Rapid environmental change may require fur seals and sea lions to make longer or deeperdives to find resources. A systematic review of diving behaviour and physiology revealedthat a foraging strategy (epipelagic vs mesopelagic or benthic) was more important inpredicting dive behaviour than morphology . et al.  and Arnould and Costa  onbehavioural (dive duration and depth) and physiological  parameters. We estimated calculated aerobic dive limit(cADL—estimated duration of aerobic dives) for species and used simulations to predict theproportion of dives that exceeded the cADL. We tested whether body morphology or foragingstrategy was the primary predictor of these behavioural and physiological characteristics.We found that the foraging strategy compared to morphology was a better predictor of mostparameters, including whether a species was more likely to exceed their cADL during a diveand the ratio of dive time to cADL. This suggests that benthic and mesopelagic divers aremore likely to be foraging at their physiological capacity. For species operating neartheir physiological capacity (regularly exceeding their cADL), the ability to switchstrategies is limited as the cost of foraging deeper and longer is disproportionally high,unless it is accompanied by physiological adaptations. It is proposed that some otariidsmay not have the ability to switch foraging strategies and so be unable adapt to achanging oceanic ecosystem.Physiology places constraints on an animal’s ability to forage and those unable to adaptto changing conditions may face increased challenges to reproduce and survive. As theglobal marine environment continues to change, small, air-breathing, endothermic marinepredators such as otariids  and particularly females, who areconstrained by central place foraging during breeding, may experience increaseddifficulties in successfully obtaining adequate food resources. We explored whetherphysiological limits of female otariids may be innately related to body morphology  and/or dictate foraging strategies (epipelagic vs mesopelagic orbenthic). We conducted a systematic review of the increased body of literature since theoriginal reviews of Costa  Globally, loss of species in marine environments has been slower than in terrestrialsystems, but it now appears to be accelerating rapidly (Eumetopias jubata)], and central placeforagers while rearing offspring, and under suboptimal conditions must increase bothindividual dive duration and trip length  (Phoca sibirica)  (Aptenodytes forsteri) (2 stores for the different species (The aerobic dive limit (ADL) is a measure of the duration of a dive during which an animaluses only aerobic metabolism , 2019. S species , which m species .0.75while oxygen stores scale with body mass1.0. This means that simply due toallometry, larger animals will have a lower mass-specific metabolism for a relativelyconstant proportion of oxygen storage capacity (1.25)  . Furtherperse. They reported that benthic and mesopelagic divers were far more likely toexceed their cADL, spend more time at sea diving and have greater dive durations  consists of nine extant species offur seal  with one subspecies and six species of sea lion (Otariinae), we diffArctocephalus philippii townsendi), South American fur seals, Cape fur seals  or New Zealand fur seals  tocalculate cADL.Values of cADL are only reported for those species where either it had been previouslycalculated and published or only one required parameter was missing (either TBOS or DMR—seebelow). This enabled us to report or estimate the cADL for females of six fur seal and sixsea lion species. We focussed on females as these were most likely to be physiologicallyconstrained due to their smaller size and the impact that changes in foraging efficiencyhave on nursing offspring. There was insufficient information to include Guadalupe fur seals(2 kg−1) by the DMR (mL O2kg−1 min−1) of the animal  were used for analyses and reported cADL values are captured in the tablesbut not .Arctocephalusgalapagoensis) and South American fur seal  so the estimate for Antarctic fur seal  was . All estimates were adjusted for mass and are detailed in TBOS are the combined oxygen stores in the lung , blood  and muscle  . Valuesestimated via respirometry are generally regarded as the ‘gold-standard’ of energyexpenditure measurements and take into account only the energy expended during the dive, Subantarctic fur seals ] and, for these, DMR was calculated from an estimate from a similarspecies , the number of seals it was calculated for and the standarddeviation for each value were extracted for each species where it was available. TASD wasnot always recorded, but a diving rate (dives per hour) was available. We the following toestimate TASD from other dive parameters: Species were categorized as benthic and mesopelagic or epipelagic divers based on theirprimary mode of foraging . Speciesy = average number of dives on a single foraging trip, df = number ofseals − 1, then we simulated the dive distribution of a given species using the functionrnegbin from the MASS package with 20 000 simulations, with the estimatedtheta and the specified limits of lower = 0 and upper = max dive time. We ran the simulationfor the estimated number of foraging trips conducted on average each year for each speciesdive behaviour group. Average number of foraging trips was estimated from average durationspent at sea (days) and average colony duration (days). For example, the average number ofdives that exceed the cADL for the Australian fur seal is estimated by first calculatingtheta using an average dive time of 2.9 min for an average of 849 dives per foraging tripfrom 13 seals. Theta is then to simulate the dive distribution for a given foraging tripwith a maximum dive duration of 6.7 min, where the number of dives exceeding the cADL of2.5 min. The simulation is repeated 59 times, the average number of foraging trips conductedper year. The final value is the mean value of proportion of dives that exceed the cADL ofthe simulated foraging trips.A key goal of the study was to estimate how often animals dived beyond their cADL. Thiscannot be determined from point estimates of dive duration (e.g. mean or maximum), so wesimulated a series of dive durations for the 13 species—6 fur seals and 7 sea lions—withcomplete dive parameters available from the literature. Simulated distributions were createdwith the mean and max dive duration and the number of seals from which the parameters werederived. We simulated diving durations using negative binomial distributions using the MASSpackage in R  were tested and met. Thesummarized data for each species were rather than individual values as the data forindividuals were rarely available, and it has been shown that the conclusions and effectsizes made from summary data are very similar to those made with individual data  were to Pearson’s correlation tests were to examine the relationship between all the responsevariables . Dive performance is measured as the ratio of mean dive durationto cADL .Values to calculate the following results are in .22 min) . Some va.22 min)  where ep2 min kg0.75 vs 2 min kg0.75) and by foraging strategy with epipelagic divershaving larger TBOS (2 min kg0.75 vs 2 min kg0.75). No variation could be explained by the interactionbetween the two (2 min−1 kg−1 vs benthic and mesopelagic2 min−1 kg−1).TBOS varied both by morphology group ,with se the two 5. A smal the two , where eBoth foraging strategy, morphology and their interaction accounted for variation in divedepth and duration . Morpholstrategy . The ratstrategy  where beP > 0.05 for both tests). There was no significantcorrelation between TBOS and dive depth or duration (P > 0.05). Apositive correlation was found between dive performance (the ratio of dive duration to cADL)and dive depth , where benthic and mesopelagic divers were more likely toexceed their cADL  and behavioural  information of females from every extant otariid, we have shown that foraging mode(benthic and mesopelagic or epipelagic), rather than morphology , ismore indicative of which species operate at or near their physiological maximum. Crucially,we reviewed abilities for females that are not only more likely to be physiologicallyconstrained, but are the limiting sex, directly influencing the size of populations. Wefound that female otariids that dive using a benthic or mesopelagic strategy forage deeperand longer and exceed their cADL 1.4 times as frequently as do epipelagic divers, regardlessof whether they were a fur seal or sea lion. This may make the former more vulnerable toenvironmental changes that cause prey to move deeper or further offshore as theirphysiological scope for adaptation to diving deeper and longer is limited (and switchingforaging strategies from benthic to epipelagic would not help them find prey). In contrast,as epipelagic divers generally do not currently exceed their cADL, they may have more scopeto switch to a benthic foraging strategy; although if they do, the likelihood of exceedingtheir cADL substantially increases  for identifying species operating near their physiological maximum and accordswith earlier theorizing . We founThe otariids that are currently operating closest to their physiological maximum arebenthic and mesopelagic diving sea lions—the Australian sea lion, the New Zealand sea lion and the All other sea lion species demonstrate mixed strategies . Sea lioThe species least likely to be operating near their physiological maximum are theepipelagic diving fur seals. This includes the Antarctic, subantarctic, Galapagos,Guadalupe, Juan Fernandez and New Zealand fur seals. They are least likely to exceed theircADL (17–31% of dives, Grouping otariids by species and foraging strategy does limit how far we can drawconclusions from our data. For each combination of species and foraging strategy, a singledata point representing their dive and physiological parameters must be selected to berepresentative, even though these may have been measured several times. We are also limitedby the behavioural and physiological variables that we have included. Other behaviouralvariables such as time spent at sea, or physiological variables such as body fat orthermoneutral zones, may be important for developing a deeper understanding of thedifferences in species or foraging strategies. In addition, we did not explore the impactsof environmental variables such as oceanography  or prey An inability by some populations to display plasticity results in other responses to foodshortages such as increasing the duration of foraging trips, (This study supports the theorizing of This work was supported by a Macquarie University Research Excellence Support grant awardedto M. Ladds.


