Emotional over‐eating (EOE) and emotional under‐eating (EUE) are common behaviours that develop in early childhood and are hypothesised to play a role in weight status. Data from a British twin cohort demonstrated that environmental, rather than genetic, factors shape individual differences in both behaviours in early childhood.n = 398) of 4‐year‐old twins selected for high or low risk of obesity from another population‐based cohort of British twins (the Twins Early Development Study).The aim of this current study was to replicate this finding in a subsample , and about two‐thirds of the shared environmental factors influencing EOE and EUE were the same .Genetic influence was not significant, while shared environmental factors explained 71% (52–79%) of the variance in EOE and 77% (62–85%) in EUE. The two behaviours correlated positively (Emotional eating in childhood is shaped by the home family environment; parents are therefore promising intervention targets. Stress and negative emotions can have differential impacts on appetite, with some individuals experiencing decreased, and some increased, desire to eat Data were from a subsample of the Twins Early Development Study Parents reported on their children's emotional eating using the Child Eating Behaviour Questionnaire A), shared environmental (rC) and unique environmental (rE) influences underlying the two behaviours are the same Prior to analyses, EOE and EUE scores were regressed by gestational age, age at measurement and sex. The twin method compares the twin pair similarity of mono‐zygotic (MZ) and di‐zygotic (DZ) twin pairs to decompose variation in EOE and EUE into three latent factors – additive genetic influences , shared (C) and non‐shared environmental influences (E). A great difference between MZ and DZ twin similarity implies significant contribution from genetic factors, whereas similar twin correlations, regardless of zygosity, indicate a contribution of the shared environment. Here, in addition, a bivariate correlated factors model was used to derive aetiological correlations between EOE and EUE, indicating the extent to which the genetic  when the children were 4 years old . Heritability was not significant for either EOE  or EUE , but CIs were wide. Shared environmental influences were strong for both EOE  and EUE . The contributions from non‐shared environmental factors were moderate .The full ACE model fitted the data well compared with the saturated model which estimates means and variances freely without any constraints  were common to both behaviours because neither genetic nor non‐shared environmental correlations were significant . Figure The aetiological correlations indicated that only shared environmental factors (rr = 0.53), indicating that some children tend to both over‐eat and under‐eat in response to stress. Previous research has suggested that an individual's appetitive response to stress might be due to the nature and intensity of the stress – consistent low level stress relating to over‐eating, whereas intense stress might lead to under‐eating C = 0.67). Notably, this sample was selected to include families with varying degrees of obesity risk, increasing the heterogeneity and representativeness of the findings. The mean and SD of the BMI‐SD scores  indicated higher mean BMI than the UK population‐based reference data for children of this age and sex, as well as large weight variation in this sample. Limitations were the reduced sample size, leading to wide CIs, and the inclusion of only same‐sex DZ twin pairs, precluding testing for aetiological differences between boys and girls. Furthermore, parental weight is only one of many risk factors for child obesity and does not capture the full ‘picture’, and more research is needed to establish if the aetiology of EOE and EUE changes with developmental stage. The effect of stress on eating behaviour is complex, and a previous study has indicated a Gene–Environment interaction demonstrating that parents are more inclined to use maladaptive feeding strategies if their children are of increased genetic risk associated with emotional dysregulation This twin study of the aetiology of EOE and EUE in early childhood replicated previous findings from the Gemini twin cohort. As previously found In summary, this study supported that emotional eating is learned in early childhood, not inherited. Shared environmental factors, potentially parental feeding strategies such as emotional feeding No conflict of interest was declared.The authors' responsibilities were as follows: all authors  designed the research; M. H. performed the statistical analyses; and all authors wrote, read and approved the final manuscript.


Variability in biotic interaction strength is an integral part of food web functioning. However, the consequences of the spatial and temporal variability of biotic interactions are poorly known, in particular for predicting species abundance and distribution. The amplitude of rodent population cycles  has been hypothesized to be determined by vegetation properties in tundra ecosystems. We assessed the spatial and temporal predictability of food and shelter plants effects on peak‐phase small rodent abundance during two consecutive rodent population peaks. Rodent abundance was related to both food and shelter biomass during the first peak, and spatial transferability was mostly good. Yet, the temporal transferability of our models to the next population peak was poorer. Plant–rodent interactions are thus temporally variable and likely more complex than simple one‐directional (bottom‐up) relationships or variably overruled by other biotic interactions and abiotic factors. We propose that parametrizing a more complete set of functional links within food webs across abiotic and biotic contexts would improve transferability of biotic interaction models. Such attempts are currently constrained by the lack of data with replicated estimates of key players in food webs. Enhanced collaboration between researchers whose main research interests lay in different parts of the food web could ameliorate this. Indeed, the Ecosystem Exploitation Hypothesis, which considers tritrophic systems across a gradient of productivity, predicts that below a certain threshold of productivity food biomass is a powerful predictor of rodent abundance. Above such productivity threshold, rodent abundance should become decoupled from food plant biomass as predators generally suppress rodent peak abundance below a K  whether biomass of food and shelter plants was consistently related to rodent peak abundances within a given population cycle and (b) to what extent the models from the first peak was transferable in time; that is, were we able to predict rodent peak abundance during a population peak based on model created during a previous peak. We thus apply the framework of near‐term forecasting which states that checks of model transferability should be incorporated as a systematic part of long‐term monitoring programmes to make ecology a more predictive science Dietze, .2Myodes rufocanus). In addition, the Norwegian lemming (Lemmus lemmus) is abundant in the heath habitat during their peak years   and 2010–2011 (hereafter second peak)   Figure .2.2Small rodent populations were sampled twice a year over two trap‐nights (July and September), using the sampling quadrats as small quadrats following the snap‐trapping procedure described by Myllymäki, Paasikalio, Pankakoski, and Kanevo  Support. We usedAs plant biomass data was collected after the rodent sampling in July, we only included rodent abundance data from the September trapping in the analyses of plant–rodent interaction. The September sampling also normally represents the annual rodent peak abundance in the shrub tundra zone of Fennoscandia  were sampled using 20 points  were sampled using three points. These changes in resolution and timing of the measurements had little effect on the measured biomass .We defined plant functional groups for each rodent species separately Table . In pala2.42.4.1R=log(NSept+1)‐log(NJuly+1)), and (c) the density dependence of the growth rates for each of the two cyclic peaks. Density dependence was estimated based on a state‐space model where measurement error was explicitly incorporated by using the two trapping days for each sampling quadrat as temporal removal occasions  Spearman's correlation between the July and September censuses within peaks, (b) the quadrat‐specific summer growth rates  and because of the limits of the sampling process (the number of trap‐nights [24] per trapping session sets a maximum). Exploratory plotting supported this expected nonlinearity between rodent abundance and plant biomass. We therefore analysed the abundance of each rodent species as a response variable with generalized linear models  with log‐transformed plant biomass variables as predictors.Using data from the first peak, we started from models containing the additive effects of all food and shelter variables Table . From th2.4.3spatially and temporally; that is, assessing the spatial and temporal transferability of the models. We assessed spatial transferability using data from the first peak. We sampled randomly, without replacement, half of the sampling quadrats and estimated the model parameters based on the plant biomass data of these quadrats. We then used this model to predict rodent abundance in the remaining quadrats based on plant biomass data. This procedure was repeated 1,000 times for each model. We assessed temporal transferability by testing how well the “best” model for the first peak predicted rodent abundance during the second peak. We used the first peaks’ models parametrized with data from all quadrats and predicted the rodent abundance based on plant biomass data sampled during the second peak.We used the “best” model for each rodent species from the first peak to predict quadrat‐specific vole abundance both RAW): Xi,pred is the predicted abundance of rodents in the sampling quadrat I, Xi,obs is the observed abundance of rodents in the sampling quadrat I.We used the mean absolute error (MAE) : Xpred¯ and Xobs¯ are the average predicted and observed densities observed in the predicted year. The difference between MAERAW and MAERELATIVE is thus caused by over‐ or underpredicting the average abundance.In order to assess our ability to predict the relative differences in rodent densities between sampling quadrats irrespective of potential differences in the average yearly density , we also calculated prediction error based on abundances centred on their mean  null models and (b) models with minimum obtainable prediction error. Because of the Poisson distributed response variable, the difference between observed and predicted values even for 100% predictive power would never reach zero . Hence, the models’ prediction errors were reasonably close to the simulated minimum obtainable error, which ranged between 12% and 14% . This represents 31% and 26% error compared to the observed range of the individuals. However, spatial and temporal prediction errors were similar for the lemmings .Data are available through Dryad (doi:  Click here for additional data file.


