISA) (Panbio). The ELISA was performed and the results were interpreted according to the manufacturers’ instructions. This ELISA assay has been validated as both sensitive and specific for primary and secondary dengue virus infections Statistical analysis was performed using Graph PRISM version 6. As the data were not normally distributed , non‐parametric tests were used in the statistical analysis. Differences in the serial values of sPLA2, mast cell tryptase, PAF and viral loads in patients with DHF and DF were done using multiple unpaired t tests. Corrections for multiple comparisons were done using Holm‐Sidak method and the statistical significant value was set at 0.05 . The association between the PAF, sPLA2, mast cell tryptase and viral loads was done using Spearman correlation.Of the 43 patients with acute dengue, 30 were classified as having DF and 13 were classified as having DHF based on the WHO 2011 dengue guidelines As in our previous studies we found that PAF was significantly increased in patients with DHF when compared to those with DF and the PAF levels were highest during the critical phase of dengue Phospholipase A2s are a group of lipid enzymes, which act on cellular phospholipids to generate free fatty acids (e.g. PAF) and lysophospholipids P = 0.005) and 144 h of illness (P = 0.01) in patients with DHF when compared to those with DF   and inversely correlated with lymphocyte numbers . On further analysis, the association of viral loads with serum sPLA2 activity was significant in patients with DHF , but not in those with DF . We did not observe any relationship between the viral loads with PAF in either patients with DF or with DHF. Serum sPLA2 activity also associated with liver transaminases as it significantly correlated with levels of serum aspartate transaminase levels  and with serum alanine transaminase levels .Activity of sPLA2 also significantly correlated with viral loads (Spearmans’ P = 0.4) or with levels of PAF . However, mast cell tryptase was associated with the degree of viremia . This association of mast cell tryptase with the degree of viraemia was significant in those with DHF  . Mast cell tryptase also did not associate with any of the laboratory disease severity markers such as liver enzymes, lymphocyte or platelet counts.Mast cells have recently been shown to be important in the pathogenesis of dengue and certain mast cell mediators have been associated with vascular leak DHF is more common is secondary dengue infection, and this is thought to be due to enhancement of infection in Fc receptor bearing cells, caused by DENV‐specific poorly‐neutralising, highly cross‐reactive antibodies In this study we investigated the changes in the activity of sPLA2 and levels of PAF and mast cell tryptase throughout the course of illness in patients with varying severity of dengue infection. We found that serum sPLA2 activity was markedly increased and significantly higher in patients with DHF, during the first 120 h from the onset of illness. Levels of PAF were also significantly higher in patients with DHF at 96 and 144 since the onset of illness. Although, the mast cell tryptase levels were also higher in patients with DHF, this was not significant at any time point since the onset of illness.Phospholipase A2s are a group of lipid enzymes, which act on cellular phospholipids to generate free fatty acids and lysophospholipids and also generate PAF Activation of mast cells directly by the DENV and by DENV‐specific antibodies has been shown to occur in both in vitro and in dengue mouse models DENV specific antibodies have shown to induce activation of mast cells by facilitating autophagy and also by inducing mast cell degranulation through the FcRγ receptors In summary, we found that the serum sPLA2 activity was significantly increased in patients with DHF and that sPLA2 activity was also associated with other disease severity markers such as liver transaminases. As previously observed, levels of PAF were significantly higher in patients with DHF and serum sPLA2 activity was found to correlate with PAF. However, since mast cell tryptase levels were not significantly higher in patients with DHF nor in those with secondary dengue, this suggests that non‐mast cell sources of PAF may also be important. Since sPLA2 activity was highest during early phase of clinical disease and since it significantly associated with the degree of viraemia, it would be important to understand the triggers that increase sPLA2 activity in order to develop new therapeutic targets.None declared.


AIC and BIC were the best model selection indices and that marginal R2 values were biased toward more complex models. The model coefficients for landscape variables generally reflected the underlying dispersal model with confidence intervals that did not overlap with zero across the entire model set. When we controlled for geographic distance, variables not in the underlying dispersal models  typically overlapped zero. Our study helps establish methods for using linear mixed models to identify the features underlying patterns of dispersal across a variety of landscapes.Dispersal can impact population dynamics and geographic variation, and thus, genetic approaches that can establish which landscape factors influence population connectivity have ecological and evolutionary importance. Mixed models that account for the error structure of pairwise datasets are increasingly used to compare models relating genetic differentiation to pairwise measures of landscape resistance. A model selection framework based on information criteria metrics or explained variance may help disentangle the ecological and landscape factors influencing genetic structure, yet there are currently no consensus for the best protocols. Here, we develop landscape‐directed simulations and test a series of replicates that emulate independent empirical datasets of two species with different life history characteristics . We determined that in our simulated scenarios,  With these replicates, we (1) compared the ability of a variety of model selection indices to identify the correct underlying dispersal model  from among a candidate set of models and (2) examined the stability of model coefficients for the landscape variables in the true dispersal model  across all models in a model set. Our study assists with the development of methods for using MLPE models in a model selection framework to test hypotheses and establish the landscape features that are significantly impacting patterns of dispersal across landscapes. Further, we provide genetic simulation scripts that can be used to test population‐based spatial genetic approaches.We developed landscape‐directed dispersal simulations in which dispersal rates among simulated populations are governed by landscape features from real landscapes and produced genetic characteristics  similar to empirical datasets. Using these simulations, we derived a series of replicates where genetic exchange among populations for a wide‐ranging terrestrial vertebrate , forest (FOR), agricultural fields (AGRIC), and terrain ruggedness (RUGG); Table GenABLE package in R (R Core Team qnorm function in R). This standardized both the range and distribution of resistance values, avoided skewed distributions, and facilitated comparisons among variables . For simplicity, we equally weighted each surface by averaging the two individual component resistance surfaces. Averaging the surfaces (as opposed to adding) merged the features of both components but kept the overall ranges of the resistance values consistent with the single variable surfaces Figure . Pairwis2.1.2Our second set of simulations were derived to match an empirical population genetic dataset  for eastern foxsnakes across a fragmented region in southwestern Ontario  by taking the average of two individual component resistance surfaces.2.1.3simuPOP  between populations was derived from a negative exponential function: ij decreases with increasing resistance (Rij), with α determining the steepness of the decline and β describes the overall dispersal rate. We standardized emigration rates  so that they were consistent among populations. This avoided complete isolation of populations in low‐quality areas, which were resulting in patterns different from our observed data (see below). Biologically, this is equivalent to individuals in poor habitat having a higher