New gridded climate datasets (GCDs) on spatially resolved modeled weather data have recently been released to explore the impacts of climate change. GCDs have been suggested as potential alternatives to weather station data in epidemiological assessments on health impacts of temperature and climate change. These can be particularly useful for assessment in regions that have remained understudied due to limited or low quality weather station data. However to date, no study has critically evaluated the application of GCDs of variable spatial resolution in temperature‐mortality assessments across regions of different orography, climate, and size. Here we explored the performance of population‐weighted daily mean temperature data from the global ERA5 reanalysis dataset in the 10 regions in the United Kingdom and the 26 cantons in Switzerland, combined with two local high‐resolution GCDs  and compared these to weather station data and unweighted homologous series. We applied quasi‐Poisson time series regression with distributed lag nonlinear models to obtain the GCD‐ and region‐specific temperature‐mortality associations and calculated the corresponding cold‐ and heat‐related excess mortality. Although the five exposure datasets yielded different average area‐level temperature estimates, these deviations did not result in substantial variations in the temperature‐mortality association or impacts. Moreover, local population‐weighted GCDs showed better overall performance, suggesting that they could be excellent alternatives to help advance knowledge on climate change impacts in remote regions with large climate and population distribution variability, which has remained largely unexplored in present literature due to the lack of reliable exposure data. New products on spatially resolved weather datasets have become available but little is known on their suitability in health studiesHere, different exposure datasets yielded similar patterns in temperature‐mortality impacts across heterogeneous areasGlobally available modeled weather data could help advance knowledge on health impacts in areas with limited weather station data We compared the GCDs across the 10 regions in England and Wales and the 26 cantons  in Switzerland, representing areas with different geomorphological characteristics, temperature range, and population distribution.22.1The assessment was performed across the 26 cantons of Switzerland  and the 10 regions in England and Wales, which is the highest tier of subnational division in the United Kingdom. We considered these two sets of regions because of their heterogeneity in terms of size, geographical distribution of the population, orographic characteristics, and climate. This would allow us to evaluate patterns in temperature‐mortality associations and impacts across temperature datasets, which could potentially depend on the characteristics of the region.Switzerland is considered a country with a particularly sparse population density and with an unequal population distribution mostly dominated by its irregular orography Figure . The majEngland and Wales have a more homogenous orography and population distribution compared to Switzerland since most regions are a mix between urban and rural areas Figure . Althoug2.2http://www.ag-myresearch.com/2015_gasparrini_lancet.html. It was originally obtained from the Office for National Statistics and has been described elsewhere  weather station data, often used as the gold standard in environmental epidemiology, (2) local high‐resolution GCDs, and (3) global GCD with coarser resolution. As explained below, we used country‐specific local GCDs and a unique global GCD for both sets of regions. For each GCD and region, we derived population‐weighted and unweighted mean daily temperatures through geographic information system techniques   and modeled forecasts to estimate temperatures on an hourly basis (Copernicus Climate Change Service Climate Data Storage (CDS), 2.4We extracted hourly  or daily  mean temperatures for each grid cell for the corresponding period covering a specific region/canton. For the former, we aggregated hourly temperature observations and created daily mean temperature averages for all grid cells throughout the regions and cantons. As mentioned before, we created two pairs of population‐weighted and unweighted temperature series for each GCD and region. For the unweighted series , we estimated the average values across the cell‐specific daily mean temperatures of those grid cells intersecting the boundaries of the corresponding region. Additionally, we created a single population‐weighted daily mean temperature for each region and GCD using EOSDIS gridded population data in 2010 on a 1 km horizontal grid resolution   and very hot days (≥90th percentile), which have been attached to the supplementary file.Additionally, for each GCD and region we quantified the heat‐ and cold‐related impacts in terms of excess number of deaths and mortality fractions (%) .33.1red dots), along with the temperature distribution of each exposure dataset for a set of regions for Switzerland and in England and Wales, respectively. Tables We included 7,573,716 deaths in England and Wales between 1993 and 2006, and 1,822,622 deaths between 1989 and 2017 in Switzerland Table . Figures3.2Figure When comparing across population‐weighted series, the weather stations and local and global GCD yielded very similar ERCs. For example, the different exposure datasets provided almost identical ERCs in Zürich and Northeast England, with only slight deviations in the latter in coldest temperature ranges. Conversely, in Greater London and Ticino, we observe slight deviations in the ERCs due to differences in the absolute temperature distribution  and heat (days with mean temperature ≥75th percentile) for all regions in England and Wales and Switzerland. Consistent with the patterns observed across ERCs, local and global population‐weighted GCD series yielded very similar excess mortality estimates to the weather stations across all regions (Tables Table s Tables . For colth percentile of the temperature distribution) and extreme heat days (days ≥90th percentile of the temperature distribution)  Tables .Lastly, we aimed to explore area‐level variables  which might be associated with difference in risk estimates  obtained from the GCD temperature series, versus the ones from weather stations. For both heat‐ and cold‐related mortality, all GCDs show random variation for the estimated measures of mortality impact (excess fractions) and association when plotting against explanatory variables Figures .4Our findings suggest that temperature data from local and global GCDs can be a promising alternative to the usual weather station data for the assessment of health impacts associated with nonoptimal temperatures in ecological studies. Although the five exposure datasets yielded different average area‐level temperature estimates, these deviations did not result in substantial variations in the temperature‐mortality association or impacts, as the RR is defined on a relative scale (i.e. over the corresponding temperature distribution). More specifically, we observed that population‐weighted average levels derived from high resolution GCDs could provide a better approximation of the true exposure of the population compared to unweighted GCDs, especially in densely populated urban areas with large intracity temperature variability.Overall, local high‐resolution population‐weighted GCDs yielded very similar risk and excess mortality estimates compared to the weather station series. Additionally, models using the former provided better predictability, suggesting that the high‐resolution population‐weighted GCDs could be a more suitable alternative to weather station data in epidemiological analyses. Furthermore, global population‐weighted GCDs showed similar risk estimates as the local GCD and weather stations. To date, weather station data have been treated as the gold standard in the assessment of temperature‐related health effects. Since these are usually placed near populated areas, they are supposed to closely follow the true average temperature exposure of the study population in ecological studies  and highly heterogeneous distribution of the population as well as densely populated areas with large intracity temperature variability , which we observed for Greater London. Specifically, our results on model behavior  show that population‐weighted GCDs tend to more accurately predict the temperature‐mortality association and impacts compared to the unweighted temperature series. Temperature distributions of the population‐weighted series for both GCDs consistently shifted toward warmer temperatures, as opposed to the unweighted counterparts, because these are expected to better capture population exposure, usually residing in the warmer valleys. If no weighting is applied, area‐level temperature estimates in large regions will be partly influenced by measurements from cells covering vast mountainous surfaces characterized by colder climates but less populated. This shift was less evident in the global GCD due to the coarser resolution, as these were not able to sufficiently capture the large spatial variability in population density, which is particularly evident for Greater London  which can be attributed to the instability of the boundaries of the curves due to the low statistical power . Likewise, this deviation in temperature distributions did not substantially affect the quantification of excess mortality, as we usually use specific temperature percentiles for defining heat and cold contributions. Moreover, given that most temperature‐related deaths could be attributed to moderate ranges  or very cold days (days below the 10th percentile), the pattern of mortality fractions did not change compared the definition used in this study . Notably, the shape of the ERC was similar across temperature series but shifted toward warmer temperatures when using population‐weighted counterparts or weather station. Large deviations were only visible at the very extreme ranges (below 1y Tables . Larger y Tables . As menty Tables . When poThus far, the sparse spatial coverage of observation networks throughout the world has often impeded the assessment of the temperature‐mortality association in developing countries and consequently, most temperature‐related studies have been conducted in urban settings and developed countries alone (Gasparrini et al., Some limitations should be acknowledged. First, although GCDs provide a promising alternative to weather stations, particularly in areas with a sparse monitor network, we should be cautious with interpreting results from rural areas. Since reanalysis datasets are still model‐based data, therefore, in areas where we have less data coverage we would still expect more bias in the GCD estimated temperature compared to more densely monitored regions. Furthermore, we did not control for potential confounders such as air pollution concentrations, relative humidity, and influenza epidemics when estimating the temperature‐mortality impact. However, the role air pollution and humidity play as a confounding variable is still debated and studies found that controlling for these variables would only have a minimal to no effect on the overall temperature mortality estimates (Armstrong et al., 5Although the five exposure datasets yielded different average area‐level temperature estimates, these deviations did not result in substantial variations in the temperature‐mortality association or impacts as the temperature‐mortality association and impacts are defined at a relative scale. Additionally, our findings suggest that population‐weighted high resolution GCD could be a promising alternative to weather station data and could be particularly useful in assessments in areas with large variation in climate and population distribution. More importantly, this study has shown that global GCDs could help advance knowledge on health‐related climate change impacts in remote regions which have remained largely unexplored in present literature due to the lack of reliable exposure data.The authors declare no conflicts of interest relevant to this study.Supporting Information S1Click here for additional data file.