Improving traits in wheat has historically been challenging due to its large and polyploid genome, limited genetic diversity and in‐field phenotyping constraints. However, within recent years many of these barriers have been lowered. The availability of a chromosome‐level assembly of the wheat genome now facilitates a step‐change in wheat genetics and provides a common platform for resources, including variation data, gene expression data and genetic markers. The development of sequenced mutant populations and gene‐editing techniques now enables the rapid assessment of gene function in wheat directly. The ability to alter gene function in a targeted manner will unmask the effects of homoeolog redundancy and allow the hidden potential of this polyploid genome to be discovered. New techniques to identify and exploit the genetic diversity within wheat wild relatives now enable wheat breeders to take advantage of these additional sources of variation to address challenges facing food production. Finally, advances in phenomics have unlocked rapid screening of populations for many traits of interest both in greenhouses and in the field. Looking forwards, integrating diverse data types, including genomic, epigenetic and phenomics data, will take advantage of big data approaches including machine learning to understand trait biology in wheat in unprecedented detail. The objective of this review was to discuss how the latest developments in genomics and phenomics can be applied to understand the biology of agronomic traits in polyploid wheat. We describe the new resources and technological developments in the field, and discuss how they can be integrated to improve gene discovery and validation in wheat. Currentet al., Here we focus on polyploid wheat, which accounts for more than 20% of the protein and caloric intake of humans. Compared with other major (diploid) cereals, for example rice and maize, wheat has lagged in the development of genomic resources and the genetic understanding for many major productivity traits . This lag was principally due to its polyploid genome, which makes genetic analyses in wheat more cumbersome than in diploids , which is a hexaploid species and most commonly used for bread‐making and biscuit flours. A smaller proportion (5%) is accounted for by durum wheat , which is a tetraploid species consumed as bulgur and also used to make pasta and couscous. Although distinct species, both share wild tetraploid emmer wheat  as their common ancestor , pasta wheat arose directly from emmer wheat following two domestication events  additive where mutations in increasing numbers of copies lead to proportionally more extreme phenotypes; or (ii) non‐additive whereby single or double mutants have subtle phenotypes that become more extreme when combined as triple mutants. Additive examples include genes controlling grain protein content  were not identified in wheat through phenotypic variation, but rather were characterized in wheat as candidate genes based on knowledge from diploid model species. This leads us to conclude that the wheat genome holds a huge potential of functional variation that has remained hidden and underexploited to date. We argue that gene discovery in wheat is especially relevant to fully exploit this hidden variation as it enables the combination of allelic variation across homoeologs, which in many cases is required to expand the phenotypic spectrum. Identification of causal loci also allows a deeper understanding of allelic variation enabling its fine‐tuning to modulate the plant's phenotype in different environments , polyploid nature and large proportion of repetitive sequences (> 85%). Despite this, since 2014 several genome assemblies have been produced for the reference landrace Chinese Spring, including the International Wheat Genome Sequencing Consortium (IWGSC) Chinese Spring Survey Sequence [International Wheat Genome Sequencing Consortium, et al., Ensembl Plants  The availability of chromosome‐level assemblies is facilitating a step‐change in wheat genetics, enabling the rapid correlation of genetic and physical maps. Whereas historically gene cloning in wheat has relied almost entirely upon genetic mapping of traits, these new alignments will now accelerate trait discovery by placing genetic markers in a physical context and allowing rapid identification of candidate genes within mapped regions. A limitation, however, is that in some cases the population used for genetic mapping may have a different gene content than the reference sequence cultivar, which could lead to candidate genes being missed. This drawback is being addressed through pangenome efforts.With the completion of a high‐quality reference sequence for the wheat landrace Chinese Spring, projects are now focusing on sequencing different wheat cultivars. This is not only important to understand variation within breeding pools and diversity collections, but also to identify sequences and gene content that may be different between the single reference accession and other cultivars used in mapping populations.Triticum urartu and Ae. tauschii, respectively, alongside the AABB tetraploid progenitor T. dicoccoides, were released in the past 24 months . Concurrently, the 10+ Wheat Genomes project was launched with the aim to provide high‐quality assemblies for cultivars valuable for both research and breeding (www.10wheatgenomes.com). The project aims to sequence 18 different bread wheat cultivars from around the world, some of which are already accessible via online BLAST servers . The availability of highly contiguous reference genomes for multiple cultivars of relevance in elite wheat breeding programmes will be particularly important to identify structural variants and copy number variation. This type of variation is known to affect traits of agronomic relevance , has rapidly increased the amount and accessibility of genotype data for specific cultivars of interest  are thought to have been introduced into hexaploid wheat during the natural hybridization process. Thus, efforts have focused on reintroducing variation from Ae. tauschii through the re‐synthesis of bread wheat. This is achieved by crossing a tetraploid wheat with a diploid Ae. tauschii accession, giving rise to a synthetic hexaploid wheat .An additional important source of accessible genetic variation is found in landraces, locally adapted wheat lines that were grown as farmer‐saved seed and that have not been modified through modern breeding techniques. These landraces constitute reservoirs of genetic diversity that can be directly cross‐bred into modern cultivars. There are thousands of these landrace accessions available; however, many of them are heterogeneous, often duplicated seed stocks  genes by using targeted genome sequencing approaches . A highly detailed developmental timecourse of the spring wheat cultivar Azhurnaya  and cultivars  generated a wheat network using 20 genomics datasets, although only one of these was derived from wheat‐specific data  also presents a wheat network, which until recently was based mainly on information derived from orthology , they have recently been remapped to the RefSeqv1.0 gene models and are available on EnsemblPlants. The mutagenized populations are particularly useful due to their ease of access, with researchers being able to identify mutations in their gene of interest within minutes. However, because the sequenced mutations will lead to a truncation (premature termination codon or splice junction variant) in only 60% of genes, the use of missense mutations will also be required at times. As a result, screening more than one mutation per gene might be necessary as predicting the functional effects of missense mutations is not always easy a priori. Similarly, use of the TILLING lines typically requires multiple iterations of crossing, first to combine mutations across homoeologs of the gene of interest and secondly to reduce background mutations  of interest would require the screening of the population using conventional TILLING approaches or the development of a new bespoke mutant population using the cultivar with the gene(s) of interest.As the new genome assemblies increase the potential for gene discovery, the focus now turns to ways in which gene function can be characterized Figure . Exome‐cet al., et al., et al., et al., et al., Alternative methods for gene functional characterization focus on transgenic techniques. These can be either transient or stable transformation methods, and are able to influence gene expression levels beyond what is possible via mutagenesis. Transient methods benefit from the relative ease and speed of transformation compared with stable integration, with several transient gene expression and silencing systems now available in wheat. The use of virus‐induced gene silencing (VIGS) in wheat and other cereals has been highly successful in characterizing the impact of various genes involved in abiotic and biotic stress response  has required field trials that are labor‐intensive and can only be carried out once per year in many parts of the world. To overcome this bottleneck  chromatin has been associated with functional non‐coding sequences. In maize, for example, < 1% of the genome was defined as open chromatin, yet variation within these regions explained 40% of phenotypic variation for many quantitative traits (Rodgers‐Melnick et al., et al., Advances in phenomics have enabled us to generate large phenotypic datasets, and now opportunities will arise to understand the links between genotype, environment, agronomy and phenotype at a systematic scale. Machine learning is showing promise in predicting phenotypes in wheat based on genomic data (Grinberg et al., et al., The addition of novel data types such as epigenetics and chromatin conformation may contribute to improved wheat phenotypic prediction. Initial studies reveal epigenetic differences amongst landraces (Gardiner et al., In summary, the last decade has brought about a revolution in the resources and approaches used for wheat research and breeding. We now have a wide range of resources that provide opportunities to improve our understanding of wheat gene functions, many of which are easily accessible for researchers moving into wheat from other species (Adamski The authors declare no conflict of interest.Data S1. Calculations for daily consumption of wheat.Click here for additional data file.