threshold and being more willing to travel through high‐resistant habitat  for all populations across generations within a replicate. We simulated microsatellite loci to match the empirical datasets (14 for sage‐grouse and 11 for foxsnakes); mutation rates (mμ) were assumed to be microsatellites (most current landscape genetic literature is based on surveys of microsatellite markers), mutating under a strict stepwise mutation model. In total, our genetic model, which required a pairwise resistance matrix and four input parameters Table , modulatGST; Takezaki & Nei, We ensured that our simulations were biologically relevant by parameterizing our landscape‐directed dispersal simulations to generate simulated data with genetic characteristics similar to the empirical datasets. This was accomplished for each of the dispersal replicates by randomly sampling twenty individuals from each simulated population and comparing summary statistics to empirical data . In total, we used four steps: (1) running preliminary simulations and determining the range of parameter values that produced data approximating the genetic diversity  of the total variance (σ2) is due to the correlation between data points that share a common population. Thus, the covariance for n that share a common population is ρτσ2 and zero for those that do not , which produces unbiased estimates of model variance for mixed‐effects models  across multiple runs.Maximum‐likelihood population‐effects models account for nonindependence in a set of We assessed the power of MLPE models by quantifying their ability to identify the true dispersal model from alternate models in a complete candidate set for each simulated replicate. For both the sage‐grouse and foxsnake analyses, we considered a candidate model set of 16 models with each of our true resistance surfaces represented in the set Table . BecauseIf MLPE models have high power to correctly identify true landscape variables, true models should be among the best fitting and thus have a low percentile. Also, because each variable represents pairwise resistance derived from a resistance surface, there should be a positive  and significant relationship with genetic distance if the surface is an accurate characterization of the landscape from the perspective of the species. In circuit theory, resistance between populations will increase with increasing distance between nodes regardless of the resistance values of a surface. Thus, in the presence of isolation‐by‐distance, a variable may be spuriously classified as significant even if it does not affect dispersal. To reduce the likelihood of this, we reran all candidate models, but included a variable representing isolation‐by‐distance . Inclusion of this variable should factor out the effects of distance and reduce the percentage of nontrue landscape variables being significant.lme4 models, and DIC values were calculated from the MCMC iterations. We used three different AIC variants, but all gave similar results, so only AICREML was reported. Next, we used two marginal R2 variants, which measured the total variance explained by the fixed effects . Unlike traditional R2 values, marginal R2 do not necessarily increase with the addition of parameters 2, estimates the variance of the fixed effects by calculating the variance of fitted values predicted from a model with only fixed effects  the overall proportion of simulations where the top model was the true underlying dispersal model, (2) the proportion of simulations where all true variables were in the top selected model, (3) average difference between the top selected and true model , and (4) average correlation between the top selected and true model when the true model was not selected. These comparisons were conducted using all true underlying dispersal scenarios and averaged across replicates.33.1R2 values had a bias toward multivariate models and had much higher percentiles for true models than the AIC and BIC model selection criteria. DIC also performed poorly and generally had higher percentiles than marginal R2 values . The model selection indices AIC and BIC outperformed the other indices and had true models within the lowest percentiles for the total model set in both simulated datasets Figure . MarginaThe performance of AIC and BIC was very similar, and thus, here we only discuss BIC results which performed slightly better. The proportion of correctly assigned true models varied widely between dispersal scenarios and was not high overall Table . In geneWhen considering single landscape true models, the average coefficient estimates across models for the true landscape variables  were positive and nonoverlapping with zero Figure a,c. As pFor both the sage‐grouse and foxsnake simulations, the coefficient for UNDIF was similar and positive whether it was the true landscape variable or not. However, in both cases the average across models decreased below zero when included in a model with true landscape variables Figure  and stay4R2 values being biased toward more complex models in our simulations. However, even these model selection indices had difficulty in selecting the true dispersal surface when the dispersal was the results of a combination of multiple landscape surfaces. Model coefficients for true landscape variables generally had confidence intervals that did not overlap with zero for the entire model set. Controlling for geographic distance by including an undifferentiated covariate increased model accuracy by reducing the significance of variables not included in the true landscape surface driving dispersal. Overall, a MLPE approach using univariate models that combined AIC and BIC selection indices with an examination of coefficient stability gave the highest likelihood of correctly identifying the true landscape surfaces underlying dispersal.Model selection criteria for MLPE models varied in their capacity to identify the true landscape dispersal surface among a candidate set of models. Both AIC and BIC outperformed the other tested indices, with marginal 4.1Rβ2 to select the top models. This selection index has subsequently been used by others for landscape genetics , and in some cases, one variable's contribution to the model outweighed the other by as much as a factor of four. This is also supported by the fact that in the combined surface simulations, the top models were highly correlated with the true models when not correctly chosen.When the underlying true landscape resistance was built from two surfaces, the model selection indices were not as proficient at selecting the correct multivariate model. This is likely due to the fact we assumed that pairwise resistances derived from the combination landscape surfaces are a linear combination of the pairwise resistance from each individual landscape. We tested this by fitting models of pairwise resistances from combined surfaces with their corresponding individual pairwise resistances . If the surfaces are linear combinations, we would predict a strong fitting model with both variables contributing relatively equally to the model. For the combined sage‐grouse resistances, this was generally true with an average In our development of resistance surfaces, we made efforts to develop uncorrelated resistance surfaces that could be combined without masking the effects of one of the landscape variables. This might be difficult with some empirical datasets, particularly when equal contributions of each landscape are not expected as we simulated here. Based on our results, we suggest testing resistances derived from multilandscape surfaces against the corresponding single landscape surfaces before proceeding with multivariate models. More simply, using resistances derived from the combined surfaces in the model selection analyses and avoiding multivariate models altogether might lead to better results.4.2Many examples of MLPE models in landscape genetics present only model selection indices and do not report model coefficients , types and the numbers of genetic markers, and other approaches such as Mantel tests and multiple regression on distance matrices (MRDM) would be illuminating.The importance of simulation software that can simulate dispersal driven by landscape resistance is seen with CDPOP (Landguth & Cushman, None declared. Click here for additional data file. Click here for additional data file. Click here for additional data file.


