The relationship between soil properties and UAV‐derived variables was first evaluated at the field plot level. Then, the maps obtained were used to explore the relationship between biocrusts and terrain attributes at ecosystem level through a redundancy analysis. The most significant variables that explain biocrust distribution are: ATI , Elevation , and potential solar incoming radiation (PSIR) . Differences were found between areas dominated by lichens and mosses. Lichen‐dominated biocrusts were associated with areas with high slopes and low values of ATI, with soil characterized by a higher amount of soluble salts, and lower amount of organic carbon, total phosphorus (Ptot) and total nitrogen (Ntot). Biocrust‐forming mosses dominated lower and moister areas, characterized by gentler slopes and higher values of ATI with soils with higher contents of organic carbon, Ptot and Ntot. This study shows the potential to use UAVs to improve our understanding of drylands and to evaluate the control that the terrain has on biocrust distribution.Biocrusts  are a key biotic component of dryland ecosystems. Whilst climate patterns control the distribution of biocrusts in drylands worldwide, terrain and soil attributes can influence biocrust distribution at landscape scale. Multi‐source unmanned aerial vehicle (UAV) imagery was used to map and study biocrust ecology in a typical dryland ecosystem in central Spain. Red, green and blue (RGB) imagery was processed using structure‐from‐motion techniques to map terrain attributes related to microclimate and terrain stability. Multispectral imagery was used to produce accurate maps (accuracy > 80%) of dryland ecosystem components . Finally, thermal infrared (TIR) and multispectral imagery was used to calculate the apparent thermal inertia (ATI) of soil and to evaluate how ATI was related to soil moisture  of soils and to estimate how ATI was related to soil moisture. Finally, we used multispectral imagery to produce accurate maps of dryland ecosystem components . We integrated traditional field approaches with new methodologies to explore the relationship between biocrusts and terrain attributes at landscape level. The very fine spatial resolution maps provided by UAVs were essential for a detailed description and monitoring of these complex and threatened ecosystems. This information can be used to calculate topography‐related variables  mapping dryland constituents  through multispectral imagery; (ii) estimating terrain attributes from structure‐from‐motion (SfM) techniques applied to RGB imagery and evaluating their relation with soil properties; (iii) estimating soil moisture using maps of ATI derived from TIR imagery; (iv) evaluating through a multivariate statistical approach how terrain attributes and soil moisture affect biocrust distribution in the study area.22.1Macrochloa tenacissima tussocks and, in a lesser amount, small shrubs such as Helianthemum squamatum and Gypsophila struthium. On the surface area that is not covered by vascular vegetation, a rich biocrust community dominated by lichens develops, including Diploschistes diacapsis, Squamarina lentigera and Psora decipiens among others. A moss‐dominated crust also develops, with species such as Pleurochaete squarrosa and Tortula revolvens. Cyanobacteria genera, such as Microcoleus, Tolypothrix and Nostoc can also be found in the area  was visually assessed and the species composition of biocrust and vascular vegetation was characterized. Pictures were also taken with a camera mounted on a tripod at 1 m height. Three representative soil sub‐samples were taken in each plot from 0 to 10 cm depth (after removing the litter layer) and pooled to one sample, which represented the average soil characteristics of the plot. The samples were chemically and physically analysed in the laboratory applying standard techniques , percentage of organic carbon (OrgCarb) and total nitrogen (Ntot). Soil moisture was measured in the field at 0–10 cm depth at three representative locations within each plot using a FieldScout TDR‐100 soil moisture meter .On 21 March 2018, we established 23 2 × 2 m2.2.2The UAV flights Table  were con® panel was measured with the Sequoia camera immediately before and directly after the drone survey to calibrate the images.All flights followed a single grid flight geometry at constant height, with flight lines parallel to the slope and with the cameras in nadir‐view position. Flights were done at average flight speeds between 10 and 12 m/s. Lateral and longitudinal overlaps of at least 75% and 70%, respectively, were achieved between the RGB images, with an average distance of 22 m between the flight lines and 20 m between images. Lateral and longitudinal overlaps of at least 85% and 70%, respectively, were obtained between the multispectral images, with a distance of 12 m between the flight lines and 24 m between images. Lateral and longitudinal overlaps of at least 80% and 95%, respectively, were achieved between the TIR images, with a distance of 16 m between the flight lines and 3 m between images. The multispectral Parrot Sequoia camera is a compact bundle of four cameras with complementary metal‐oxide‐semiconductor sensors, each one equipped with an individual narrow‐band filter  