Dear Editor,The ubiquitin and ubiquitin‐like protein modifications contribute to functional changes of substrate proteins and thus regulate a range of biological processes including cancer.To further explore the SCNA patterns of UFMylation genes, we calculated the high‐level alteration of SCNAs and found that 11.08% of TCGA samples have high‐level copy number alterations in at least one of the eight genes. Noteworthy, the high‐level amplifications and deletions of UFMylation genes appeared to be occurred in a pattern of mutually exclusive Figure , suggestAlthough most UFMylation genes generally have low mutation frequencies in cancers, we found that UFSP2 is frequently mutated in colon adenocarcinoma and uterine corpus endometrial carcinoma. The high recurrent copy number loss and frequent somatic mutations of UFSP2 suggest that UFSP2 may function as a tumour suppressor. It has been previously demonstrated that knockdown UFSP2 promoted breast cancer cell growth and tumour formation, suggesting that UFSP2 is a tumour suppressor in breast cancer.In summary, we found that UFMylation family genes have a high frequency of SCNAs. Especially, UFSP2 is recurrently and focally deletion in a total of 14 human common cancers with the highest alteration score. We further demonstrated that depleted UFSP2 expression significantly promotes the growth of tumour cells both in vitro and in vivo, suggesting that UFSP2 may function as a tumour suppressor in colon cancers. Our integrated genomic analysis and functional studies provide insights in understanding this new post‐translational modifier in cancer and potential therapeutic opportunities.Supporting informationClick here for additional data file.


Nonalcoholic fatty liver disease (NAFLD) is a growing health problem, and a major challenge in NAFLD management is identifying which patients are at risk of progression to more serious disease. Simple measurements of liver fat content are not strong predictors of clinical outcome, but biomarkers related to fatty acid composition  may be more effective. MR spectroscopic imaging (MRSI) methods allow spatially resolved, whole‐liver measurements of chemical composition but are traditionally limited by slow acquisition times. In this work we present an accelerated MRSI acquisition based on spin echo single point imaging (SE‐SPI), which, using appropriate sampling and compressed sensing reconstruction, allows free‐breathing acquisition in a mouse model of fatty liver disease. After validating the technique's performance in oil/water phantoms, we imaged mice that had received a normal diet or a methionine and choline deficient (MCD) diet, some of which also received supplemental injections of iron to mimic hepatic iron overload. SE‐SPI was more resistant to the line‐broadening effects of iron than single‐voxel spectroscopy measurements, and was consistently able to measure the amplitudes of low‐intensity spectral peaks that are important to characterizing fatty acid composition. In particular, in the mice receiving the MCD diet, SE‐SPI showed a significant decrease in a metric associated with unsaturated fat, which is consistent with the literature. This or other related metrics may therefore offer more a specific biomarker of liver health than fat content alone. This preclinical study is an important precursor to clinical testing of the proposed method.MR‐based quantification of fatty acid composition may allow for improved characterization of non‐alcoholic fatty liver disease. A spectroscopic imaging method with appropriate sampling strategy allows whole‐liver mapping of fat composition metrics in a free‐breathing mouse model. Changes in metrics like the surrogate unsaturation index (UIs) are visible in mice receiving a diet which induces fat accumulation in the liver, as compared to a normal diet; such metrics may prove useful in future clinical studies of liver disease. MR‐based quantification of fatty acid composition may allow for improved characterization of non‐alcoholic fatty liver disease. A spectroscopic imaging method with appropriate sampling strategy allows whole‐liver mapping of fat composition metrics in a free‐breathing mouse model. Changes in metrics like the surrogate unsaturation index (UIs) are visible in mice receiving a diet which induces fat accumulation in the liver, as compared withto a normal diet; such metrics may prove useful in future clinical studies of liver disease. BWbandwidthCIRCUSCIRcular Cartesian UnderSamplingCScompressed sensingFOVfield of viewHSVDHankel singular value decompositionMCDmethionine and choline deficientMRSImagnetic resonance spectroscopic imagingNAFLDnonalcoholic fatty liver diseaseNASHnonalcoholic steatohepatitisPDFFproton density fat fractionPRESSpoint resolved spectroscopyPUIpolyunsaturation indexROIregion of interestSE‐SPIspin echo single point imagingSPIOsuperparamagnetic iron oxideSVSsingle‐voxel spectroscopyTEecho timeTRrepetition timeUIunsaturation indexUIssurrogate unsaturation index1Nonalcoholic fatty liver disease (NAFLD) is on the rise globally; according to several estimates, 25%‐40% of the populations in developed countries have NAFLD to some extent The clinical gold standard for detection of liver disease and characterization of its severity is biopsy, but this carries risks due to its invasive nature, and is therefore not ideal for evaluating low‐risk patients or for following the progression of disease over time One common approach, which is increasingly used in clinical settings, is to measure the proton density fat fraction (PDFF) using a chemical shift‐encoded imaging sequence There is evidence that the composition of liver fat, ie, the proportions of saturated and unsaturated fatty acids, may indicate patients at risk of disease progression MR spectroscopy offers opportunities to examine not only the concentration of fat in liver tissue, but also the relative fraction of different lipid types, by measurement of the various peaks in the fat spectrum Spectroscopic imaging approaches In this work we demonstrate the ability of spin echo single point imaging (SE‐SPI) 22.12* relaxation due to iron overload will broaden the spectral lines but will not produce blurring or other artifacts in the corresponding images Spectroscopic imaging approaches are distinguished from traditional imaging sequences by the lack of a readout gradient during data collection, allowing the complete signal evolution to be sampled at each location in the image. In the case of SE‐SPI, a 180‐degree refocusing pulse is applied to reverse signal decay due to magnetic field inhomogeneity, which is important in liver imaging due to the high iron concentrations that can accompany fatty liver disease Any sequence used for in vivo abdominal imaging must provide compensation for respiratory motion during the scan. In our SE‐SPI implementation, several navigator points are acquired at the start of each readout prior to phase encoding, and these are used to retrospectively remove samples corrupted by motion. A moving average of the navigator phase is computed, and any points that deviate by more than one standard deviation from that average are discarded. The pulse sequence is illustrated in Figure To ensure that the central regions of k‐space are fully sampled even after respiratory compensation, the center of k‐space is oversampled while the periphery is randomly undersampled using a pattern based on CIRCUS of the k‐space center, sorted by zenith and azimuthal angle. This formula has been empirically devised to yield a fairly constant number of points per shell on the periphery of k‐space such that those regions are not too highly undersampled, while also ensuring that the central region is fully sampled. Examples of sampling patterns are shown in Figure 2.2Analysis and reconstruction of spectra obtained with SE‐SPI, or with a point resolved spectroscopy (PRESS) acquisition for comparison, were performed in Matlab 2017b . Characterization of fat spectra used the Hankel singular value decomposition (HSVD) x is the relative amplitude of the peak at a chemical shift of approximately x ppm. These values represent the unsaturation index , a surrogate unsaturation index , which is useful when the 5.3 ppm methene peak is unreliable, and the polyunsaturation index  For a given spectrum, HSVD analysis permits computation of the fat fraction and the relative amplitudes of spectral peaks. Based on these values it is possible to compute various metrics related to the degree of saturation of the fatty acid chains; these metrics are candidates for a biomarker to distinguish benign from potentially progressive disease. While several such metrics have been defined in the literature 2.3x is expressed as a linear combination of R basis functions,Undersampled data were reconstructed with Blind‐CS The Casorati matrix of the entire M‐pixel dataset can then be expressed as the product of a matrix U containing all the coefficients (assumed sparse), and a dictionary V of basis functions of length N:b allows joint recovery of both U and V according to the optimizationThe supplied undersampled data 1‐norm sparsity constraint on the coefficient matrix U, the Frobenius norm of the dictionary V is constrained to assist in convergence In addition to the data consistency constraint and the λ‐regularized lIn the context of spectroscopic imaging, the basis functions are time‐domain representations of signal from one or more spectral peaks. Working in the time domain rather than the spectral domain yields basis functions that are less orthogonal and helps to promote sparsity in the coefficient matrix U. This approach also avoids biasing the result towards any particular spectral characteristics since the basis functions are learned for each dataset.To evaluate the impact of undersampling and CS reconstruction, a fully sampled 3D phantom dataset was retrospectively undersampled by a factor of 5.5 with the same CIRCUS sampling strategy used for in vivo mouse data. The results of HSVD‐based fat quantification and saturation indices for each oil sample after Blind‐CS reconstruction were compared with the fully sampled equivalent. The performance of Blind‐CS is controlled primarily by the number R of basis functions in the dictionary and the regularization parameter λ, which controls tradeoff between data consistency and sparsity of the coefficient matrix. For all of the reconstructions presented in this work, the values R = 35 and λ = 0.01 were used; these were empirically determined (data not shown) to minimize the root mean squared error between fully sampled data and data reconstructed with Blind‐CS after undersampling.2.4Imaging experiments were performed on a 3 T horizontal bore preclinical system  operated by a Varian/Agilent console, and using a 30 mm i.d. quadrature RF coil .1 values.A series of phantom experiments was performed to assess the accuracy and stability of quantification with SE‐SPI, as well as its robustness to undersampling and CS reconstruction. NMR tubes (10 mm) were filled with either pure food oils  or mixtures of soybean oil and water  produced by dilution of Intralipid . These oils have previously been used to characterize methods for quantifying fatty acid composition Tubes were scanned in groups of five using SE‐SPI, using a 64 x 64 matrix for 2D scans or 64 x 64 x 16 for 3D scans, 10 mm slice thickness, 30 x 30 mm field of view (FOV), TR/TE = 200/13 ms, BW = 3 kHz and 512 complex FID points. With full sampling, 2D scans took 13.5 minutes and 3D scans took 3.5 hours. For comparison, a 5 x 5 x 5 mm PRESS spectroscopy voxel was placed over each oil tube and data were acquired using matched TR, TE and BW, with 25 signal averages collected in an acquisition time of ~ 5 seconds. HSVD analysis was performed at each voxel in the SE‐SPI dataset, and for comparison with PRESS, results were averaged across the region matching the PRESS voxel.2.5To simulate fatty liver disease in an animal model, we supplied BALB/c mice  with a methionine and choline deficient (MCD) diet , which causes large amounts of fat to be sequestered in the liver 0C  using a warm air blower. Anatomical images were obtained using a bSSFP/TrueFISP sequence , and this was used to plan the placement of the PRESS spectroscopy voxel and the SE‐SPI imaging volume over the liver. 