People with mental illnesses and substance abuse disorders are important targets for smoking cessation interventions. Mental health professionals (MHPs) are ideally placed to deliver interventions, but their attitudes may prevent this. This systematic review therefore aimed to identify and estimate quantitatively MHPs attitudes towards smoking and main barriers for providing smoking cessation support and to explore these attitudes in‐depth through qualitative synthesis.The online databases AMED, EMBASE, Medline, PsychINFO, HMIC and CINAHL were searched in March 2015 using terms relating to three concepts: ‘attitudes’, ‘mental health professionals’ and ‘smoking cessation’. Quantitative or qualitative studies of any type were included. Proportions of MHPs' attitudes towards smoking and smoking cessation were pooled across studies using random effects meta‐analysis. Qualitative findings were evaluated using thematic synthesis.Thirty‐eight studies including 16 369 participants were eligible for inclusion. Pooled proportions revealed that 42.2% [95% confidence interval (CI) = 35.7–48.8] of MHPs reported perceived barriers to smoking cessation interventions, 40.5% (95% CI = 30.4–51.0) negative attitudes towards smoking cessation and 45.0% (95% CI = 31.9–58.4) permissive attitudes towards smoking. The most commonly held beliefs were that patients are not interested in quitting  and that quitting smoking is too much for patients to take on . Qualitative findings were consistent with quantitative results, revealing a culture of smoking as ‘the norm’ and a perception of cigarettes as a useful tool for patients and staff.A significant proportion of mental health professionals hold attitudes and misconceptions that may undermine the delivery of smoking cessation interventions; many report a lack of time, training and confidence as main barriers to addressing smoking in their patients. The prevalence of smoking among people with mental illnesses and substance use disorders is much higher than in the general population. Smoking rates stand at above 70% for those with severe mental illnesses such as schizophrenia and bipolar disorder Mental health professionals (MHPs), broadly defined as those who received specialist training to offer services designed to improve an individual's mental health , have a crucial role in reducing tobacco smoking among people with mental illness, as they are best placed to encourage and support smokers to quit One possible barrier to the delivery of smoking cessation intervention is MHPs' attitudes towards and beliefs about smoking and/or smoking cessation among individuals with mental illnesses and substance abuse disorders. For instance, previous research has identified that some hold concerns that patients' mental health or abstinence will suffer To implement smoking cessation interventions effectively for people with mental illness and substance abuse disorders, it is necessary to understand the relevant attitudes and beliefs of MHPs who engage with these individuals. Such an understanding would lead to greater insight into the potential barriers to delivering smoking cessation support which, in turn, can then inform strategies to reduce tobacco use. However, to our knowledge, there has been no recent systematic investigation of MHPs' attitudes to smoking cessation to identify possible barriers, if any.The current systematic review and meta‐analysis aims to synthesize the qualitative and quantitative literature on MHPs' attitudes towards smoking and smoking cessation among people with mental illnesses and/or substance abuse disorders. Specifically, it sought to (a) identify and estimate quantitatively MHPs' attitudes towards smoking and main barriers for providing smoking cessation support such as negative attitudes towards smoking cessation and permissive attitudes towards smoking, and (b) to explore these attitudes towards smoking, smoking cessation and support in‐depth through qualitative synthesis.The current review followed Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines The literature was searched for studies reporting on MHPs' beliefs and attitudes relating to smoking among people with mental illnesses and substance use disorders. An initial search strategy was developed in the databases Medline and Embase, and through the identification of key terms used commonly in the literature.The main keywords used in the search strategy were structured around three key concepts: ‘attitudes’, ‘mental health professionals’ and ‘smoking’, and customized to each database. The final search was conducted on 17 March 2015 in the following databases: AMED (OVID platform), CINAHL (EBSCO platform), classic + Embase, Embase, HMIC Health Management Information Consortium, Medline and PsycINFO (OVID platform) . To find further eligible papers, forward and backward citation searches of included studies were also conducted.The sample was health‐care professionals working in mental health, drug or alcohol treatment (referred to as MHPs throughout).The study measured attitudes/beliefs related to patients' smoking or the delivery of smoking cessation support/advice to patients.It was a primary quantitative or qualitative study published in a peer‐reviewed journal .Studies were eligible for inclusion if they met the following criteria:Studies were excluded if they were not in the English language, focused only on attitudes towards smoke‐free policies, were based on child and adolescent services (the focus of this review was adult services), if the sample was composed only of health professionals in training or if they were published prior to 2003. This date limit was chosen as this was the year in which the World Health Organization Framework Convention of Tobacco Control (WHO FCTC) was published. The WHO FCTC states that parties to the convention should adopt or implement legislation that promotes training on tobacco control for health workers, community workers and social workers An inclusion/exclusion criteria checklist was used to screen located articles for inclusion. To establish the reliability of the checklist, two independent reviewers (K.S. and I.T.) screened a random subset (34%) of papers, yielding excellent reliability (Cohen's kappa = 0.95). Disagreements were resolved through discussion.Studies were evaluated with the Mixed Methods Appraisal Tool (MMAT), which has good validity and reliability Data were extracted by one researcher (K.S.) using a standardized data extraction form to provide consistency, reduce bias and increase validity and reliability For quantitative studies, all measures of MHPs' attitudes or beliefs relating to smoking among patients or the delivery of smoking cessation support to patients were extracted. Measures of attitudes towards smoke‐free policies and attitudes reported by patients were not extracted. Extracted measures deemed to be reflective of the same beliefs or