which features a spectral range from 350 nm to 2500 nm, an optical resolution of 1 nm and a nominal field of view of 25°. Two types of reference targets were measured during the flight campaign: white and black 2 × 2 m2 targets made of polyvinyl chloride (PVC)‐coated canvas material  assumed to be lambertian surfaces, and selected homogeneous plots from the main biocrust communities in the study site. These measurements covered homogeneous surfaces of at least 30 cm in diameter. Before each target measurement, the downwelling solar radiance was measured on a calibrated 99% reflective Spectralon® panel  to optimize the instrument parameters and calculate the reflectance factors. Eight to ten spectra were taken on each target and were averaged to obtain the final spectrum for each target. These ground spectral measurements were acquired around solar noon, contemporaneously to the multispectral images collected by the Parrot Sequoia camera (UAV flight 2). Their exact location was registered using a differential global navigation satellite system (dGNSS) including one Topcon HiPer Pro antennas and one Topcon GPR‐1 . The spectra of all ground measurements were resampled to the Sequoia spectral resolution using the response function of the sensor  and altimetry (Z direction), the targets were evenly distributed across the whole study area of each zone, since the target distribution might affect later model generation accuracy  was enough to guarantee high accuracy in the derived digital models . To optimize the geometric accuracy of the UAV‐derived products in both planimetry  was calculated as the cosine of each cell of the aspect model. Since this variable ranges from −1 to 1, +1 was added to each pixel value to avoid problems in later calculations.Besides elevation, the slope of each cell was also calculated from the filtered DTM, applying the nine parameter second‐order polynomial method  of each pixel of the DTMs was modelled using the TauDEM toolbox  was used in this study as an indicator of the potential evapotranspiration  was calculated using the vegetation filtered DTMs of each area and the geometric solar radiation model implemented in ArcGIS Solar Analyst tool by assuming a uniform clear sky condition with a constant transmissivity of 0.5  of each pixel were converted to pseudo‐radiance in arbitrary units R according to Equation γ is the ISO number, ε is the exposure time in seconds, f is the f‐number and A, B and C are camera‐specific calibration coefficients which model the non‐linear behaviour of the sensor  to obtain the final reflectance for each spectral band of the image. First, the calibration coefficient ρ) of the scene was derived as in Equation Finally, the reflectance per pixel . The CRred was used to improve later classification of the images.The CR algorithm was computed on the geometrically and radiometrically corrected multispectral orthomosaic. This method normalizes the reflectance spectrum to a common baseline at specified wavelengths and allows the comparison of absorption features in the spectra that are produced by target components, for example pigments for vegetation covers. This is achieved by approximating the continuum between local spectral maxima through straight‐line segments; a value of 1 is assigned to the local maxima, and a value between 0 and 1 is obtained in correspondence of the absorption features. Interpolating the reflectance between 550 nm (Green band) and 735 nm (Red Edge band) as the continuum baseline. Although this algorithm is more typically applied to hyperspectral data, it has already been used in multispectral imagery to map drylands , bright lichens with moss , moss , Fulgensia spp. and moss , green vegetation  and dry vegetation . These surface covers were used as reference for the digital classification of the multispectral orthomosaic.Seven different surface covers were identified in the study site during the field surveys Figure : bare soAt least 15 polygons (around 100 pixels) per class were selected on each orthomosaic to train the support vector machine (SVM) algorithm used in the classification. These training areas were selected using ancillary information such as field notes, global positioning system (GPS) points and high resolution RGB orthomosaics. The four bands of the multispectral images were used as input in the SVM.red was used to improve the discrimination of some categories with similar spectral behaviour such as DryVeg and Moss, but different pigment absorption. Pixels classified as DryVeg with CRred values lower than 0.75 were assigned to Moss and pixels of BL with CRred values of 1 were assigned to Soil. These thresholds were defined from the CRred mean and standard deviation values calculated in correspondence with the training polygons of soil, DryVeg and Moss classes.SVM is a statistical learning based supervised classification method  to temperature in Celsius degrees according to Equation Two orthomosaics (one captured before sunrise and one at noon) of each target area with a spatial resolution of 15 cm were generated using Pix4Dmapper (Pix4D). The geometric accuracy of these TIR orthomosaics was assessed by calculating the RMSE, the mean error and standard deviation of error of the GCPs and the GVPs.