3D SE‐SPI data were acquired using the same parameters as for phantom imaging, with the scan time reduced to 55 minutes using the modified CIRCUS strategy. This represents a prospective undersampling factor of R = 4, which is further increased to ~ R = 5 after respiratory compensation.Mice receiving the MCD diet were scanned three times: the day before they were started on the MCD diet (day 0), then again after 4 and 11 days. Mice receiving the normal diet were scanned twice, 1 week apart (days 4 and 11). All mice were anesthetized with 3% isofluorane and each had their temperature maintained at 37While efforts were made to ensure that the PRESS and SE‐SPI imaging volumes overlapped  to provide an ex vivo measurement of fat concentration for comparison with the in vivo results. After computation of fat fraction and saturation indices from all three scans , values were compared between groups using a Welch test . A significance level of α = 0.05 was used, with a Bonferroni correction for multiple comparisons applied as appropriate; eg, with n = 6 comparisons for each scan, the 3Figure Figure Typical spectra from PRESS and SE‐SPI are shown in Figure Figure Figure In general, the quality of the PRESS data was generally not sufficient to reliably compute saturation indices for many of the mice  The breakdown of individual data for these indices is shown in Figures One significant difference was observed in the UIs values at the group level, which are summarized in Figure 4Proper characterization of NAFLD is essential to patient management, and the limitations to traditional biopsy‐based screening are increasingly being addressed by noninvasive biomarkers such as MRI‐based measurements of PDFF. While methods to measure PDFF have achieved significant clinical deployment, PDFF is not a strong predictor of eventual disease progression, despite its strong correlation with liver steatosis The MCD diet used in this mouse model may not fully reproduce the changes in fatty acid composition seen in NAFLD, since NAFLD involves different biological mechanisms that occur over significantly different timescales. Nonetheless, the ability of SE‐SPI to discern changes in saturation indices related to the MCD diet indicates that such techniques may be useful in determining whether similar changes are observed in patient populations.1 saturation caused by short repetition times, a limitation inherent to many practical fat quantification techniques. Differences between the T1 of water and fat mean that spectral peak areas are not a direct measure of fat concentration without appropriate compensation, and similarly, differences in T1 between individual peaks within the fat spectrum mean that relative amplitudes of those peaks are also dependent upon the TR of the sequence.It should be noted that the saturation indices used in this work are not identical with the actual chemical proportion of saturated fat in the liver, nor is the reported fat fraction necessarily identical to the volume fraction of fatty acids. This is due to T1 dependence of the saturation indices may be an asset; if further studies show particular peaks in the fat spectrum to be of interest in monitoring liver disease, then knowledge of the T1 of those peaks may inform a choice of scan parameters that maximizes their contribution to the overall signal.However, the ultimate application of this work is not absolute quantification of fat spectra, but reliable identification of spectral features that may be useful in studying particular disease models over time. Metrics such as the UIs, which reflect the relative importance of certain fat peaks, still have potential use as a diagnostic biomarker if they can be reproducibly measured, which should be possible with SE‐SPI at a fixed TR and field strength. Indeed, the T0 over the larger voxel. Even ex vivo PRESS  fails to capture all of the fat peaks in the normal diet group. Future experiments exploring the limits of quantification accuracy with SE‐SPI must strive to overcome these factors through optimized PRESS voxel size and placement, increased signal averaging or more advanced respiratory compensation strategies.Reliably identifying the spectral components needed for calculation of the saturation indices can be challenging, and due to insufficient signal or other artifacts, the HSVD analysis was not always able to discriminate all of the six desired spectral peaks in each supplied signal. When this occurs , the corresponding saturation indices are also set to zero, and are omitted from the analysis. Table In the present work, however, rather than using either PRESS measurement as a gold standard against which the saturation values obtained with SE‐SPI can be validated, we sought to determine whether SE‐SPI could reliably measure changes in saturation indices that are consistent with how this particular diet should impact fat composition. The literature generally indicates that the MCD diet should decrease the proportion of polyunsaturated fat. Although no significant change in UI or PUI was observed (reflecting the difficulty in resolving the 5.3 and 2.8 ppm peaks even with SE‐SPI), there was a decreasing trend in PUI  and UIs did show a significant decrease after 11 days, consistent with predictions from the literature. As indicated by Table In clinical applications, fat measurements made with traditional single‐voxel MR spectroscopy are more reliable than the preclinical data presented here; the use of larger voxels and multichannel RF arrays to boost SNR mean that the small peaks necessary to compute saturation metrics can be more easily resolved. More advanced motion compensation techniques are also available. Nonetheless, SVS remains limited by spatial coverage and can fall prey to some of the same drawbacks as biopsy in that it can mischaracterize heterogeneous tissues, including the liver, which is known to exhibit nonuniform fat accumulation in NAFLD The major obstacle to clinical deployment of MRSI techniques is acquisition time; without some form of acceleration, even a modest 32 x 32 x 8 matrix would require almost 30 minutes of scan time at a minimal TR of 200 ms. Compensation for respiratory motion is also a necessity for any abdominal applications. Our approach to both these problems was to use a variable density sampling strategy based on CIRCUS, which oversamples the center to ensure sufficient coverage after respiratory compensation, while undersampling the periphery to reduce the overall scan time. For the in vivo mouse scans in this work we used a high‐resolution 3D sampling trajectory (64 x 64 x 16), which cannot be acquired on a clinical system in a reasonable scan time, even with multichannel RF arrays to provide further acceleration via parallel imaging. However, high‐resolution 2D (64 x 64) and lower resolution 3D (40 x 40 x 8) patterns are both possible, and we are now exploring which is most appropriate for clinical validation.The use of undersampling and CS always carries the potential for loss of information, usually in the form of high‐resolution, low‐contrast features which do not fit assumptions of sparsity in the model‐based reconstruction. The algorithm used in this work, Blind‐CS, attempts to discern the underlying temporal basis functions from a time‐resolved dataset from the data itself, assuming that a small number of such basis functions can adequately describe the signal evolution. It is possible that, in a situation where fatty acid composition differs significantly throughout an imaging volume, the algorithm will assign greater weight to the more dominant component and suppress others. The stability of saturation indices in the pure oil phantoms Figure  before a5In this work we have demonstrated that free‐breathing, accelerated spectroscopic imaging can provide spatially resolved measurements of fatty acid composition, both in oil phantoms and in an in vivo animal model of fatty liver disease. SE‐SPI generally agrees with SVS measurements, but is able to provide reasonable estimates of saturation indices based on individual peak heights in many cases where SVS cannot adequately resolve the necessary spectral features due to line broadening. Clinical testing of this technique can now be undertaken to assess whether saturation indices can provide a reliable imaging biomarker for severity or progression of NAFLD.This work was supported by an Investigator Sponsored Research Agreement with GE Healthcare, funding from the Atlantic Canada Opportunities Agency's Atlantic Innovation Fund, a Brain Canada Technology and Platform Grant, a National Sciences and Engineering Research Council Discovery Grant (S.D.B.), a Canadian Institutes of Health Research Canada Graduate Scholarship (M.H.) and a Killam Predoctoral Scholarship (M.H.).Supporting Information S1Click here for additional data file.Supporting Information S2Click here for additional data file.Supporting Information S3Click here for additional data file.Supporting Information S4Click here for additional data file.Supporting Information S5Click here for additional data file.Supporting Information S6Click here for additional data file.Supporting Information S7Click here for additional data file.