attitudes were grouped into categories by K.S. and L.S. These categories were organized further into higher‐level grouping on the basis of the types of attitudes or beliefs they represented. The proportion of participants reporting either negative attitudes towards providing smoking cessation support or permissive attitudes towards patients' smoking was extracted for measures within each category. Proportions were extracted systematically using predefined criteria (see Box 1). If relevant data were not included in published reports, authors were contacted to request data.I2 statistic Where more than one measure from a single study was included in a category, the mean proportion across measures was calculated prior to pooling. Pooling of proportions within each category and within the higher‐level groups was carried out in Stata version 13 using standard methodology Additionally, a meta‐regression was conducted to examine whether study characteristics were predictive of study outcomes using the ‘metareg’ command in Stata. Following convention All text contained in the ‘Results’ or ‘Findings’ section was extracted from published reports and analysed using thematic synthesis. First, textual data were coded line‐by‐line and were then categorized by similarity to generate descriptive themes occurring across included studies Database searches yielded a total of 327 records after the removal of duplicates. After full‐text screening, 33 papers met inclusion criteria. Forward/backward citation searches yielded an additional eight papers, resulting in a total of 41 papers reporting on 38 studies being included in this review  was 16 215. One qualitative study All studies included stated clear research questions or objective, and in all but one study (which did not provide the requisite information in the published report n = 30) the sample representativeness could not be determined, either because the inclusion/exclusion criteria were unclear or because reasons for non‐response or differences between responders and non‐responders were unknown. Two studies were judged to have unrepresentative samples: in one study the sample was attendees at a smoking cessation training programme n = 28) used established measures which were clearly reflective of the variable of interest. For the remainder, the source and/or wording of measures was unclear. Fewer than half (n = 15) of the studies had a response rate of ≥ 60%.Twenty‐two quantitative studies were judged to have used an adequate random (stratified or non‐stratified) sampling strategy. The remainder used convenience or unclear sampling. For most studies n = 0 the samAll qualitative studies used data sources (i.e. participants/recruitment settings) that were relevant to the research question, and used relevant approaches to data collection and analysis. Four of the seven qualitative studies discussed their findings in consideration of the research context, but only one explicitly considered the researchers' influence on their findings.Fourteen categories of attitudes were measured in at least five of the studies included and were therefore considered to be reliable and replicable. These categories were organized into three higher‐level groups: ‘perceived barriers to providing support’ (three categories), ‘negative attitudes towards smoking cessation’ (seven categories) and ‘permissive attitudes towards smoking’ (four categories).The most frequently measured categories were ‘lack of knowledge/training/skills in providing smoking cessation treatment’, ‘quitting smoking might have a negative impact on symptoms/recovery’, ‘smoking cessation is not a priority’, ‘patients are not interested in quitting’ and ‘lack of time to provide smoking cessation treatment’ , data were pooled using a random‐effects meta‐analysis  beliefs about patients quitting smoking; (2) barriers to the provision of smoking cessation treatment; (3) attitudes to the provision of smoking cessation treatment; 4) acceptance of patients' smoking; and (5) smoking as a useful tool. Table  acceptanThe most apparent subtheme within this theme was negative perceptions of patients' ability and motivation to quit, which was identified in all studies. This perception appeared to arise from beliefs that patients would not be interested in quitting smoking A perceived lack of opportunity to provide smoking cessation support was evident In a number of studies, staff did not appear to feel that they had the capability to treat nicotine dependence effectively The behaviour of MHPs was identified commonly as a barrier to addressing smoking among patients Smoking cessation generally was viewed to be important for patients The provision of smoking cessation treatment was often not seen as part of MHPs' role Overall, a general acceptance of patients' smoking by MHPs could be noted. This seemed to stem from the view that there was a long‐standing ‘culture of smoking’ in in‐patient mental health and drug and alcohol services Across studies, MHPs viewed cigarettes and smoking as useful tools in managing patients We identified 38 relevant studies investigating MHPs' attitudes towards smoking and smoking cessation among people with mental illnesses and substance abuse disorders, most of which were quantitative rather than qualitative. A significant proportion of MHPs held negative attitudes towards smoking cessation and permissive attitudes towards smoking, and perceived a number of barriers to providing smoking cessation treatment. Meta‐regression analyses revealed no associations between attitudes and year of publication or type of service, but showed that MHPs in US‐based studies were less likely to hold concerns about the negative impact of smoking cessation on symptoms and recovery. The thematic synthesis of qualitative studies was consistent with the quantitative results, and in addition revealed a richer insight into MHPs' views on patients' smoking, particularly in the context of in‐patient services. Cigarettes were viewed as a useful tool for both patients and staff, and the smoking behaviour of staff was identified as a barrier to providing effective smoking cessation support. A general acceptance of patients' smoking was also apparent in the qualitative findings, with a culture of smoking being seen as the ‘norm’ in some services.This synthesis of the existing literature examining MHPs' attitudes towards smoking and smoking cessation among patients reveals that a significant minority hold attitudes and beliefs that may prevent them from delivering smoking cessation support. The relationship between attitudes/beliefs, intentions and behaviour is well established e.g. , 45, andIt is encouraging that the current review identified that most MHPs felt that it was part of their role to address patients' smoking, even though a minority of approximately one‐fifth felt that it was not part of their role. Further, the qualitative findings indicated