Technological advances have led to the generation of large amounts of data, both in surgical research and practice. Despite this, it is unclear how much originates in low‐ and middle‐income countries (LMICs) and what barriers exist to the use of such data in improving surgical care. The aim of this review was to capture the extent and impact of programmes that use large volumes of patient data on surgical care in LMICs.A PRISMA‐compliant systematic literature review of PubMed, Embase and Google Scholar was performed in August 2018. Prospective studies collecting large volumes of patient‐level data within LMIC settings were included and evaluated qualitatively.A total of 68 studies were included from 71 LMICs, involving 708 032 patients. The number of patients in included studies varied widely (from 335 to 428 346), with 25 reporting data on 3000 or more LMIC patients. Patient inclusion in large‐data studies in LMICs has increased dramatically since 2015. Studies predominantly involved Brazil, China, India and Thailand, with low patient numbers from Africa and Latin America. Outcomes after surgery were commonly the focus (33 studies); very few large studies looked at access to surgical care or patient expenditure. The use of large data sets specifically to improve surgical outcomes in LMICs is currently limited.Large volumes of data are becoming more common and provide a strong foundation for continuing investigation. Future studies should address questions more specific to surgery. Fig. The concept of ‘big data’ describes the use of unstructured digital information, usually from multiple sources, that is often collected with no clearly defined purpose for future useThe analysis and translation of big data to maximize quality and improve patient care is a priority for healthcare systemsHowever, discussions around large‐volume patient data frequently place little emphasis on their application in low‐ and middle‐income countries (LMICs), despite the potential for vast gains in patient outcomes and surgical service qualityThe aim of this review was to evaluate the current applications of large‐volume patient‐level data in surgery in LMICs, together with highlighting where further focus is required to improve outcomes, define quality indicators and achieve universally available safe surgery.An electronic systematic search of the PubMed, Embase and Google Scholar databases was performed in accordance with the PRISMA guidelinesAppendix S1 (supporting information). A further supplementary search of Google Scholar was also undertaken. Search limits applied were English language, full text, humans and articles published from 2008 onwards to provide contemporary studies that were likely reflective of current approaches to data capture.A search of Embase and PubMed was undertaken using the keywords ‘surgery or surg*’, ‘big data’, ‘large data’, ‘informatics’, ‘database’, ‘cohort’ and ‘registry’, combined with LMIC filters as specified by the Cochrane libraryThe inclusion criteria were: prospectively collected data  on patients undergoing surgery with care being provided, at least in part, in a LMIC, defined according to the World Bank classificationFollowing the literature search, article titles were screened by four investigators and those meeting the inclusion criteria were screened further by abstract and then full text as appropriate. Any disagreements were resolved by consensus within the group. Bibliographies from included articles were hand‐searched to identify any further relevant articles.Data were extracted independently using a standardized pro forma, including year of publication, countries involved in the study, number of patients for each LMIC, patient‐level data type , surgical specialty and measured outcome(s). In multinational studies where the number of patients for individual countries was not reported, the number of patients in the study was recorded. These studies were excluded from analysis mapping of the global distribution of patients across included studies to avoid data skewing. Individual LMICs where there were fewer than 100 patients in multinational studies were also excluded from analysis mapping. However, studies that did not report patient numbers for individual LMICs and all data from multinational studies were included in all other analyses.– studies meeting database classification but performed over a wide geographical area .Data types were defined as follows: cohort – collection of patient‐level data over a defined short period; database – concerted and long‐term collection of patient‐level data of consecutive patients over a small geographical area; or registry https://www.R‐project.org/) and the tidyverse packagehttps://argoshare.is.ed.ac.uk/bigdata_review.Definitions were discussed and consensus reached within the group where doubt existed regarding particular studies. Owing to the narrative nature of the review, a qualitative analysis was performed using the R statistical program . Country‐specific patient numbers were reported in 60 studies but were absent from sixThe literature search identified 3805 articles, of which 218 full texts were assessed for eligibility . Relatively few studies were found for the interval 2012–2014 despite no decrease in the total number of studies returned in the initial literature search  for other years).Studies using big data were well represented across the 10‐year analysis period; however, a dramatic increase in study and patient numbers was seen from 2015 onwards Fig. a. RelatThe number of patients in the included studies ranged from 335 to 428 346, with a median of 2483 per study. Over 3000 patients were included in 25 of 68 studies; the biggest studies were published in the interval 2015–2018. Studies based on database and registry data were most common and represented 43 of 68 included studies. The majority of data sets identified arose from prospective cohorts of patients. Several of these studies were performed in single centresFig. a). Patient‐level data were collected from 71 LMICs in total; overall, patient representation was particularly low in Africa and Latin America .The studies had a wide geographical LMIC distribution. The majority, however, were from Brazil (12), China (11), India (5) and Thailand 4) The past 5 years has seen an exponential rise in the number of patients included in studies from LMICs, with some very large cohorts in countries such as Brazil, China and India. Geographical disparities are apparent and are particularly obvious in Africa, where far fewer large studies have been published. The focus is predominately on short‐term outcomes after surgery, together with the epidemiology of diseases commonly treated by surgery. Few studies have focused on the specific needs of resource‐poor environments. It is perhaps too early to determine any positive effects of such work on outcomes in populations of individuals receiving surgical care.The use of big data to capture patient‐level outcomes in an LMIC setting has increased exponentially over the past 10 years. However, in global cohort studies the proportion of patients recruited from high‐income countries remains much greaterIn high‐income settings, big data are currently the focus of genomewide data analysisCombining data from multiple sources to draw population‐level conclusions worldwide is epitomized by the Global Burden of Disease project by the Institute for Health Metrics and Evaluation at the University of Washington. This is a global effort to examine comprehensively the prevalence, incidence and impact of multiple diseases and environmental factors using an extensive network of more than 2500 collaborators from 133 countriesSuch projects require accurate national data, which do not exist in many regions. National registries can be expensive to establish and run, but are becoming more common in middle‐income countries, such as the Chinese Guangzhou Occupational CohortComprehensive patient‐level databases or registries are yet to be adopted in the majority of LMICs. Barriers limiting broad adoption include a lack of resources and infrastructure, such as electricity and reliable internet connectivity, combined with skill shortages in medical informatics. The advent of the electronic patient record (EPR) may present the best opportunity for routine data analysis at a health‐system levelLinked to this is the explosion in mobile phone technology. Three‐quarters of the population of sub‐Saharan Africa already lives in an area with mobile internet connectivityThere are important areas of study that are more specific to resource‐poor areas, such as access to surgical care and the cost of surgical care to patients. Only one studyThe landscape of healthcare data is changing rapidly. Ensuring that LMICs have the resources to keep up to date with technological advances will ensure future global health equalityIn parallel with future advances, ensuring that electronic data are kept secure is of utmost importance. Respecting an individual patient's rights to confidentiality, autonomy and privacy is fundamental to ensuring public trust in electronic data collection methods. Beyond good data governance practice, technologies such as blockchain may facilitate the safe and secure sharing of healthcare data within increasingly complex interconnected systems.There are weaknesses to the approach taken in this review. Pragmatic limitations around the scope of the review search were required and important studies may have been omitted. The synthesis of such a heterogenous group of studies is difficult and conclusions must be made at a high level.This review has demonstrated a significant growth in the use of large‐volume patient‐level data across many surgical specialties and LMICs. At least 71 LMICs currently involved in big data projects were identified, with evidence of an exponential growth in patient numbers totalling more than 700 000. However, to date, the majority of studies using big data have been limited to short‐term outcomes after surgery and few have addressed the needs that are particular to LMICs. Funders, policymakers and specialists in medical informatics urgently need to reorientate this focus if the potential of big data to improve surgical outcomes, particularly in LMICs, is to be realized fully.The authors declare no conflict of interest.Table S1 Studies included within the systematic reviewTable S2 Aims of included studies grouped by primary outcome measure and surgical specialtyClick here for additional data file.