Generally, vaccination uptake in Japan lags behind World Health Organization targets.This study aimed to understand how risk information and advice affect intention to receive vaccinations.This study had a within‐subjects design. An online survey based on the Health Belief Model was sent to 2501 Japanese individuals (≧20 years) to assess the intention to be vaccinated for influenza and rubella after receiving minor and severe risk information and hypothetical advice about each vaccine. Regression analysis was used to measure changes in intentions to receive each vaccination after being provided with (1) risk information about each vaccine and (2) hypothetical encouragement and discouragement to be vaccinated.The main outcomes included changes in vaccination intentions from baseline.N = 1030) of those sent the survey completed it. At baseline, 43% and 65% of the respondents intended to have influenza and rubella vaccinations, respectively. Being provided with information about severe risks and susceptibility increased the intention to have the influenza vaccination among females in their 40s. Receiving inaccurate and discouraging information from one's mother significantly decreased the intention to have the rubella vaccination. Women 50 and older were more likely to intend not to have vaccination for rubella. Severe risk information decreased rubella vaccination intention in all age groups, except women in their 30s and 40s (p < .05).Forty‐one percent  and their role in transmission (for rubella) to encourage uptake of essential vaccinations.Members of the Japanese public responded to our online questionnaire on vaccination risk. In Japan, rubella vaccination was mandatory for junior high students from 1977 to 1989, after which it became voluntary and vaccine coverage rates decreased, leading to rubella epidemics in the early 2000s. Since 2006, rubella vaccination guidelines recommend two childhood vaccinations: At 12 months of age and immediately before entering elementary school. The Ministry of Health, Labour and Welfare (MHLW) recommends rubella vaccination for adults, including healthcare workers who have not had a rubella vaccination in many years, those who are unsure whether they been previously infected with or vaccinated against rubella and those who plan to travel overseas.The aims of this study were to discover how exposure to different risk messages and social cues affect intentions to be vaccinated for influenza and rubella in Japan. Identification of differences in vaccination intentions between influenza and rubella could reveal how Japanese people appraise the risks of side effects alongside the benefits of being vaccinated. We designed risk messages around likely concerns about vaccination, including adverse reactions, consequences of remaining unvaccinated and social cues to action.22.1We designed an online survey administered by Macromill Inc. in Japan from 11 to 31 March 2014. Macromill Inc. is a private marketing research company that maintains a database of layperson registrants in Japan interested in participating in different research surveys. We selected Macromill Inc. to distribute the questionnaire and collect responses; their national reach of participants, experience with online survey research and their ability to build in cut‐off criteria suited our study design. The survey was designed to solicit intentions around receiving two elective vaccinations: seasonal influenza and rubella vaccinations. Both are voluntary in Japan; however, Japanese immunisation law states that influenza vaccines be generally obtained at individual expense, preferably annually and timed appropriately to provide immunity during the peak influenza season, while the rubella vaccination is strongly recommended and provided free, with resultant immunity persisting for many years.To minimize bias in respondent risk perception about influenza and rubella, we avoided the peak influenza season. A within‐subjects design was used for the analyses; individuals under 20 years of age and medical professionals were excluded from the study. Variables included (1) demographics, (2) information‐seeking behaviours regarding healthcare‐ and vaccination‐related risks and (3) responses after receiving different risk information. Demographic questions included gender, age and education level to assess how these strata interpret the risks of vaccination. We also included having/not having a child or children under 20 years of age, based on evidence that having children affects influenza vaccination uptake.We developed risk statements around influenza and rubella vaccinations for the survey guided by the Health Belief Model (HBM).2.2First, respondents were asked about their intentions to receive influenza and rubella vaccinations, when provided no information about either vaccination. Then, respondents were asked about their intentions to receive each vaccination after being provided different levels and types of information: Description of the risk of a minor adverse reaction, description of the risk of a severe adverse reaction and an adverse health risk faced by unvaccinated persons (susceptibility). Self‐efficacy was assessed through questions inquiring about other health information‐seeking behaviours. For cues to action, we asked respondents to consider two hypothetical nonmedical advice statements: (1) being discouraged by one's mother from getting the vaccine and (2) being encouraged to get the vaccine by a friend. These scenarios were selected based on studies showing that parental advice  and peer influences have a strong influence on preventive health behaviours and vaccination uptake among young adults of childbearing age.Minor and severe risk explanations were designed by the authors based on information published on the home page of the MHLW, including the National Institute of Infectious Diseases Table . The infα (α = .90) with a subgroup of respondents: .89 for the influenza vaccination and .82 for the rubella vaccination.We piloted the survey to measure the reliability of the questionnaire using a test–retest approach, adapting the questions to reach a sufficiently high Cronbach's no intention) and scores of 4, 5 and 6 were converted into 1 (intention).At baseline and after being presented with each explanation of risk or cue to action, respondents rated their intentions to receive each vaccine along a 6‐point Likert scale, where 1 indicated no intention of having a vaccination and 6 indicated strong intention to have a vaccination. The results were dichotomized so that scores of 1, 2 and 3 were converted into 0 .33.1n = 103 per group). The respondents' mean age was 45 years (SD: ±14.65). Slightly more than approximately half  had attended a 2‐year college or higher. Approximately one‐third of the respondents had one or more children under 20 years of age . At baseline, before being provided any risk information, 440 (43%) stated an intention to have the influenza vaccination and 665 (65%) stated an intention to have the rubella vaccination.The questionnaire was electronically distributed to 2501 individuals. Of these, 1030 respondents (41%) completed the survey, of whom 515 were male and 515 were female. Macromill implemented an automatic cut‐off for enrolment in each age group to ensure a 1:1 ratio of males to females and an even distribution among the five age groups: 20s, 30s, 40s, 50s and 60s and older  information‐seeking behaviours, (2) preinformed vaccination intentions (baseline) and postinformed vaccination intentions  for influenza vaccinations and (3) pre‐ and postinformed vaccination intentions for rubella vaccinations.3.23.2.13.2.1.1p < .05 for all associations; Table No gender association was found with intention to have the influenza vaccination. Overall, respondents in their 40s and 50s, regardless of gender, did not intend to have the influenza vaccination at baseline; intentions did not change after risk information or advice was presented  and susceptibility information . Conversely, females 60 and older showed no intention of having influenza vaccination at baseline ; intentions remained unchanged by provision of any risk information . Those in their 40s who had children intended to have the influenza vaccination at baseline  and after any risk information was provided . Those in their 30s with children indicated an intention to be vaccinated only when provided severe risk information . Highly educated respondents in their 30s and 40s intended to have the vaccination at baseline  and after any risk information was provided , susceptibility information  and a friend's comment . Even severe risk information and a mother's discouragement did not influence the respondents' vaccination intentions  were significantly more likely to refuse the rubella vaccination after being hypothetically discouraged by their mother  and 40s (n = 103) were significantly more likely than other age groups to intend to have the vaccination at baseline  and after any risk information was provided . However, females 50 and older (n = 206) were statistically significantly more likely than other groups to refuse the rubella vaccination after a mother's discouragement .Overall, gender was not associated with intention to receive the rubella vaccination. However, females (n = 168), respondents in their 40s with children (n = 111), highly educated respondents with children (n = 158) and highly educated respondents in their 40s (n = 102) all responded to information about minor risk with slight increases in intention to have the vaccine . Severe risk information decreased intention somewhat for most of these groups , though there was a 3% increase in intention for respondents in their 40s with children . Susceptibility information seemed to generate larger increases in intention than any risk information about having the vaccination , hypothetical maternal discouragement  and even a friend's hypothetical encouragement to have the rubella vaccination . Hearing a mother's discouragement first seemed to influence subsequent responses to a friend's encouragement. Therefore, a McNemar test was conducted on the results to assess the relationship between the mother's discouragement and the friend's encouragement. There was a significant increase in vaccination intention when the friend's encouragement was provided  stated that they would compare the advantages and disadvantages of a medical procedure if treatment were required; 49% (n = 509) reported reading the warning labels on over‐the‐counter flu medication, 49% (n = 508) stated that they researched the risks of