that most felt that smoking cessation was important, suggesting that MHPs view the provision of smoking cessation treatment positively. However, despite this generally positive attitude towards providing support, MHPs' reported beliefs about patients' ability and/or motivation to quit, and perceptions of their own ability to successfully deliver interventions and intervention effectiveness which may prevent them from providing support. Most notably, more than half of MHPs in this review reported that patients are not interested in quitting smoking and almost 40% felt that quitting smoking was too much for patients to take on, suggesting that one of the main barriers to the delivery of smoking cessation support may be implicit beliefs about patients, and a tendency to shift responsibility for smoking cessation to patients alone. In agreement with previous work It is unclear why MHPs in the United States were less likely to be concerned about the negative impact of smoking cessation than those from other countries. This may reflect differences in the training provided to MHPs in different countries. However, clinical practice guidelines on smoking cessation from the United States, Australia and the United Kingdom (the two countries that formed the majority of studies not conducted in the United States) do not provide a clear explanation for this divide. While guideline recommendations in the United Kingdom do not cover the topic of smoking cessation, psychiatric symptoms and addiction recovery explicitly, they clearly encourage smoking cessation in this setting The main strength of this review is that is provides an up‐to‐date overview of the most prevalent beliefs and attitudes that may present a barrier to the delivery of smoking cessation intervention in mental health and drug and alcohol services. This review also has some limitations. Data for pooled proportions were not available from all studies, and there was significant heterogeneity among studies. However, quantitative results were largely confirmed by the qualitative synthesis, increasing confidence in these findings. The study selection might be biased due to the focus on English language and full‐text publications; however, every effort was made to make the search strategy as inclusive as possible. None the less, relatively little qualitative work was identified, and further studies should explore potential solutions to overcome common barriers and enable the effective integration of stop smoking service provision into mental health care.In summary, a significant proportion of MHPs appear to hold negative attitudes towards offering smoking cessation advice and support to patients with mental illness and substance use disorders. These present a potential barrier to the successful implementation of smoking cessation interventions in mental health/substance abuse services, and highlight the continued need for dedicated education and training amongst this group of health professionals.L.S. has received a research grant and honoraria for a talk and travel expenses from a Pfizer, manufacturer of smoking cessation medications.Table S1. Full search strategy and records identified.Supporting info itemClick here for additional data file.


Genetic testing has multigenerational and familial repercussions. However, the “trickle‐down effect” of providing genetic counseling and testing to family members at risk after an initial identification of a pathogenic variant in a medically actionable gene has been poorly understood.eMERGEII  to have variants in genes associated with autosomal dominant adult‐onset disorders determined to be actionable by the American College of Medical Genetics (ACMG). Two of the three probands had variants that were classified as pathogenic and the third proband had a variant ultimately classified of uncertain significance, but of concern due to the proband's own phenotype. All probands had additional family members at risk for inheriting the variant. Two of the three probands had family members who received their medical care from the same health care system, Group Health Cooperative (GHC). It was recommended that the proband contact their family members at risk to be referred to genetic counseling for consideration of genetic testing.Three probands were identified during the pharmacogenetics research phase of GHC. To the best of our knowledge, siblings and more distant relatives at risk were not informed by the proband of their genetic risk.The two probands with pathogenic variants contacted some of their family members at risk. Individuals contacted included children and adult grandchildren, particularly if they received their medical care at eMERGE participants with identified variants, providing the probands with appropriate genetic counseling and care coordination, and recommendations for contacting family members at risk. Greater challenges were observed for coordinating genetics care for family members and extending the family network to include other relatives at risk.Establishing a family network is essential to disseminate knowledge of genetic risk. These three initial cases describe our experience of contacting  As more patients have genomic testing for clinical reasons or as part of research programs such as the electronic MEdical Records and GEnomics (eMERGE) Network, Clinical Sequencing and Exploratory Research (CSER), and Precision Medicine Initiative (PMI), more individuals will receive results from their genomic testing that are not related to their reason for enrollment. Many of the results will represent highly penetrant pathogenic variants, some of which are associated with phenotypes that are medically actionable. These will have medical implications for biological family members. We call these results additional findings, due to patient preference for that term over the terms incidental or secondary findings  Network offered a setting through which to examine the “trickle‐down effects” of genetic testing for extended family members. eMERGE is an NHGRI‐supported consortium of biorepositories combined with electronic health records (EHR) for conducting genomic studies that includes a special emphasis on related ethical, legal, and social issues . Two patients were recruited as part of a pharmacogenomics study through eMERGE. The participants specifically agreed to participate in a research study using sequencing to identify pharmacogenomics variants and to return of actionable information , c.1603G>A, resulting in a truncating mutation p.Arg535X. SCN5A is a sodium channel gene with variants associated with Brugada syndrome and other inherited cardiac conduction abnormalities. . Additional medical history was remarkable for hypercholesterolemia, obesity, and depression. Genetic testing showed that the proband's daughter shared the This daughter of the proband had adult children in their 20's both of who receive their health