Epidermolysis bullosa (EB) is the umbrella term for a group of rare inherited skin fragility disorders caused by mutations in at least 20 different genes. There is no cure for any of the subtypes of EB resulting from different mutations, and current therapy only focuses on the management of wounds and pain. Novel effective therapeutic approaches are therefore urgently required. Strategies include gene‐, protein‐ and cell‐based therapies. This review discusses molecular procedures currently under investigation at the EB House Austria, a designated Centre of Expertise implemented in the European Reference Network for Rare and Undiagnosed Skin Diseases. Current clinical research activities at the EB House Austria include newly developed candidate substances that have emerged out of our translational research initiatives as well as already commercially available medications that are applied in off‐licensed indications. Squamous cell carcinoma is the major cause of death in severe forms of EB. We are evaluating immunotherapy using an anti‐PD1 monoclonal antibody as a palliative treatment option for locally advanced or metastatic squamous cell carcinoma of the skin unresponsive to previous systemic therapy. In addition, we are evaluating topical calcipotriol and topical diacerein as potential agents to improve the healing of skin wounds in EBS patients. Finally, the review will highlight the recent advancements of gene therapy development for EB. Apart from secondary extracutaneous involvement, this also explains the occurrence of primary extracutaneous manifestations and relevant complications especially in the severe forms of EB, making them a multisystem disease with significant morbidity and mortality.Type (homo‐ vs heterozygosity), number  and location of mutation(s) within the gene or gene segment, as well as the spectrum of subsequent quantitative  or qualitative  disruption of protein expression, result in considerable genetic heterogeneity with complex genotype‐phenotype correlations.http://www.eb-haus.org), a designated Centre of Expertise implemented in the European Reference Network for Rare and Undiagnosed Skin Diseases (ERN Skin) with currently 56 partners (http://skin.ern-net.eu/), and at other centres. Albeit still largely experimental and facing major hurdles including safety and efficiency to overcome, these techniques should contribute to determine curative perspectives.Currently, no general curative therapy is available for all EB types. In light of the morbidity as well as lethality of numerous subvariants as well as the current availability of largely only symptomatic treatment options, causative therapeutic approaches are therefore urgently required. Such strategies include gene‐, protein‐ and cell‐based therapies.2As stated above, the severe forms of EB are not restricted to the skin but affect the entire body. Several approaches have therefore been developed in the quest for a systemic therapy. Attempts using allogeneic bone marrow transplantation (BMT) with or without infusion of mesenchymal stem cells (MSCs) have shown some transient beneficial clinical response in a small number of patients with RDEBSeveral substances that elicit premature termination codon (PTC) read‐through showed promising results in vitro for specific RDEB‐ and JEB‐associated mutations.Systemic recombinant human type VII collagen protein administration is another therapeutic approach that is pursued for the treatment of RDEB patients. It has previously shown promising results in a mouse model for RDEBCurrent clinical research activities at the EB House Austria include the development of novel therapies that have emerged out of our translational research initiatives, as well as commercially available medications that are used for “off‐label” uses.2.1In a prospective, multi‐centre, phase II trial (Eudra CT‐No. 2016‐002811‐16), we are evaluating the administration of nivolumab  for the palliative treatment of patients with DEB who have locally advanced or metastatic squamous cell carcinomas of the skin (SCCS) that have been unresponsive to other systemic therapies. The target population also includes patients suffering from generalized severe recessive dystrophic epidermolysis bullosa, in which SCCS, owed to a highly aggressive course with early metastatic spread, is the primary cause of death with a cumulative risk of 70% to die by age 45.For both EB and non‐EB SCCS, evidence on overall clinical effectiveness of standard chemotherapeutic agents (with rather poor tolerability among older patients) as well as systemic therapies targeting the epidermal growth factor receptor (EGFR) pathway remains mostly limited and is often of short duration.Immunosuppression plays a major role in the pathogenesis of SCCS,Against this background, current immunotherapy efforts attempt to break the apparent tolerance of the immune system to tumor cells and antigens by either introducing cancer antigens by therapeutic vaccination or by modulating regulatory checkpoints of the immune system.Plausible molecular features of SCCS,Despite obvious progress, current knowledge to correlate clinical effectiveness of checkpoint inhibitors with the tumor immune microenvironment is still limited in SCCS and should be subject to further investigation.Our trial seeks to determine the objective response rate of immunotherapy with nivolumab in index patients with using Response Criteria in Solid Tumors version 1.1 (RECIST1.1) per site assessment up to 2 years as the primary objective. Treatment efficacy will be correlated with the number of tumor‐infiltrating lymphocytes (TILs) and CD8‐positive lymphocytes at baseline.2.2Enhanced tissue fragility, persistent wounds and inflammation in EB predispose to complications including infections, sepsis and the aforementioned development of aggressive SCCS.Staphylococcus sp., Streptococcus sp., Candida sp. and Pseudomonas aeruginosa,Common wound colonizers in EB, such as Most recently, a role for innate immune sensing of microbial products, such as bacterial flagellin via toll‐like receptor 5, in promoting wounding‐ and inflammation‐induced skin tumorigenesis was demonstrated,Staphylococcus aureus.All currently existing approaches for the treatment of bacterial infected wounds have some disadvantages. Antiseptic baths, which are recommended for dystrophic EB patients, are often time‐consuming and exhausting as well as painful for the patients since all dressings have to be carefully removed. Despite beneficial results, silver‐containing creams (eg Flammazine) should not be applied for more than maximal 2‐4 weeks due to emerging silver toxicities attributable to systemic absorption. Finally, long‐lasting application of antibiotic ointments for the treatment of infected wounds may lead to multi‐resistant bacterial strains, such as methicillin‐resistant Antimicrobial peptides (AMPs) form part of the body's innate immune response, serve as potent antibacterial substances that control pathogenic infections and activate the innate and adaptive immune system.Cathelicidin is directly regulated by vitamin D.E coli with supernatants from cultured calcipotriol‐treated RDEB cells compared to controls while retaining any anti‐proliferative effect of calcipotriol detrimental to wound healing.Our preliminary data on hCAP18 mRNA levels in skin tissue samples taken from RDEB patients and RDEB patient‐derived keratinocyte cell lines support this hypothesis.Based on our results including a promising single‐patient observation study,2.3KRT5 or KRT14, with subsequent disintegration and collapse of the intermediate filament network, characteristic protein aggregation and increased fragility to mechanical stress and osmotic shock.We and others have recently shown a significant constitutive upregulation of interleukin‐1beta (IL‐1ß) in keratinocytes of patients with severe generalized EB simplex (EBS‐gen sev), an autosomal dominant subvariant based on mutations within the keratin genes This mechanism is suspected to increase the expression of the dominantly interfering mutated K14 allele, thereby potentially aggravating the EBS‐gen sev phenotype as compared to milder subtypes of EBS caused by nonsense mutations within the same gene. Additionally, blister formation was found to be related to matrix metalloproteinase (MMP)‐9 and chemokine CXCL8/IL8, whose expression is also dependent on the IL‐1β signalling pathway, that thereby modulates the tissue microenvironment.trans‐splicing (SMaRT), which shifts the expression ratio of wild‐type vs mutated K14 alleles towards wild type.Therapeutic approaches to inhibit IL‐1β could thus be beneficial to patients through reduction of downstream cellular inflammation. Indeed, treatment of EBS‐gen sev patient keratinocytes with diacerein, a small molecule component of rhubarb root and reported IL‐1β inhibitor, not only reduced the expression levels of K14 and IL‐1β and the phosphorylation levels of JNK, but also stabilized the intermediate filament network upon heat shock.Based on our in vitro data, we launched a double‐blind, randomized, placebo‐controlled phase 1 pilot study of topical diacerein 1% cream in 5 patients with EBS‐gen sev.While the low patient numbers and no invasive data acquisition because of clinical burden in children pose relevant limitations, this trial provides evidence of the impact of 1% diacerein cream in the treatment of EBS‐gen sev.2.4LAMB3COL7A1, EudraCT‐No 2015‐004592‐74) and the other one for junctional EB , are currently recruiting. A similar study in which RDEB patients received transgenic autologous epidermal equivalents was recently performed at Stanford University.So far, only a small number of EB patients have undergone gene therapy. These individuals received the classical treatment approach termed replacement gene therapy. The treatment, which is suitable for recessive forms of EB, relies on ex vivo viral transfer of a functional cDNA copy of the defective endogenous gene into keratinocytes and/or fibroblasts isolated from skin biopsies, which are then grafted back onto the skin. The approach has first been applied in a patient with junctional EB caused by mutations in While replacement gene therapy is incapable to overcome dominant‐negative interference in the majority of EBS or DDEB forms, sustained expression of the functional transgene can replace the function of the endogenous non‐functional genes sufficiently to revert the phenotype in autosomal recessive diseases. An enduring replacement gene therapy relies on viral transfection of human epidermal stem cells with (full‐length) wild‐type cDNA. The protocol involves isolation of primary patient keratinocytes, which are expanded ex vivo in cell culture from a small skin biopsy. The presence of a sufficiently high number of epidermal stem cells (EpSCs) in the primary cultures prior to gene transfer and growth of transgenic cells into epidermal equivalents used for grafting accounts for permanent regeneration of a healthy, functional and renewing epidermis and extra‐/cellular environment. This can be a major challenge as EB patients may harbour a very limited number of EpSCs, which further decreases with the age of the patient as a result of continuous wounding and scarring.As part of clinical studies involving gene therapy, several parameters need testing such as the efficiency of the viral gene transduction and safety with respect to genotoxicity. Finally, the transgenic cells, including EpSCs, are expanded and grown into cohesive epidermal sheets, which are grafted back onto a surgically prepared wound bed following established procedures similar to those used in the treatment of burn injuries.While the vast majority of transduced keratinocytes are transit‐amplifying progenitors and differentiated keratinocytes, which are lost within weeks to few months after grafting, survival of a small number of long‐lived, extensively renewing transgenic EpSCs that produce progenitors replenishing terminally differentiated keratinocytes is sufficient to restore and sustain normal skin function and regeneration, when being transplanted onto wounded sites.LAMB3, COL7A1, COL17A1) to replace the function of the mutant endogenous genes have become a realistic treatment for generalized intermediate junctional and recessive dystrophic EB.Although this is not a systemic therapy, wound closure especially at sites of chronic and/or large blistering erosions can improve quality of life by reduction of itch, pain, inflammation, body fluid and protein loss, strengthening of microbial defense and prevention of cancer formation out of predisposing long‐standing wounds in junctional and dystrophic variants of EB. Therefore, ex vivo gene therapies based on highly efficient retroviral transduction of full‐length cDNA /CRISPR‐associated protein 9 (Cas9) capable of mediating gene editing to correct distinct mutations at their endogenous loci. Instead of replacing the function of the mutant gene by adding a wild‐type cDNA, this technology allows the potentially traceless repair of the genetic mutation itself, eliminating the risk of insertional mutagenesis resulting from random transgene integrations.3.1Whereas retroviral transduction of a cDNA is highly efficient, the random integration of the transgene remains a risk. This risk can be eliminated by using the next‐generation gene therapy technology relying on designer nucleases. The nucleases are engineered to target the locus of interest specifically. They are transiently transfected and capable of inducing deletion or repair of disease‐causing mutations.COL7A1,LAMA3LAMB3KRT5KRT14COL7A1 with a size of >30 kb and disease‐causing mutations spread almost along the entire length of the gene, this is challenging. Among the first targets chosen from our laboratory and others to develop efficient nucleases were therefore hot‐spot mutations such as the c.6527insC in exon 80 of COL7A1, which is highly prevalent in the Spanish dystrophic EB patient population.Most efforts to develop gene editing–based therapies for EB have focused on the correction of RDEB or DDEB mutations in KRT14 mutation,KRT5 allele by inducing insertions or deletions (indels) via the error‐prone non‐homologous end‐joining (NHEJ) repair pathway causing a frameshift at a site within the target gene that is independent on the location of the disease‐causing mutation.Dominant‐negative mutations such as those common in EBS can be corrected in different ways. In addition to a mutation‐specific repair approach for a Streptococcus pyogenes Cas9 (SpCas9) nuclease variants, we have recently developed double nicking approaches based on single‐strand DNA breaks (nicks) at the targeting site with the intention to reduce off‐target site effects.First attempts of gene editing mutations associated with EB used meganucleases.While most gene editing approaches published to date for EB used viral transfer of the nuclease or the repair template or both,Gene therapy targeting keratinocytes and/or fibroblasts3.2trans‐splicing (SMaRT) technology allows correction of dominant or recessive mutations at mRNA level. Specifically designed RNA trans‐splicing molecules (RTMs) bind to the target pre‐mRNA and replace mutant exons by wild‐type sequences. RTMs are capable of replacing large parts of a transcript and a single type of therapeutic molecule could therefore be used to treat patients with several mutations.COL7A1, Col17A1, KRT14 and PLECSpliceosome‐mediated COL7A1, exons 79, 73 and 80 are dispensable and can, in the presence of specifically designed antisense oligonucleotides (ASOs), be skipped during pre‐mRNA splicing.Some EB‐causing mutations reside in exons that are non‐essential for the function of the protein that is encoded by the gene.4Epidermolysis bullosa research has advanced considerably in the past decade Table , and wouThe molecular tools that allow micro‐surgery to correct disease‐causing mutations within the affected genes were discovered only recently and have since been continuously improved. Gene editing technology is breaking new grounds of research with the prospect of devising permanent, safe, tolerable and feasible delivery of local and possibly systemic treatments for inherited diseases. Applied at an early stage, efficient gene therapies may prevent the development of symptoms and at later stages prevent disease progression involving the development of devastating chronic EB lesions and life‐threatening cutaneous SCC. There are still major challenges but also exciting discoveries ahead.JWB owns shares of the company Diaderm, which receives licence payments from Castle Creek Pharma (CCP). CCP is conducting a phase 2/3 study with a diacerein‐containing ointment (NCT03154333). JWB was holder of the EMA orphan drug designation on diacerein in epidermolysis bullosa.CP, JR and ML wrote the original draft. CP, JR and ML and JWB reviewed and edited the manuscript. All authors have read and approved the final manuscript.