having an influenza vaccination and 62% (n = 643) stated that they researched the risks of having a rubella vaccination. Elderly individuals, as well as females more generally, were statistically significantly more likely to seek vaccination information and assess the risks and benefits  and after being provided any risk information or comments . Those who researched the risks of the influenza vaccination had significantly higher influenza vaccination intentions after being provided any risk information , after being provided minor  and severe risk information  and a mother's discouragement . Those who had researched the risks of the rubella vaccination had significantly higher vaccination intentions even after being provided a mother's discouragement  and susceptibility. It is possible that this demographic, most likely to have young children at home, has better information about vaccination benefits and more favourable attitudes to vaccination based on their children's vaccination experiences at their paediatrician and/or at school. Additionally, connections made with other parents through their children would allow for an exchange of information, possibly leading to an increase in vaccination uptake.4.2Remarkably, even for older generations whose mothers are likely infirm or deceased, maternal influence was stronger than any of the medical information provided about the rubella vaccination. Japanese culture and family patterns may influence these responses. In East Asian cultures including Japan, people tend to respect the opinions of their elders because of their life experienceHypothetical advice from one's mother was intentionally based on a potentially unreliable source (her memory) as well as medically incorrect information. Regardless, a sizeable proportion of respondents of all ages reported that this advice would decrease their intention to receive the rubella vaccination. Respondents who were influenced by maternal advice appeared to accept vaccination information unquestioningly. A previous study has reported that parental influence, especially maternal influence, affects young adults' decision‐making about preventive vaccinations for women's diseases.Peer influence on younger generations was not particularly evident in this study, as peer encouragement did not seem to increase vaccination intention in younger cohorts as it did among the middle‐aged with children at home, who are more likely to be exposed to information and opinions through school activities through their children and parental meetings at school. Peer influence seemed to have no effect on rubella vaccination intentions. Those with high information‐seeking behaviours generally had higher vaccination intentions, especially for influenza. An exception was the elderly, who had high health information‐seeking behaviour, but lower vaccination uptake. High self‐efficacy among the elderly appeared to be influenced or reinforced by peers; therefore, providing information and vaccinations in gathering places like existing community resources for seniors might enhance vaccine uptake.4.3We examined intentions around vaccination for two very different vaccinations. Barriers to action are logically much higher to achieve personal and population protection when it comes to influenza vaccines than rubella, given the out‐of‐pocket cost and frequency of vaccination required. Providing information based on increasing risk level helps people better appraise differences in risk. The MHLW home pages describing the influenza and rubella vaccinations describe their risks in the side effects section, not in conjunction with information about susceptibility to disease or the benefits of vaccination. In our study, information on both the risks of side effects as well as susceptibility to adverse outcomes from getting the disease was provided sequentially, following the HBM categories, so that individuals could consider the benefits.Providing risk information in a sequential manner seemed to effectively allow younger generations to rationally consider the advantages and risks of having vaccinations, especially for influenza. In contrast, older generations indicated low intention to have either vaccination at baseline, and presentation of medical information about vaccination risks and their susceptibility did not change their minds, despite high self‐efficacy around health decisions. Vaccine hesitancy in the elderly should be a focus of future research.4.4In Japan, a high‐income nation with a well‐developed vaccination programme, vaccine hesitancy may be driven by mistaken impressions about vaccinations, some of which may be driven by misinformation provided by peers or on the Internet; however, poor messaging, changing recommendations and outreach by vaccination campaigns may also play a role.For both vaccinations, those aged 50 and older showed high vaccine hesitancy and were unswayed by information in our survey, despite self‐reported high levels of health information‐seeking behaviours and widespread availability and accessibility of vaccinations. High vaccine hesitancy in this vulnerable group is problematic, and further research will be needed to develop appropriate messages to motivate older vaccination recipients. Other factors may also encourage vaccine hesitancy in older age groups, who are more likely than others to encounter difficulty due to cognitive and physical mobility issues in accessing and paying for vaccines. Our study design did not tailor risk information by age group, but highlighting elderly individuals' higher susceptibility to adverse outcomes of influenza infection in vaccination messages may be one avenue to increase influenza vaccination rates in Japan. Involving family physicians in vaccine campaigns might complement information provided by national campaigns, help the elderly better understand the need for each vaccination and address any concerns about the side effects of vaccination. Higuchi et al.The Japanese government has promoted rubella vaccination primarily by focusing on the risk of congenital rubella syndrome in unborn children—an important benefit to women of childbearing age and their children. However, this emphasis may have inadvertently contributed towards indifference among those older than reproductive age. Sensitizing older individuals to understand that if they are infected, they could spread rubella to pregnant unvaccinated females and cause birth defects in children might motivate them to get vaccinated. Overcoming rubella vaccine hesitancy among these populations in Japan may require messages that help this group view vaccination uptake as a prosocial contribution.4.5Use of an Internet survey excluded individuals who do not have online access or do not use computers or smartphones, potentially under‐representing the very poor and very old. The survey relied on self‐report, which may be unreliable and could include some social desirability bias . Using a private marketing firm's database for the study population relied on their roster of registered participants, which may introduce some selection bias. However, the vast majority of Japanese people are highly computer literate, and the large number of responses across Japan indicates that geographic reach was good.Other limitations pertain to study design and analysis. Due to changing policies and recommendations around vaccination, the proportions of unvaccinated individuals are not evenly distributed by age group in Japan, particularly for rubella, and some respondents probably had had adult rubella vaccination, which may have decreased the observed effect of the risk information provided. The way in which different types of information were provided  may have created an order or cumulative effect. Additionally, our questionnaire design made it impossible to ascertain whether the impact of advice from friends and family was attributable to the content of the advice or the relationship with the person giving the advice. However, within‐subjects designs have two advantages: Higher statistical power and a lower probability of failing to detect a true difference.Subjective expressions such as ‘the severity is high’ and ‘the probability of the outcome is so low’ may have been understood differently by different respondents according to their risk tolerances and subjective interpretations of these phrases. Using congenital rubella syndrome as the example of susceptibility for the rubella vaccination may have skewed favourable intentions towards women of reproductive age. However, these are common ways to communicate vaccination risk information to the public used by major national healthcare organisations, such as the CDC and MHLW. Additional research is needed to evaluate how the citizens of Japan and other countries perceive these messages.Our analytical decision to collapse our 6‐point Likert scales to a dichotomous scale introduced potential bias, but is a common approach in social research to allow for analysis of a discrete outcome of interest . As Japanese people, like people from other East Asian nations, tend to choose the middle choices in questionnaires,5Messages and information to increase vaccine uptake in Japan and elsewhere must target specific demographics with tailored approaches that target the main factors underlying vaccine hesitancy for specific vaccines and for each sociodemographic group, particularly the elderly, who show higher vaccine hesitancy than other groups despite higher susceptibility to many vaccine‐preventable diseases. Risk information about severe side effects tends to decrease vaccine intention and should be delivered carefully and in the proper context  to groups most concerned about these risks. Messages to motivate individuals to receive vaccines that may not benefit them directly, such as for rubella vaccine promotion among men and older individuals, will require inventive approaches, possibly by appealing to the sense of shared social obligation that animates Japanese culture.The findings of our study confirm studies from other East Asian countries that have identified high vaccine hesitancy, particularly among the elderly, for a range of different vaccinations. Our findings highlight the need for vaccine campaign strategies that identify segments of the populations where vaccine hesitancy is high and to develop culturally appropriate and effective messages and approaches tailored to the concerns and norms of different age and educational groups.The authors declare that there are no conflict of interests.Supporting information.Click here for additional data file.