−1), which is an approximation of thermal inertia and is derived directly from multi‐spectral remote sensing imagery  were performed using the marginal effect of the terms in the anova.cca function.The relationship between the different biocrust covers and the terrain variables in the whole study area was evaluated through a redundancy analysis (RDA) performed using the r2, but avoiding multicollinearity. This was estimated by the variance inflation factor (VIF), which was calculated through the vif.cca function of vegan R package. Variables with a VIF higher than 10 were excluded from the analysis.The CCA variable was removed from the analysis since it was used to calculate TWI and LSF. Based on this, a set of seven terrain attributes were considered in the analysis: (i) PSIR as an indicator of the potential evapotranspiration , while GreenVeg was the class showing the highest absorption of all the evaluated classes. While similar in the spectral shape, DryVeg and Moss presented differences in their CRred and reflectance values. The red absorption feature was present in all classes but Soil, and allowed to better differentiate it from biocrust classes. These subtle differences allowed an improvement in the classification carried out by the SVM, which slightly confused these two classes, by using thresholds in the CRred.Mean reflectances and standard deviations of the training classes used for the classification procedure are shown in Figure red thresholds on the Soil and DryVeg classes. Final accuracies are reported in Table κ equal to 0.8 and 0.93 in areas A and B, respectively. Only BLM in Area A had an OA below 80%. As shown in the confusion matrices . The first two RDA‐axes accounted for 34.0% of the variation for biocrust data , Elevation , Northernness  and Veg   appeared on the left side of the first axis, where vegetation presence and soil moisture  were higher and soil was richer in OrgCarb, Ptot and Ntot. Nevertheless, Tortula revolvens develops in soils with similar characteristics to those where lichens dominate, characterized by low elevation and low ATI and vegetation presence.The best fitted RDA model excluded Northernness and Slope variables, which showed multicollinearity, with VIF values around 20. The RDA results indicated that terrain variables significantly explained variation in the biocrust distribution in our study area  Table . For tho4red allowed us to improve the classification results by exploiting the differences between the biocrust classes.Previous studies have evaluated the effect of the terrain on biocrust spatial distribution . This moisture gradient promotes a diversification of ecological niches that also explains the distribution pattern of biocrust communities. However, long‐term studies are still necessary to better understand the dynamics of soil moisture and the feedback effects on biocrust cover, and to try to decouple the biocrust effect on water from the water effect on biocrusts, which are strongly interrelated. ATI could be a useful variable to expand our knowledge in this direction.It should be noted that UAV data collection took place during the wet season, when the water content in biocrusts is high and pigments are metabolically active . Fulgensia spp. has already been observed in unstable terrains several times, highlighting the pioneering behaviour of this genus , dominated areas with low PSIR, high ATI, and a high presence of vascular vegetation, where soils were richer in organic carbon and nutrients. A positive plant‐biocrust relationship is common for bryophytes . They appeared in more stable zones , as already observed in geographic areas with similar characteristics , Diploschistes diacapsis is more adapted to establish than other lichens, representing here the early stage of biocrust development.The RDA showed a lower explanatory power of the terrain attributes regarding We found instead mixed patches of lichens and moss (BLM) (thought to be of the last stages of development) in the left axis of the RDA plot, where water availability is still scarces but the terrain presentes lower elevation and LSF and less concentrations of gypsum. Moss‐dominated biocrusts become dominant in areas with higher soil moisture and north‐facing areas, where soil and micro‐environmental conditions are less selective. In the Tabernas desert  and minimum and maximum air temperatures  registered in the study area during 2018, the year when the field campaign took place. The red line evidence the day when the drone flights were conducted.Table S1. Mean emissivity value in the thermoMAP range (8.5–13.5 µm) of typical soil and biocrusts of the study area.Table S2. Confusion matrices of the classification of both study areas. Top: confusion matrix of Area A. Bottom: confusion matrix of Area B. BL: bright lichens; BLM: bright lichens and moss; Fulg: Fulgensia spp. and moss; GreenVeg: green vegetation; DryVeg: dry vegetation.Table S3. Explained variance of individual factors in the Redundancy Analysis (RDA) of the coverage of biocrust. Df: degrees of freedom. ATI: apparent thermal inertia; TWI: topographic wetness index; LSF: length slope factor; Veg: vegetation; Soil: bare soil; PSIR: potential incoming solar radiation. ***: p‐value < 0.001.Click here for additional data file.