Our research is focused on the development of decentralized waste water treatment technologies enabling onsite water reuse. Accumulation of solids with recycling of treated blackwater increases the energy required for disinfection with an electrochemical process. We hypothesized that improving the preprocess settling of blackwater by increasing the tortuosity of the liquid flow path would reduce this energy demand by reducing particle‐associated chemical oxygen demand (COD). This approach successfully reduced the total suspended solids and turbidity in the process liquid accumulated per user‐day equivalent. A modest reduction in the apparent steady‐state accumulation of COD was also observed, likely because of the retention of COD associated with larger particles in the settling tanks. Interestingly, these improvements did not improve the energy efficiency of the electrochemical disinfection process, as predicted. These observations suggest that improving the energy efficiency of electrochemical disinfection will require remediation of dissolved COD. The lack of access to improved sanitation facilities amongst approximately 1/3 of the global population  of the process liquid  required for electrochemically produced oxidant inactivation of Our system is designed to handle up to 10 users per day in high population density settings, which limits the physical footprint of the overall system. As such, large settling tanks enabling very long retention times are not practical. Our previous prototype system made use of a compact, three‐tank design with a total effective volume of 30 L to settle particulates out of the process liquid prior to electrochemical treatment  and faecal masses (∑mfeces) flushed into the system were continuously logged and used to calculate user‐day equivalents (UDE) by the following equation:Our prototype liquid disinfection system and the sample collection and laboratory procedures used in this study have been described in detail previously  liquid waste was recycled through the system as flush liquid for subsequent flush cycles, with excess processed liquid  discharged.2 in area each, separated by a 3‐mm gaps. Current through the electrochemical cell was monitored with a Mastech MS2138R AC/DC clamp meter, and electrochemical energy per volume of process liquid used at time n (nE) was estimated by:Liquid waste was treated in 30‐L batches with a two‐stage electrochemical process (60–120 min at 24 Vdc followed by 90–180 min at 32 Vdc) using a commercially available electrochemical cell . The electrochemical cell consisted of 13 dual‐sided mixed‐metal oxide (MMO) electrodes, 64 cmV is the voltage, I is the current, ν is the volume being treated. The integral of current with time was estimated by the trapezoid method.where 2O. Blanks consisted of 2 mL of DI H2O. Turbidity was measured with a HACH 2100Q IS following the manufacturer’s instructions. Total suspended solids (TSS) were determined using Standard Method 2540D. This was accomplished by weighing liquid samples (~10 mL) in tared tubes, washing the samples through tared 0.7‐μm filter paper (Fisher) and weighing the filter papers after drying at 103–105°C. Microbes were enumerated with a most probable number (MPN) method as previously described . COD was measured using the Reactor Digestion Method (HACH method 8000) using a HACH DRB200 reactor and a HACH DR 900 colorimeter . Samples were run according the manufacturer’s instructions; briefly, 2 mL of sample were added to a digestion vial, mixed well and reacted at 165°C for 2 h. After cooling to room temperature absorbance was measured using program 435 COD HR. Samples with readings out of range were diluted using DI H3Flush cycles were performed for each set of tests over several weeks as previously described  and the geometry of the system  and the faecal solids that passed through the solid‐liquid separator. The rates at which we flush urine and feces into the system result in a net input to the system of ~22 g feces per L of total liquid  was lower than it was with the original design. However, even if we revise our estimated influent TSS down to 500 mg/L we still saw 58 ± 23% TSS removal in the enhanced settling system, which is comparable to the reported performance of modern primary clarifiers in waste water treatment plants , suggesting that this fraction of COD is associated with suspended solids, in good agreement with previous reports . Energy required to meet the 5/mL threshold increased with increasing UDE in both systems , leading to the ‘long tail’ in the disinfection curve observed (Hawkins et al., Taken together, these data indicate that whilst up to 50% of COD in blackwater is associated with larger particulates that can be partially remediated by improved preprocess settling, the COD associated with smaller particles and soluble species likely represent the biggest energy drag on the electrochemical disinfection process. It is possible that particle‐associated COD is partially shielded from oxidants in the bulk solution, making it resistant to removal by oxidation but also making it relatively unavailable to compete with microbes for oxidants; thus, its removal has minimal impact on the energy efficiency of electrochemical disinfection. High levels of soluble COD in the bulk solution, on the other hand, present many more opportunities for oxidants to be chemically neutralized rather than kill microbes, particularly when microbe counts are very low (<104Increasing the tortuosity of the liquid flow path through the settling system improves retention of particulates, as demonstrated by substantial reductions in TSS and turbidity in the process liquid.These observations, together with the determination that ~50% of COD in blackwater from this system is found in soluble species and in particles too small to be readily settled, suggest that focusing on remediation of soluble components of COD is necessary to achieve a significant decrease in electrochemical disinfection energy demand.