To assess the feasibility of conducting a randomised controlled trial (RCT) to assess whether avoiding ureteric drainage is superior to performing ureteric drainage after Uncomplicated Ureteroscopy and/or Flexible Ureterorenoscopy (URS/FURS) treatment of a urinary tract stone in improving patient reported outcome measures (PROMs) and 30‐day unplanned readmission rates. A secondary objective was to understand current practice of urologists regarding ureteric drainage after uncomplicated URS/FURS (UU).We undertook an online survey of urologists, circulated amongst members of international urological societies and through social media platforms. Uncomplicated URS/FURS was defined as completion of URS/FURS treatment for a urinary tract stone, with the absence of: ureteral trauma, residual fragments requiring further lithotripsy procedures, significant bleeding, perforation, prior urinary tract infection or pregnancy. The ureteric drainage options considered included an indwelling stent, stent on a string or a ureteric catheter. The primary outcome was to determine the proportion of urologists willing to take part in a RCT, randomising patients after UU to a “no ureteric drainage” arm or ureteric drainage arm. Secondary outcomes included determining in their current practice, the proportion of clinicians performing routine ureteric drainage after UU, the reasons for performing ureteric drainage following UU and their preferred optimal duration for ureteric drainage if it is used. The study was reported according to the Checklist for Reporting Results of Internet E‐Surveys (CHERRIES).Total of 468 respondents from 45 countries took part in the survey, of whom 303 completed the entire survey (65%). The majority agreed that they would be willing to randomise patients  in the proposed RCT. Perceived lack of equipoise to randomise was the most common reason for not being willing to participate .92% (308/335) reported that they use ureteric drainage after UU. This was most often due to wanting to prevent possible complications from post‐operative ureteric oedema (77%) or to aid passage of small fragments (43%). Complexity of the case (i.e. impacted stone 90%) and length of the procedure (46%) were the most important intraoperative factors influencing the decision to use ureteric drainage post procedure. If required, the median stated ideal duration of ureteric drainage was 5 days (IQR: 3–7 days) after UU. If having UU personally, 30% would want no stent postoperatively and over half would prefer a stent on a string.We have highlighted wide variation in practice regarding ureteric drainage after UU. Our results support the feasibility of an RCT evaluating if no ureteric drainage is superior to ureteric drainage in improving PROMs and 30‐day unplanned readmission rates following UU. The rationale for this includes the prevention of obstruction of the ureter by a blood clot or a residual stone which requires a further procedure or to allow recovery of a ureter that may have been affected by the procedure. However, as these factors are less of a concern after an uncomplicated URS/FURS (UU), which applies to most ureteroscopic procedures,Following Avoiding a ureteric drain may be advantageous because ureteric stents have a significant negative impact on patients’ quality of life.However, there is conflicting evidence, supporting the role of stenting after URS/FURS. In two other meta‐analyses, although unstented patients were less likely to experience symptoms of dysuria or pain, the rate of unplanned medical visits and further admission to hospital rehospitalization was significantly higher in the unstented group.The National Institute for Health and Care Excellence (NICE)Stone disease has a significant impact on a patient's quality of life, with adverse symptoms from ureteric drainage after UU often more bothersome than the original stone itself. Following an UU, the impact that ureteric drainage vs no drainage has on a patient's quality of life should be one of the critical outcomes in a RCT evaluating the necessity of ureteric drainage.To assess the feasibility of conducting a RCT on this we decided to survey clinicians’ attitudes and opinions regarding ureteric drainage following UU.2Survey on ureTEric draiNage post uncomplicaTed ureteroscopy (STENT)  residents’ newsletter and the BAUS 2019 conference programme).The survey was obtained using a combination of sampling techniques.2.2The survey was exempt from requiring ethical approval, though informed consent was obtained from participants in the survey. The survey was anonymous and responses were stored in a password‐protected REDCAP database hosted at University College London (UCL). Responses were only accessible to three authors in the study group designated a priori.2.3The REDCAP survey was piloted prior to final release. The scope, choice of questions, and format were drafted by NB, DS, VK, and edited by the STENT study group as part of the BURST Research Collaborative peer review process involving internal peer review in the collaborative and external peer review by invited experts in the field.2.4The survey was first advertised in June 2019 and was open for 3 months from 20/06/19 to 16/09/19. Advertisement was to the sampling frames described above. Urologists and trainee urologists routinely performing URS/FURS were permitted to take part in the survey. Their experience was ascertained objectively as part of the survey.2.5Instructions to permit only single completion of the survey were given in advance with contact details of the study team in the case of any technical difficulties or questions in order to prevent multiple entries. We collected information on the place of work, timing of survey completion, and whether the respondent was a trainee or a consultant which allowed us to find duplicate records.2.6The participants of the survey were presented with a clinical scenario and asked to comment on their practice in the last month:The typical clinical scenario is a patient who has had a definitive routine URS/FURS with or without fragmentation using laser for ureteric or renal stones. Following the procedure there is an opportunity to either place a ureteric stent or other form of ureteric drainage  or to decide not to place any postoperative ureteric drainage. Definitive URS/FURS means the final URS/FURS for stone disease . Uncomplicated means (as based on EAU guidelines) the absence of:ureteral trauma,residual fragments,bleeding,perforation,UTIs orpregnancy.The survey had a combination of closed and open‐ended questions containing free text to allow respondents to explain or elaborate their answers  of ureteric drainage after UU in their current practiceUrologists’ preferred stated optimum duration of stenting after UUEstimated current typical duration of ureteric drainage in UU in “real life” clinical practiceDescription of any difference between urologists’ clinical practice, and what they would recommend for themselves or their family.2.8The overall response rate was determined based on the number of fully completed questionnaires. The data reported in partially complete questionnaires were used, we determined the attrition rate by page, screen and question. The questionnaires that were terminated early were analyzed and the questions that were answered were included in the analysis. The data were assessed for normality and descriptive statistics were performed. The qualitative data were analyzed using thematic analysis and the Braun and Clarke method33.1The email list sampling frame by email consisted of 4671 clinicians comprising 2500 members of The Endourological society, 1337 members of BAUS , 737 urologists on the BURST mailing list, and 97 members of ISU (Irish Society of Urology). The number of potential respondents will have been less than the total sampling frame due to multiple affiliations to these societies. In addition, the total number of impressions generated from tweets on the survey were 35 549 with 861 engagements. Overall, 468 respondents took part in the survey, of whom 303 (65%) completed all of the questions. Sixty‐nine percent of the respondents (321/468) were consultants, and 31% (147/468) were trainees; of those who completed all the questions 72% (217/303) and 28% (85/303) were consultants and trainees, respectively.3.2The median number of URS/FURS performed per month was 11 (IQR 2‐12) and a quarter performed more than 16 URS/FURS per month .Ninety‐two percent (308/335) of urologists reported having performed some form of postoperative ureteric drainage following UU in the past month. Nearly two‐thirds of respondents would more likely than not leave a stent after an UU, whereas only 8% (27/335) would never leave a stent after UU Figure .The most common reason for leaving a stent was the perceived risk of ureteric obstruction from edema 77%, 256/333) with 43% (143/333) leaving a stent to “aid the passage of small fragments”  while in their actual clinical practice, respondents specified that stents are typically left in for a median of 7 days (IQR 5‐14)  followed by the duration of the procedure 152/332, 46%) and the size and nature of the stone  , when performing rigid ureteroscopy without ureterorenoscopy (52%), when the total operative time was no more than 45 minutes (46%), and when using a dusting only technique with laser lithotripsy (41%). Respondents felt least comfortable not leaving any ureteric drainage after treating an impacted stone (8%), after using an access sheath in an unstented ureter (8%), and when the operation time reached 90 minutes (15%).In terms of the types of ureteric drainage options, the least preferred in all circumstances was a ureteric catheter left overnight (range 6%‐12% across various indications). The more complex the clinical scenario, the more likely a respondent would prefer a stent with flexible cystoscopy removal over leaving a stent on a string with removal by the patient or health‐care professional. For the majority of scenarios, a stent with flexible cystoscopy