care at GHC including a daughter who has not pursued genetic counseling or testing and a son with a history of epilepsy and fainting spells. This 21‐year‐old male was diagnosed with ADHD at 6 years of age and began treatment with dextroamphetamine. He had his first seizure at 7 years of age and was subsequently placed on Dilantin. This patient described recurrent childhood episodes of blanking out or freezing, particularly following physical activity. He had a normal EKG and EEG as a child. The family decided to discontinue all medications at 8 years of age because of concern of side effects. The patient did well until 18 years of age when he was treated for depression with citalopram. Within a month of starting the medication, he fainted while taking a shower. No EEG or EKG was performed when he was evaluated in urgent care on the day of the event. Antidepressant medication was discontinued.SCN5A pathogenic variant. A subsequent EKG showed nonspecific interventricular conduction delay, but no evidence of Brugada syndrome. An echocardiogram showed mildly impaired left ventricular diastolic function, mild pulmonic valve insufficiency, and frequent premature ventricular contractions. A 24‐h Holter monitor showed sinus rhythm with isolated PVC's and without evidence of heart block. Annual follow‐up in cardiology is planned.The genetic testing of the proband's grandson was positive for the familial RYR1 gene (OMIM 180901)that was previously reported to be associated with malignant hyperthermia , c.1975G>A resulting in p.Val133Ile. Pathogenic variants in LDLR are associated with familial hyperlipidemia. Although this variant has been reported in associating with hypercholesterolemia, its allele Exome Aggregation Consortium (ExAC) frequency is 0.0008  to disclose additional findings of pathogenic variants identified in genomic sequencing in 56 actionable gene‐disease pairs in clinical care  at a rate comparable to informing her children (85% for children 14–18)  in other individuals ; U01HG006828 ; U01HG006830 ; U01HG006389 ; U01HG006382 (Geisinger Clinic); U01HG006379 (Mayo Clinic); U01HG006380 (Icahn School of Medicine at Mount Sinai); U01HG006388 (Northwestern University); U01HG006378 ; and U01HG006385 . Additional support came from the State of Washington Life Sciences Discovery fund award to the Northwest Institute of Genetic Medicine and the University of Washington Clinical Sequencing Exploratory Research Program (1U01HG006507 and 5U01HG007307).


Evidence has been accumulating that community health workers (CHWs) providing evidence–based interventions as part of community–based primary health care (CBPHC) can lead to reductions in maternal, neonatal and child mortality. However, investments to strengthen and scale–up CHW programs still remain modest.We used the Lives Saved Tool (LiST) to estimate the number of maternal, neonatal and child deaths and stillbirths that could be prevented if 73 countries effectively scaled up the population coverage of 30 evidence–based interventions that CHWs can deliver in these high–burden countries. We set population coverage targets at 50%, 70%, and 90% and summed the country–level results by region and by all 73 high–burden countries combined. We also estimated which specific interventions would save the most lives.LiST estimates that a total of 3.0 (sensitivity bounds 1.8–4.0), 4.9 (3.1–6.3) and 6.9 (3.7–8.7) million deaths would be prevented between 2016 and 2020 if CBPHC is gradually scaled up during this period and if coverage of key interventions reaches 50%, 70%, and 90% respectively. There would be 14%, 23%, and 32% fewer deaths in the final year compared to a scenario assuming no intervention coverage scale up. The Africa Region would receive the most benefit by far: 58% of the lives saved at 90% coverage would be in this region. The interventions contributing the greatest impact are nutritional interventions during pregnancy, treatment of malaria with artemisinin compounds, oral rehydration solution for childhood diarrhea, hand washing with soap, and oral antibiotics for pneumonia.Scaling up CHW programming to increase population–level coverage of life–saving interventions represents a very promising strategy to achieve universal health coverage and end preventable maternal and child deaths by 2030. Numerous practical challenges must be overcome, but there is no better alternative at present. Expanding the coverage of key interventions for maternal nutrition and treatment of childhood illnesses, in particular, may produce the greatest gains. Recognizing the millions of lives of mothers and their young offspring that could be achieved by expanding coverage of evidence–based interventions provided by CHWs and strengthening the CBPHC systems that support them underscores the pressing need for commitment from governments and donors over the next 15 years to prioritize funding, so that robust CHW platforms can be refined, strengthened, and expanded. The launch of the new Sustainable Development Goals (SDGs) in 2015 [Devising better approaches to expand coverage of key evidence–based interventions is clearly needed considering that each year 5.9 million deaths still occur among under–5 children , 289 000Over the past two decades, evidence has been steadily accumulating that community health workers (CHWs) can play an essential role to deliver many evidence–based interventions for improving maternal, neonatal, and child health (MNCH) ,8. CHWs In this paper, we estimate the impact of MNCH outcomes, if CHWs were able to expand the population coverage of evidence–based interventions across the continuum of care through community–based programming. Our analysis estimates the numbers of deaths that could be prevented in 73 Countdown countries if coverage of these life–saving MNCH interventions were expanded by CHW cadres as a result of robust capacity building and enhanced training to complement services provided at facilities.Disease Control Priorities Volume 2 [We identified evidence–based interventions included in the community platform  as defined for the Volume 2 . The comVolume 2 ,13. As sWe used the Lives Saved Tool (LiST), a data–driven modeling platform, to estimate the number of lives that could be saved by reducing the risk of death through the expansion of CHW–led population coverage of specific evidence–based health interventions .Details about the LiST methodology have been described elsewhere . BrieflyLiST was applied at the country level to calculate the number of deaths that would be averted in Countdown countries if coverage of each CHW–provided intervention was expanded to reach at least 50%, 70% or 90% in the target population. Mexico and China were excluded from the analysis due to limited data about intervention coverage and a low under–five mortality rate (<15 deaths per 1000 live births). The final sample included the remaining 73 Countdown countries. Version 