FDA box warning raised concerns about increased suicidal ideation among youth taking antidepressants, antidepressant use decreased for White youth but slightly increased for Black and Latino youth. Better understanding of patient and provider factors contributing to these differences is needed to improve future risk warning dissemination.After the 2004 CA, FL, NC, and NY). In multilevel models, we assessed provider‐ and patient‐level contributions to changes in antidepressant use by race/ethnicity and compared responses to the box warning between providers with large (>2/3) and small (<1/3) proportions of minority patients.We analyzed antidepressant prescriptions for youth aged 5‐17 in 2002‐2006 Medicaid claims data from four states (ICC) was explained at the provider level. Significant provider‐level variation was also identified in the differential effect of the box warning by racial/ethnic group. In a test of the influence of provider panel mix, we found that providers with large proportions of minority patients reduced antidepressant prescribing more slowly after the box warning than other providers.A significant amount of variance in overall prescribing patterns (calculated by the This study is the first to assess provider‐ and patient‐level variation in the impact of a health care policy change on treatment disparities. Black and Latino youth Medicaid beneficiaries were seen by largely different providers than their White counterparts, and these distinct providers were influential in driving antidepressant prescription patterns following the box warning. Concerted outreach to providers of minority beneficiaries is needed to ensure that risk warnings and clinical innovations diffuse swiftly across racial/ethnic minority groups. The issuance of box warnings has led to significant declines in overall use of the targeted drugs;Whether a racial/ethnic minority youth with depression is prescribed an antidepressant is likely to depend largely on the provider from whom they receive care. In studies of adult patients, providers that treat predominantly racial/ethnic minority patients are less likely to be influenced by new and emerging external scientific evidence compared to providers that treat predominantly White patients.Ideally, providers and patients (and caregivers of youth patients) make decisions jointly about the treatment plan.Providers with specialty training in mental health  are more likely to effectively receive, interpret, and disseminate information regarding EBPs than are pediatricians and other primary care providers (PCPs). This suggests that youth that receive mental health treatment from only a PCP  files for California, Florida, New York, and North Carolina for the years 2002‐2006. These four states were chosen because they are representative of other racially/ethnically diverse states, their large Medicaid beneficiary populations (these states make up over 33 percent of the entire Medicaid population of the United States), and their relatively low rates of Medicaid managed care penetration during the years of study, allowing for a focus on fee for service beneficiaries for whom MAX contains complete data. The MAX data are extracted annually from the Medicaid Statistical Information System (MSIS) and include information on beneficiary demographic information, services used, and medications supplied, as well as International Classification of Diseases, Ninth Revision (ICD‐9) diagnostic codes for each service provided. We linked services rendered and prescription drug claims to state provider identification numbers. The final dataset merges the outpatient and pharmacy MAX files and includes eligibility, encounter, and pharmacy data for all youth aged 5‐17 years enrolled in Medicaid programs in these four states during the study period. We defined three time periods: pre–box warning (January 2002 to September 2003), “phase‐in” (October 2003 to October 2004), and post–box warning (November 2004 to December 2006). In October 2004, the FDA issued the warning that antidepressants were associated with an increased risk of suicidal ideation in youth. We excluded claims from the “phase‐in” period because of preliminary FDA advisories starting in October 2003 that could have affected provider awareness of suicidality concerns and prescribing of antidepressants.The sample consists of claims from non‐Latino White, Black, and Latino youth eligible for Medicaid in each month of analysis, totaling 7 026 029 claims for outpatient visits, inpatient visits, and medication fills, attributed to 1 228 596 Medicaid beneficiaries . We excluded Asian, Native American, and multiracial youth due to small sample sizes.Claims were aggregated to the patient‐month unit of analysis; each observation contains antidepressant data for a given month for a specific patient. For each patient‐month, we assigned the patient to the provider that he/she saw for the greatest percentage of their outpatient visits in that calendar year. In the case of ties, one of the tied providers was randomly chosen. If there were no visits during the year or there was no available provider identifier, then the patient data were not used for that year. The list of antidepressants was determined using Multum medication classification codes.This data structure allows for multilevel modeling, which can account for the nonindependence of multiple months of data from the same individual.2.2uj00 a provider‐level random intercept (equation j31 in equation uj01 through uj30 (in equations uj31 (a provider‐level random effect on βj31) in equation We implemented a multilevel linear probability model to examine the differential impact by race/ethnicity of the box warning :Level 2 (patient):Level 3 (provider):Ytij is the dichotomous dependent variable, coded as 1 if there is a filled prescription for an antidepressant for individual patient i from provider j at month t, and 0 otherwise. Months is a counter variable that equals 1 for the first month of the study period and increases by 1 for every month thereafter, Post‐BW is a 0/1 indicator of whether or not a given month was before or after the box warning came out, and Months‐Post‐BW is a counter variable that equals 1 for the first month after the box warning came out and increases by 1 for every month thereafter. Race/ethnicity (race) was determined using categories of non‐Latino White (“White”), non‐Latino Black or African American (“Black”), and Latino or Hispanic (“Latino”). The coefficients on the raceij variables in level 2 represent interactions between raceij and time variables. Covariances between random effects were assumed to be zero.In the third analysis of interest, in order to better understand provider‐level variance, we tested the significance of observed provider‐level covariates, estimating a new multilevel model (equations Level 1 (time):Level 2 (patient):Level 3 (provider):j.., represents the providers’ patient panel, consisting of >2/3, between 2/3 and 1/3, and <1/3 of racial minority patients (Black or Latino). The coefficients on the provider_comp..j variables in level 3 represent interactions between provider_comp..j and the time variables. In particular, we are interested in whether the reactions immediately after the box warning  and changes in the post–box warning slope (γ301) were greater or less among providers who had >2/3 racial/ethnic minority patients, as compared to providers who had <1/3 racial/ethnic minority patients. All models were estimated using the STATA 14 software package .The categorical variable, provider_comp3We first describe, by race/ethnicity, the gender, Medicaid eligibility type, probability of any antidepressant fill, and age as of January 2002 or a patient's first appearance in the MAX data Table . As has A majority of all Medicaid youth beneficiaries (66 percennt) in this study, regardless of race/ethnicity, received treatment from providers that have panels composed of >2/3 Black or Latino patients . The ICC indicates that provider‐level variation contributed 12 percent of the total variance in antidepressant prescribing compared to a contribution of 44 percent at the patient level, after conditioning on the race/ethnicity and time variables ; unfortunately, the MAX data used in this study do not contain National Physician Identification Numbers for the majority of the claims, making it impossible to link our analytical dataset with other datasets with physician specialty information.The delicate balance of risks and benefits of antidepressants (and other psychotropic medications) complicate the implications from our findings. Although there is a robust body of evidence demonstrating the effectiveness of psychotropic medication in the treatment of mood, psychotic, anxiety, developmental, and behavioral disorders,We offer evidence that providers contribute to larger shifts in prescribing antidepressants for Whites as compared to Black and Latino patients, in relative and absolute terms, as differences in the speed of risk diffusion varied by the racial/ethnic composition of the patient panel of providers. The reaction to the box warning was slower among providers with more than 2/3 minority patients compared with providers with panels of predominantly White patients. This result is consistent with prior studies showing that providers of racial/ethnic minority patients are less likely to be influenced by the research findings of the FDA and other organizations than providers of White patients.In conclusion, this study identified that the reduction in racial/ethnic differences in antidepressant use after the box warning (caused by the decline among White youth and steady rates among Blacks and Latinos) was in large part explained by the fact that racial/ethnic minority youth largely seek care from a different subset of providers than White youth and that minority‐serving providers reacted differently to the box warning. As rates of psychotropic medication use in youth continue to climb in the United States, Click here for additional data file.


Dear editor,10.1051/sicotj/2016008 (PMID: 27163103). The objective of the study was to assess the TTTG distance in 100 MRI scans of skeletally matured Indian knees.We were interested in reading “Patellar instability in Indian population: relevance of tibial tuberosity and trochlear groove distance” by Sourabh Kulkarni et al. published in the esteemed Sicot Journal Published online on 2016 Mar 25. DOI: The authors defined TT–TG distance by measuring the distance between two parallel vertical lines, one passing through the apex of tibial tuberosity and the other through the apex of the trochlear groove . The tecFurthermore, the author uses the center of the patellar tendon as a reference point for tibial tuberosity to obtain the TT–TG distance. This in fact is PT–TG (patellar tendon–trochlear groove) distance which is found to be different from the osseous TT–TG distance. Wilcox et al.  in his sTo conclude, the methodology used in the study needs to be verified and the TT–TG distance measured should be ideally referred to as PT–TG distance.