removal was preferred but a stent on a string removed by the patient or health‐care professional was more commonly preferred to flexible cystoscopic when the operation time was no more than 45 minutes , after the use of an access sheath in a pre‐stented ureter  or when rigid ureteroscopy was done alone without URS/FURS .Despite the responses summarized above, when asked to choose a ureteric drainage option if they themselves or their family member underwent an UU, 30% of the respondents would not want any form of ureteric drainage at all. In terms of the type of ureteric drainage option they would chose, the majority (52%) preferred a stent on a string with removal by themselves or a health‐care professional compared to a stent requiring flexible cystoscopy removal (17%) or ureteric catheter (9%) Figure .3.3Eighty‐one percent (244/303) of respondents agreed that they would be willing to randomize patients to an RCT assessing whether no ureteric drainage is superior to ureteric drainage with respect to patient reported outcomes and 30‐day readmission rates Figure . The mos4The principal finding of this study was establishing sufficient equipoise among clinicians and willingness to randomize patients to a future RCT to assess whether no ureteric drainage after UU is superior to ureteric drainage with respect to PROMs and 30‐day unplanned readmission rates. These findings support the feasibility to conduct such an RCT. We also gained unique perspectives on clinicians’ current practice following UU including the specific criteria that would lead to a lower threshold for postoperative ureteric drainage as opposed to no ureteric drainage, and their ideal choice of ureteric drainage method.The vast majority of respondents (92%) used some form of ureteric drainage in their routine clinical practice even when URS/FURS is uncomplicated. Clinicians reported that they would use ureteric drainage primarily due to concerns of potential complications from postoperative ureteric edema or to aid passage of small stone fragments. Stents may however impede the passage of stone fragments rather than aid their passage, as evidenced in studies on stenting prior to shockwave lithotripsy.Our results show that an RCT comparing stent ureteric drainage with flexible cystoscopic removal of the stent or an arm of stent on a string with health‐care professional or patient removal to no ureteric drainage at all would be feasible. However only a small proportion of urologists considered ureteric drainage catheter left overnight and removed the next day as a suitable option for a large range of clinical scenarios, possibly as it converts an otherwise day‐case URS/FURS into a procedure requiring an overnight stay.PROMs in urolithiasis patients have garnered interest as a decrease in the general quality of life in stone formers has been reported in the last decade.Previous surveys on ureteric drainage practice after UU have demonstrated a similar high rate of stenting. A prospective multicenter audit of 8 UK centers on 249 patients undergoing URS showed that 74% of patients had some form of ureteric drainage (68% stents and 6% ureteric catheter).There is no consensus between international guidelines such as the EAU, AUA, and NICE guidelines on the definition of “uncomplicated” URS/FURS and indications for ureteric stenting. Our survey identified some key factors beyond those that guidelines typically consider, to be considered an uncomplicated ureteroscopic procedure, such as a pre‐stented ureter, performing rigid ureteroscopy without ureterorenoscopy, an operative time of less than 45 minutes, and using a dusting only technique with laser lithotripsy.There is also no consensus on the optimal stent dwell time or the most appropriate method for stent removal, if one is inserted, following UU. Respondents in our survey felt that the ideal duration of ureteric drainage, when required, was 5 days however in the respondents’ practice, issues related to logistics and resources commonly led to small delays. Animal studies have shown ureteric edema and upper tract obstruction on imaging persist for at least 96 hours after ureteric dilation, though there are no equivalent human studies.Studies have previously reported that a ureteric catheter for up to 24 hours post URS/FURS may be a reasonable compromise between stenting vs not stenting after UUOf note, there was disparity in the respondents’ clinical practice and their personal preference for stenting after uncomplicated URS/FURS for themselves. If having such a procedure, 30% would want no stent postoperatively compared to 8% who apply this routinely in their practice. The most commonly preferred option was a stent on a string for less than 7 days. Though clinicians would stent the majority of their patients, the fact that they would not prefer the same treatment for themselves perhaps suggests that many of the stents inserted following UU could be avoided and gives further support for an RCT to investigate this question. Future work should include patient and public member, clinician, and methodologist involvement in the design and development of a pilot RCT comparing whether no ureteric drainage is superior to ureteric drainage with respect to PROMs and 30‐day unplanned readmission rates.The insights gained from this work on clinicians’ views on the complexity of a URS/FURS procedure for urinary tract stones requiring ureteric drainage may help to redefine criteria for what an uncomplicated URS/FURS may be in contemporary practice. These criteria could be explored and defined in a formal consensus meeting.There are limitations of this work. Due to the different methods of survey distribution including the use of social media platforms, it was not possible to calculate the exact response rate. However, the utilization of social media platforms is becoming more common in contemporary survey practice,5This work supports the feasibility of an RCT assessing whether no ureteric drainage after UU is superior to ureteric drainage with respect to PROMs and 30‐day unplanned readmission rates. This work also highlights that urologists' decision to place a ureteric stent is multifactorial and involves components which are not currently included in international recommendations.The authors of this manuscript have no conflicts of interest to declare.Supplementary MaterialClick here for additional data file.


Moreover, a polarity descriptor often related to permeability (SA‐3D‐PSA) was calculated for all the conformers and its variation with the environment analyzed. Results showed that the conformational behavior of rifampicin in solution and in the solid state is not superposable. The identification of dynamic intramolecular hydrogen bonds can be assessed by NMR spectroscopy but not by X‐ray structures. Moreover, SA‐3D‐PSA revealed that dynamic IMHBs do not provide rifampicin with chameleonic properties. Overall, this study highlights that the peculiarity of rifampicin, which is cell permeable probably because of the presence of static IMHBs but is devoid of any chameleonic behavior, can be assessed by a proper analysis of experimental 3D structures.The beyond‐Rule‐of‐5 (bRo5) chemical space is a source of new oral drugs and includes large and flexible compounds. Because of their size and conformational variability, bRo5 molecules assume different privileged conformations in the compartments of human body, i. e., they can exhibit chameleonic properties. The elucidation of the ensemble of 3D structures explored by such molecules under different conditions is therefore critical to check the role played by chameleonicity to modulate cell permeability. Here we characterized the conformational ensembles of rifampicin, a bRo5 drug, in polar and nonpolar solvents and in the solid state. We performed NMR experiments, analyzed their results with a novel algorithm and set‐up a pool of  The bRo5 space includes large and flexible drug candidates which may assume different privileged conformations and exhibit chameleonic properties. We characterized the conformational ensembles of rifampicin in polar and nonpolar solvents and in the solid state. We performed NMR experiments, analyzed CSD structures and calculated a polarity descriptor. Results show that rifampicin is not a chameleon and its conformational behavior in solution and in the solid state is not superposable. A dramatic increase in the number of drugs approved in the chemical space outside of Lipinski's rule of 5, i. e. the so called beyond rule of 5 (bRo5) space, has been registered in the last years.a priori as a single average conformation but rather a pool of biorelevant conformations should be individuated as early as possible in any bRo5 drug discovery program.Because of their size and conformational variability, bRo5 molecules can assume different privileged conformations in the various compartments of the human body. Some authorsin vitro properties like solubility and permeability.Recent studies showed that up to now, computational tools have significant issues in the identification of biorelevant conformations of large and flexible structures., we used an implicit‐solvent model because in explicit solvent the reweighting scheme is poorly effective, the change in energies being much smaller than the total energy of the (rifampicin+water) system and because it is more difficult to equilibrate it .www.wavefunction.com).Three‐dimensional PSA (named SA‐3D‐PSA) was calculated following the protocol described in Rossi Sebastiano et al.HySA was calculated using Maestro with default parameters.The authors declare no conflict of interest.As a service to our authors and readers, this journal provides supporting information supplied by the authors. Such materials are peer reviewed and may be re‐organized for online delivery, but are not copy‐edited or typeset. Technical support issues arising from supporting information (other than missing files) should be addressed to the authors.SupplementaryClick here for additional data file.