5.43 beta19 of LiST was used for all analyses.Each country was analyzed separately to examine three scenarios of scale up  for the subset of MNCH interventions in the community platform. The counterfactual was a baseline model for each country which assumed no change in health intervention coverage between 2015 and the end year of 2020. Projected changes in fertility, HIV/AIDS, and demography were available based upon the Spectrum defaults for secular trends. A pattern of linear increase was modeled to reach designated targets by the end year of 2020. If coverage of an intervention was already reported to be equivalent or above the designated coverage target, coverage was maintained at its current level. The difference between the estimated number of deaths that would occur when coverage is expanded to one of the three coverage targets compared to baseline (with no change in coverage) represents the mortality impact  attributable to MNCH coverage expansion.Online Supplementary Document(Online Supplementary Document)), and results were combined to quantify regional and global impact. The mortality impact was estimated cumulatively (for the period from 2016–2020) and for the target year (2020). Mortality rates were projected by country, and mortality risk for each sub–group was calculated by applying weights for 2015–2020 according to the number of births projected by the UN Population Division for this time period.Mortality reduction was examined for mothers, stillbirths, neonates, and children (1–59 months) for 73 countries (see ) could expand to reach 50% in 2020 , an estimated total of 3.0 (sensitivity bounds 1.8–4.0) million lives would be saved during the five–year period from 2016 to 2020. If coverage reached 70% and 90%, the cumulative number of lives saved during this time period would increase to 4.9 (3.1–6.3) and 6.9 (3.7–8.7) million, respectively. Neonates and children 1–59 months of age would be the greatest beneficiaries of increased delivery of interventions at the community level. At the lowest threshold of 50% coverage, one–quarter  of the total impact would be among neonates and half  would be among children aged 1–59 months. A reduction in the number of stillbirths accounts for one–quarter of the impact  and the number of maternal lives saved remains relatively small . The distribution of relative impact across these MNCH categories was similar for the three levels of coverage expansion which were modeled.If population–level coverage of CHW–provided maternal, neonatal and child health interventions  if near–universal coverage (90%) were achieved (Online Supplementary Document(Online Supplementary Document) contains the total numbers of lives saved among mothers, stillbirths, neonates, and children aged 1–59 months by target coverage level.The under–five mortality rate (U5MR) in 2020 would drop 15%, 25%, or 35% if coverage in these Countdown countries were increased to 50%, 70%, or 90% respectively. With scale–up to near–universal coverage (90%), the U5MR is projected to decline to 38 deaths per 1000 live births in 2020 compared to 59 deaths per 1000 live births in 2015 for this weighted sample of 73 countries  for diarrhea, and multiple micronutrient supplementation during pregnancy  of the projected 8.2 million deaths in 2020, including fetal, maternal, neonatal, and child (aged 1–59 months) deaths, would be prevented if near–universal (90%) coverage of key interventions is achieved. With more modest improvements in coverage, the achievements would be notable as well: 23% of deaths would be saved at 70% coverage, and 14% would be saved at 50% coverage.Evidence of the effectiveness of community–based approaches to improve the health of mothers, newborns, and children in geographically–defined populations is abundant ,18. MostDespite the established benefit of known lifesaving interventions, coverage of essential interventions remains surprisingly low in many settings. In Nigeria, with a population of 31 million children younger than 5 years of age, for example, the population coverage of two highly effective interventions remains abysmally low: only 34% of under–5 children with diarrhea are treated with ORS and only 17% of children younger than 6 months of age are exclusively breastfed . SimilarRelying exclusively on facility–based platforms  to end preventable child and maternal deaths and to achieve universal coverage of basic and essential services remains a challenge for several reasons. The utilization of facility–based services decreases exponentially as the household’s distance from the location increases, especially if the facility is greater than 3 km or more than 30 minutes away . In manyExisting evidence suggests that using CHWs to deliver essential health services can be a cost–effective approach for health programs in LMICs . AlthougHowever, in our view, the human resources are available in communities to expand the coverage of community–based MNCH interventions. Experience teaches that people with limited education can learn the skills needed to provide these interventions, and there are adequate numbers of people who are eager and willing to serve their community for the purpose of saving lives. The needed trainers and supervisors can be acquired if the financial investment is adequate.The organizational challenges of scaling up community–based delivery systems globally in order to reach all households on a regular basis will require innovation and commitment. Identifying the population most at risk and vulnerable subgroup(s) is essential for addressing equity and closing the coverage gap with CHW–led initiatives. Countries such as Brazil, Bangladesh, Ethiopia, Nepal and Rwanda have made major strides to adapt and develop community–based delivery systems with CHW programs, and they have all made major progress in reducing maternal and child mortality . GuidancThe strengths of our approach include the use of a validated model that has been used for multi–country assessments ,34 and dOur mortality impact estimates may be somewhat optimistic if effectiveness of certain interventions in LiST is derived from efficacy studies in which interventions are delivered under relatively ideal conditions. On the other hand, our estimates may be considered conservative because we did not estimate or account for the possible benefits of scaling up other community–based interventions, including oral misoprostol for prevention of post–partum hemorrhage, promotion of care seeking for antenatal and delivery care at facilities (highlighted in a recent review ), promotOverall, our findings do nonetheless point to the strong benefits of giving priority to strengthening and expanding community–based delivery systems so that the rate of increase in population coverage of evidence–based interventions for mothers, newborns, and children can begin to accelerate. The highest–impact interventions highlighted by our