The aim of this study was to evaluate by light microscopy analysis the effect of the use of miniaturised piezoelectric tips versus mini‐five area specific curets on calculus removal and postoperative root surface alterations.A total of 20 extracted teeth were used. Two square surfaces (5×5 mm) were marked on each root surface with a diamond bur mounted on a high‐speed handpiece. Before and after instrumentation, a series of magnified images (4.2×) of each experimental surface were taken with a standardized approach. According to a randomization list, the two surfaces on each sample were instrumented in a standardised fashion either with a mine‐five curet or a slim piezoelectric tip. The images were processed using an imaging software. Data were summarised as means and standard deviations for the two outcomes  at each time (pre and post) for both of the groups .p < .001) without significant differences between the two groups. Both manual and mechanical treatments significantly increased alterations (p < .01). There was a statistically significant evidence of a greater increase in alterations from mechanical treatment.Both manual and mechanical instrumentation significantly reduced the calculus deposits (Slim mechanical piezoelectric tips and manual mini‐five area‐specific curets have similar effects on calculus removal. Manual instrumentation results in a more homogeneous postoperative root surface with less root alterations. The tip was kept as much parallel as possible to the tooth long axis, and a series of light horizontal apico‐coronal movements with light lateral pressure were performed under abundant irrigation. The working time for each mechanical specimen was 30 s, and the power was set on a value of 5 in a scale from 1 to 10.The control areas (B) were mechanically instrumented with a piezoelectric unitOnce the instrumentation procedures were completed, each specimen was first cleaned with distilled water and then dried with light air‐pressure jet to remove any remaining non attached calculus residual and smear layer, and the photographic analysis was carried out as described above.A qualitative and quantitative assessment of the images was made independently by three authors not involved in the instrumentation phase .6Preview, Apple Inc., Cupertino, USA. and displaying the images on a wide high‐definition desktop computer screen.All the pictures were analysed before and after the different procedures using an imaging softwareFor this purpose, a rectangular grid composed of 40 equivalent squares  was superimposed to each picture Figure .This allowed to quantify the number of squares with calculus residuals out of the total number of squares before and after the instrumentation procedures.Any evident groove, scratch, cavity, demineralized, and/or porous areas that were visible on the screen after the instrumentation was considered as a surface alteration and assessed before and after the instrumentation procedures.0 = no obvious irregularities, resulting in an essentially glass‐like surface;1 = faint irregularities noticeable, but surface was essentially smooth;2 = distinct irregularities visible, resulting in a visibly roughened surface; and3 = gross irregularities of exaggerated depth with a distinct roughened, irregular surface.For this purpose, a quantitative analysis of the irregularities was carried using a modification of a previously published scale. This scale ranged from 0 to 3  at each time (pre and post) for every group . For both calculus and surface alterations measures, values from the three raters were averaged together to give a single estimate for each surface at each time. As both outcomes were overdispersed, negative binomial regression was used rather than Poisson regression to model the number of squares (between 0 and 40) scored as positive for calculus or irregularities. For between group comparisons, postmeasurements were compared adjusting for premeasurements. As for within group tests, mixed effects negative binomial regression was used with a random surface id effect to accommodate the paired data. All statistical analyses were performed using a specific software,3Changes in deposits amount and irregularities have been observed in both groups after instrumentation Table .p < .001). There was evidence of a greater reduction in calculus from the manual treatment without any statistical difference . More specifically, there was statistically significant evidence of a greater increase in irregularities from the mechanical treatment . It is therefore essential to select the instruments and the instrumentation pattern that minimizes the risk of having morphological alterations on the root surface and excessive cementum removal  for a limited marked area (roughly 25 mm), some deposits could still be detected after both the instrumentation modalities.This confirms the results of other studies that have shown that a complete removal of the biofilm and calculus is overambitious .Our microscopic analysis shows that mini‐five area‐specific curettes are optimal instruments for root instrumentation in terms of both calculus removal and surface alterations.This is in contrast with other studies that compared standard area‐specific curets versus standard tip mounted on machine‐driven instruments and that showed that curets can create deep grooves and remove sound tooth substance from tooth surface when compared with machine‐driven instruments (Santos, Pochapski, Leal, Gimenes‐Sakima, & Marcantonio, In addition, our results confirm that manual instrumentation with curettes results in a more homogenous and smoother root surface.Within the limits of the present in vitro study, slim mechanical piezoelectric tips and manual mini‐five area‐specific curets have similar effects on calculus removal.Manual instrumentation with mini‐five curets results in a more homogeneous postoperative root surface.A combination of manual and mechanical approach may still be considered the best instrumentation methodology.The authors declare that they do not have any conflict of interest in relation to this project.No financial support has been received for this study.


With a growing access to free ART, switching of ART to second line regimen has also become common following failure of first line ART regimens. Patients failing on first line ART regimens have been shown to stand a high risk of failing on subsequent second line ART regimens. The magnitude of those who are failing virologicaly on second line ART is not documented in our setting. This study was designed to assess the magnitude and correlates of second line ART treatment failure.1 year was done at Bugando care and treatment center. Information on demographic, clinical and laboratory data were collected and analyzed using STATA 11. The proportion of patients with Virological failure was calculated and potential correlates of virological failure were determined by logistic regression model.A retrospective analysis of patients on second line ART for at least p = 0.001), being on first line for less than 3 years  and CD4 at switch to second line ART of less than 200cells/μl .In total 197 patients on second line ART were included in this study and 24 (12.18%) of them met criteria for virological failure. The odds of having virological failure on second line ART were independently associated with age of less than 30 years (AOR = 12.5, Virological failure among patients on second line ART is common. Predictors of virological failure in this study could assist in planning for strategies to improve the outcome of this subgroup of patients including close clinical follow up of patients at risk, a continued adherence intensification and a targeted resistance testing before switching to second line ART. The patients experiencing first-line antiretroviral therapy (ART) treatment failure have been shown to stand a higher risk of failing on subsequent second line regimens due to side effects and complex regimens which could lead into selection of resistant strains . These pSwitching to potent second line ART regimens has been shown to have a number of benefits including improving virological containment and immune response –8, reducThe literature on the extent of this problem in our setting is still scarce. This study therefore was designed to determine the prevalence and assess the risk factors of treatment failure among adult HIV patients who are receiving protease inhibitor (PI) based second line ART regimen in northwestern Tanzania. This information is important in devising strategies to optimize the outcome of this subgroup of patients but we also believe it will significantly add to the existing body of knowledge on virological performance of PI based second line ART regimen in resource limited settings like ours.This was a case control study which was done during elective research period from September 2017 to May 2018 at Bugando medical center (BMC) HIV Care and treatment center (CTC). BMC is a tertiary level and a university teaching hospital located in the North Western part of Tanzania. Currently the hospital has a capacity of 1000 beds, and serving about 16 million people. As one of its core services BMC also runs HIV activities with a referral CTC department. The center started a way back 2004, and it currently serves a total of more than 14,000 clients. Core activities at CTC include provision of ART, follow up and treatment monitoring. ART drugs are provided for free of charge and about 10,000 patients are currently on ART. In our setting first line ART are basically Non Nucleoside/ Nucleotide Reverse Transcriptase Inhibitors (NNRTI) based regimens; whereas patients failing on first line ART regimens are usually switched to Protease Inhibitor (PI) based second line ART regimen. Around 500 patients are currently receiving PI based second line ART regimen. ART treatment monitoring is routinely done using clinical and immunological parameters where CD4 counts are checked 6 monthly since viral loads (VL) are still expensive for routine use. Targeted VL and adherence intensification are usually done before switching to second line ART is done. Patient with VL of more than 1000copies/ml usually get a repeat testing after 3 months of adherence intensification and those with log drop of less than 0.5 are classified as failing virologicaly. Our current cohort of patients on PI based second line ART had a regular VL test 6 monthly. Those found with VL of more than 1000copies/μl had adherence intensification and a conclusion of virological failure was reached if a subsequent VL was more than 1000copies/μl. The adherence was assessed by a combination of patients’ report and pill count as done previously [The study involved all adult HIV positive patients who are currently receiving PI based second line ART regimens at Bugando CTC in Mwanza. A minimum sample size of 178 was estimated from Leslie Kish formula 1965) for cross sectional studies assuming 13.35% of patients on second line ART will experience virological failure as found previously 65 for cr. Files op value was less than 0.05.Data were computerized using Epi data version 3.1 and STATA version 11  was used for data analysis. Continuous variables were expressed as medians with interquartile range (IQR) while categorical variables were expressed as proportions with percentages. The treatment outcome in this study was defined as development of virological failure as used previously where patients who had a second VL of more than 1000copies/μl while receiving PI based second line ART regimen for at least a year were coded as failing virologicaly . The proThe permission to conduct and publish the results from this study was sought from the catholic University of Health and allied Sciences/ Bugando Medical Center joint ethical committee. The patient’s files were handled by the researchers alone and the patients’ identifiers including names and registration numbers were not included in the analysis to further maintain confidentiality.In total 197 patients were enrolled in this study. About 3 quarters, 146 (74.11%) of the study participants were female patients and almost a third of participants, 64 32.65%) had lost their spouse. At enrollment to CTC most patients, 114 (57.87%) had WHO clinical stage 3 & 4 AIDS defining illnesses and 57 (28.93%) had severe immune suppression. With a median time on second line ART of 14 –18 month.65% had p = 0.001), being on first line ART regimen for less 3 years  and CD4 counts of less than 200cells/μl at switch to second line ART . Adherence level of less than 95% had a significant association with virological failure on univariate analysis alone  while the difference in distribution of other variables was not different statistically including the type of ART regimens and time on second line ART as summarized in Table A total of 24 12.18%) participants were found to meet criteria for virological failure in this study .Several factors were investigated for possible independent association with virological failure in the index study. In our study we found that patients who experienced treatment failure after being on first line ART for less than 36 months were more likely to fail on subsequent PI based second line ART. A similar observation was reported by Boerma in 2017 indicating that of those patients who failed on first line ART regimen less than 24 months were also more likely to fail on second line ART , 26. In Additionally in this study young patients were found to have increased risk of virological failure especially among those who were younger than 30 years. Onoya and colleagues had similar observation indicating that patients who were younger than 40 years were more likely to fail on second line ART . SimilarPoor adherence would limit virological control and a loss of immunological and clinical improvement . In a reThis study is potentially liable to a number of limitations. Being a single center study its results may not be generalizable. It was a retrospective study from which some information could not be retrieved including assessment of attendant opportunistic conditions. However even with these limitations this is probably the first study to evaluate virological performance of PI based second line ART without resistance guidance in Tanzania and thus we think the findings from this study are valuable and will serve as a potential foundation for further studies to maximize the outcome of HIV patients in this part of resource limited setting which is currently serving as CTC referral facility for the northwestern Tanzania. A prospective analysis of patients with probably resistance testing component might give us a better insight of this subgroup of patients.In conclusion these findings are clinically important in our setting suggesting that virological failure on present PI base second line ART is a prevailing problem though its size is relatively small in this study as compared to most other studies. Patients failing on second line ART have increased risk of mortality as shown in previous studies , 33. Sin


Implantable cardioverter defibrillator (ICD) was implemented into clinical routine more than 20 years ago. Since then, ICD therapy became standard therapy for primary and secondary prevention of sudden cardiac death in clinical practice.Aim of the study was to evaluate the benefit‐harm profile of contemporary primary prophylactic ICD therapy.A total of 1222 consecutive patients of a prospective single‐center ICD‐registry were analyzed who underwent primary prophylactic ICD implantation between 2000 and 2017. Patients were divided into two groups according to the implantation year: 2010‐2017  and 2000‐2009 .P < .001). The complication rate changed slightly from 53% to 47% (P = .005). This decline was mainly driven by the reduction of inappropriate ICD shocks  whereas the rate of ICD shock lead malfunction and device/ lead infection remained unchanged over time. Nonischemic cardiomyopathy was an independent predictor for ICD complications without benefit of ICD therapy .The rate of estimated appropriate ICD therapy after 8 years was 51% in the 2000s and 42% in the 2010s (The ICD therapy rate for ventricular arrhythmias in patients with primary prophylactic ICD implantation is decreasing over the last two decades. Complication rate remains high due to an unchanged rate of ICD shock malfunctions and device infections. Nonischemic cardiomyopathy is an independent predictor for ICD complications without benefit of ICD therapy in primary prophylactic ICD‐therapy. Since then it became standard therapy for primary and secondary prevention of sudden cardiac death in clinical practice. Randomized studies like the Multicenter Automatic Defibrillator Implantation Trial (MADIT) or Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT) which introduced the ICD therapy for primary prophylactic indication to standard heart failure treatment were conducted in the 90s or beginning of the 2000s.22.1A total of 1222 of 2378 (51%) patients of the prospective single‐center ICD‐registry Ludwigshafen who underwent ICD implantation between 2000 and 2017 and had a primary prophylactic ICD indication with an ejection fraction (EF) ≤ 40% were included into the present study. The prospective single center ICD‐registry Ludwigshafen has been previously described in detail.Benefit of ICD therapy was defined as appropriate termination of ventricular tachyarrhythmias by ICD. Harm of ICD therapy included perioperative complications related to ICD‐implantation or revision, ICD lead failure or lead malfunction requiring lead revision or termination of ICD therapy, device recalls, inappropriate ICD shocks, ICD pocket problems and device infection. The time to follow‐up was the period up to the most recent follow‐up visit or the time to death. For the present analysis, the maximum follow‐up duration was 8 years. The follow‐up ended in September 2018. In 49 patients, ICD therapy was stopped due to the clinical status of the patient or heart transplantation.2.2From 2000 to 2005 all patients received two zones of therapy: (a) a VF zone which was defined as an episode of tachycardia with at least 12 beats at a rate of 200 beats per minute or more; in this zone up to six shocks could be delivered per episode; (b) a VT zone with an episode of tachycardia with at least 12 beats at a rate between 167 and 200 beats per minute. Three ATP bursts were followed by up to five shocks if the tachycardia did not terminate previously. In 2005, clinical routine changed. Patients with newly implanted ICD due to primary prophylactic ICD indication received only a VF therapy zone and a monitor zone was programmed for detection of VTs between 167 and 200 beats per minute. If VT was detected in the monitor zone during follow‐up, a VT therapy zone was activated, too. Since 2012, the device programming was adapted according to the MADIT Rit trial, which consisted of a prolonging of the number of beats for detection of VT and VF.2.3The patient population is described by absolute numbers and percentages. The distribution of continuous variables is characterized by means and SD, or medians with upper/lower quartile. Patients were divided into two groups according to the implantation decade: 2010‐2017  and 2000‐2009 . Categorical variables were compared by using the Pearson chi‐square or Fisher's exact test, as appropriate.Kaplan‐Meier curves were calculated to compare the different endpoints. Differences were compared by using the log rank test. Cox regression analysis was performed to find independent predictors for benefit or harm from ICD therapy. The following parameters were included into the multivariate analysis: age > 70 years, female gender, EF < 30%, nonischemic heart disease, diabetes, atrial fibrillation, CRT, Riata ICD lead and implantation decade. All P‐values were two‐tailed. A P‐value <.05 was considered to be statistically significant. The tests were performed using SPSS. The authors had full access to the data and take complete responsibility for the integrity of the data. All authors have read and agreed to the manuscript as written.33.1Baseline clinical data of the patients stratified according to the implantation decade are summarized in Table 3.2P < .001). The rate of estimated appropriate ICD therapy after 8 years was 51% in the 2000s and 42% in the 2010s  had a 12% lower 8 year mortality than patients implanted in the 2000s , the incidence of pocket revision after 8 years  or the incidence of device recalls needing revision . There were 4 ICD‐related deaths in the 2000s and no ICD‐related death in the 2010s. Two patients died from device infection, one patient from superior vena cava rupture and cardiac tamponade during lead extraction due to lead failure and one patient from ventricular fibrillation induced by inappropriate shock which occurred due to artifact sensing caused by lead fracture. The induced VF could not be terminated by the ICD due to the lead fracture.The overall complication rate changed slightly from 53% to 47% (The benefit‐harm profile at the end of follow‐up was as follows: 33% of patients had benefit from ICD therapy (n = 409) and 35% ICD complications n = 427). Twenty‐two percent (n = 264) of ICD patients had only harm from ICD without benefit. In a multivariate analysis including the factors age > 70 years, female gender, EF < 30%, nonischemic heart disease, diabetes, atrial fibrillation, CRT, Riata ICD lead and implantation decade the only independent predictor for increased incidence of ICD‐treated ventricular tachyarrhythmias was atrial fibrillation whereas implantation in 2010s was associated with a lower incidence of appropriate ICD therapy (Table 7. Twenty44.1The ICD therapy rate for ventricular arrhythmias in patients with primary prophylactic ICD implantation is decreasing over the last two decades. The complication rate has slightly reduced due to a substantial decrease of inappropriate ICD shocks whereas ICD shock lead problems and device infection remain a major issue in ICD therapy. Nearly a quarter of primary prophylactic ICD patients has only ICD complications without receiving appropriate ICD therapy. The presence of nonischemic cardiomyopathy is an independent predictor for ICD complications without benefit of ICD therapy.4.2The rate of appropriate ICD therapy decreased over the last two decades. This reduction included ICD shocks, and ATP therapy as well as VT and VF episodes. One important reason might be attributed to the temporal trend of a less aggressive programming of the VT/VF zones. Several studies showed that change of ICD programming to less aggressive therapy resulted in lower mortality rates.Another explanation for the lower rate of VT/VF episodes in the primary prophylactic ICD population might be the change of clinical characteristics towards a less severely progressed heart failure disease at ICD implantation as well as a better heart failure treatment. The 2010s primary prophylactic ICD group had less often renal failure at implantation, less often digoxin therapy and more often spironolactone compared to the 2000s group. The 8‐year mortality rate was 12% lower compared to patients implanted in the 2000s. In addition, the reduction of ICD therapy did include a reduction of VF episodes which cannot be explained only by a change of ICD programming. Our observations are supported by a previous study where Boveda et al. observed a significant change in patterns of use and outcomes in primary prevention ICD over the last decade with reductions in mortality and appropriate therapies. These reductions were counterbalanced by an increase in late ICD complications.4.3A substantial decrease of inappropriate ICD shocks was seen between 2000 and 2018 which can be explained partly by changes of ICD programming as mentioned above. Additionally, improved discrimination algorithm of lead noise or supraventricular tachycardias from ventricular tachyarrhythmias prevented inappropriate ICD shocks in the later implantation groups.The most serious ICD complication is the device infection which remained unchanged during the two decades. Standard guidelines for prevention of device infection were applied as accurate as possible.4.4In the present study 33% had termination of potentially malignant ventricular tachyarrhythmias at the end of follow‐up. But more important, 22% had only ICD complications including potentially life‐threatening harm without need of appropriate ICD therapy during follow‐up. Nonischemic cardiomyopathy was the only predictor for ICD complications without benefit from ICD therapy. Importantly, nonischemic cardiomyopathy was not associated with a lower benefit with regard to termination of ventricular tachyarrhythmias by the ICD. The potential benefit of ICD therapy in nonischemic cardiomyopathy is questioned at least since the publication of the DANISH trial, which showed no benefit of ICD therapy in this patient group.4.5As the current study is a single‐center registry, our observations and conclusions may not be necessarily generalized. ICD related complications might dependent from local conditions like operation technique, choice of manufacturer or device programming. Especially the rate of ICD shock lead malfunctions might be influenced by certain leads having higher rates of malfunction like the Riata lead.5The rate of ICD therapy for ventricular arrhythmias is decreasing while the complication rates remain high due to an unchanged elevated malfunction rate of ICD shock leads after 8 years and an unchanged device infection rate. Future efforts should focus on improving the long‐term performance of ICD shock leads and reduction of device infections. Careful selection and detailed informed consent of patients is necessary before implantation of primary prophylactic ICD implantation.The authors declare no potential conflict of interests.