analysis may be used as a starting point to guide prioritization of community–based programming. Recent experience highlights the need to rigorously plan, evaluate, and refine community–based approaches .CHWs can act as not only agents of change who directly provide health care services but also as liaisons who facilitate proper referrals and timely transfer if complications arise to foster an “integrated continuum of care” . There iThe findings of our study complement those of another recent global MNCH analysis which compared the number of deaths that could be averted by three service delivery platforms: the community platform, the primary health center platform, and the hospital platform . AccordiStrengthening community–based delivery strategies can provide additional benefits beyond reducing the number of stillbirths and maternal, neonatal and child deaths. Community–based approaches are becoming increasingly important in the prevention, identification, and treatment of HIV infection (and ending the HIV epidemic), tuberculosis, and non–communicable diseases such as hypertension, diabetes, and mental illness as well as medical care of the elderly ,47,48. FFor decades, CHWs have been seen by many as a second–class temporary solution for second–class citizens and therefore not viewed as viable long–term members of the national health workforce, especially once countries pass through the epidemiological transition and maternal and child health are no longer epidemiological priorities. However, with not only the growing evidence of the effectiveness of CHWs for improving maternal and child health services but also the increasing recognition of the CHW potential for addressing the growing burden of chronic, non–communicable diseases in developing countries , as wellThe full potential of community–based approaches to improve population health through CHWs is only beginning to be appreciated by the global health community. Better utilization of existing CHWs, establishing new CHW programs where none are now present, expanding the CHW workforce, creating attractive long–term career development opportunities for CHWs, and strengthening the overall quality of CHW programs will all be required to achieve the full potential of community–based programming for mortality reduction. The three specific interventions that could save the most lives by expanding coverage to 90% are balanced energy and protein supplementation for pregnant women, antibiotic treatment of childhood malaria, and childhood treatment of pneumonia. These are high–impact interventions partly because the current levels of coverage are so low .If near–universal (90%) coverage of evidence–based interventions for mothers and children were achieved in 73 Countdown countries, 6.9 million lives would be saved during the period from 2016 to 2020, and the overall number of death would be reduced by 41% compared to baseline levels. The full cost of achieving this goal would be far less than the cost of reaching this level of coverage through expansion of facility–based care provided by higher–level providers.


In order for a neurone to become a functional component of the network it needs to know its abilities and limitations. These two main features of any neurone are determined by the set point of the excitability, which regulates its operational range. This in turn is determined by sodium, calcium  before eventually the auditory cortex is reached. The rat auditory pathway has to undergo several plasticity steps to continuously adapt to changes in environment, but it also experiences a great amount of developmental plasticity, in particular during the time period of hearing onset at around the end of postnatal week 2. A fundamental goal for developmental neuroscience is to understand how neurones assemble into the network to carry out their specific functions. Some progress has been made in understanding the general neuronal functions, but much less is known about other central features of developing neural circuits.et al.  within the cochlea?’ These cells are important and essential relays to auditory neurones that transmit sound information to the central nervous system. The authors employed electrophysiological methods and pharmacology to characterise synaptic activities of IHC before maturation, i.e. hearing onset. IHCs release the excitatory neurotransmitter glutamate, which activates ionotropic glutamate receptors (iGluRs) on the afferent dendrites of neurones within the spiral ganglion. Importantly, this released glutamate can also activate G‐protein‐coupled metabotropic glutamate receptors (mGluRs), in general expressed either post‐ or presynaptically. The activation of presynaptic mGluRs has been shown to act as a feedback loop and is involved in neuronal plasticity and development  of efferent terminals that contact IHCs. This study uses pharmacology to enhance mGluR activity and shows increases in efferent inhibition by potentiating ACh release. The authors went further to show that endogenous release of glutamate also involves the same pathway in a process called glutamate spill‐over, which can activate not only synaptic but also extrasynaptic receptors. The spill‐over, which is usually limited by glutamate uptake systems, is enhanced following high frequency firing activity (up to 10 Hz) such as seen in immature IHCs  or inhibition of K+ currents that repolarise the membrane potential (such as large conductance Ca2+‐activated BK channels). This Ca2+ and K+ channel‐dependent modulation of release is present at the developing cochlea and might be responsible for the observations made by Ye et al. Other molecular pathways that have not been addressed in this study involve the modulatory activities of nitric oxide  are present presynaptically in the cochlea nucleus and their activation has been shown to inhibit Ca2+ influx through L‐type Ca2+ channels and thereby reduce release. Moreover, given the high firing activities of IHCs before reaching maturity and their high‐Ca2+‐triggered nNOS activity (Shen et al. + channels could potentially contribute to a developmental adjustment of excitability.But what are the underlying mechanisms for such signalling? The mGluR‐mediated enhanced inhibition could arise from activation of Caet al. strongly supports the notion that activation of mGluRs present presynaptically at efferent terminals at the IHC synapse contributes to a physiological signalling during the development of this neuronal connection before hearing onset and synapse maturation. Thus, the high spike rates reported for the IHCs allow for a glutamate spill‐over and activated mGluR signalling, which represents an essential and new signalling pathway in the developing auditory system. This pathway provides a negative feedback control of IHC excitability by locally strengthening synaptic inhibition.Regardless of the mechanisms, the study by Ye None declared.