Bacillus subtilis uses serine not only as a building block for proteins but also as an important precursor in many anabolic reactions. Moreover, a lack of serine results in the initiation of biofilm formation. However, excess serine inhibits the growth of B. subtilis. To unravel the underlying mechanisms, we isolated suppressor mutants that can tolerate toxic serine concentrations by three targeted and non‐targeted genome‐wide screens. All screens as well as genetic complementation in Escherichia coli identified the so far uncharacterized permease YbeC as the major serine transporter of B. subtilis. In addition to YbeC, the threonine transporters BcaP and YbxG make minor contributions to serine uptake. A strain lacking these three transporters was able to tolerate 100 mM serine whereas the wild type strain was already inhibited by 1 mM of the amino acid. The screen for serine‐resistant mutants also identified mutations that result in increased serine degradation and in increased expression of threonine biosynthetic enzymes suggesting that serine toxicity results from interference with threonine biosynthesis.The Gram‐positive bacterium  Many bacteria such as the model organisms Escherichia coli and Bacillus subtilis are capable of synthesizing all amino acids whereas others such as the minimal bacteria of the genus Mycoplasma completely depend on the uptake of amino acids.As building block of proteins, amino acids are central to the physiology of any living cell. In addition to their role as substrates in protein biosynthesis, they can be used as carbon and nitrogen sources. Moreover, some amino acids are also required for bacterial cell wall biosynthesis and as osmoprotectants. Accordingly, the acquisition of amino acids is an essential task of all cells. This can be achieved by the direct uptake of amino acids present in the growth medium, by the uptake and intracellular degradation of peptides and by et al., et al., et al., et al., B. subtilis, amino acid metabolism is one of the few functions in core metabolism that have not yet been completely elucidated. This is the case both for the biosynthetic pathways and for amino acid transport.While amino acids are essential for the cells, increased concentrations of some amino acids such as glutamate, threonine or serine can be harmful . However, as indicated above, no transporters have been identified for several amino acids. Accordingly, biosynthetic pathways were included for those amino acids. A minimal organism capable of transporting amino acids but not to produce them is expected to be viable on complex media but would be unable to grow on minimal medium in the absence of added amino acids. As minimal bacterial strains have a huge potential for biotechnological applications . Moreover, the reasons for serine toxicity have remained enigmatic. In E. coli, it has been suggested that serine binds and inactivates the bifunctional enzyme aspartate kinase/homoserine dehydrogenase (ThrA)  mutants and the remaining strains exhibited genetic lesions related to amino acid metabolism. Interestingly, the ybeC mutation was also found in the serA mutant as a suppressor, indicating that serine can be transported in ybeC mutant.We selected for loss of serine toxicity in the wild type strain and in a ΔB. subtilis  had mutations targeting ybeC. Additionally, the glpQ mutant (BKE02130), a strain from the whole‐genome screen (Selection #3) that suppressed serine toxicity due to overexpression, likely generates an abundant ybeC antisense RNA , and recorded growth of the bacteria. While the wild type strain was unable to grow at concentrations exceeding 244 μM, the ybeC mutant was able to tolerate as much as 11 mM serine . As shown in Fig. ybeC mutant was somewhat more resistant. Thus, loss of YbeC confers resistance to both serine and its toxic analogue serine hydroxamate, suggesting that the protein is a serine transporter.To test whether the B. subtilis wild type strain 168 in the presence of different concentrations of serine. Moreover, we used the serine auxotrophic serA mutant that depends on the uptake of serine for growth, and the ybeC mutant that already tolerates up to 11 mM of serine (see above). In total, we isolated eight mutants that exhibited increased resistance to serine in five distinct selection experiments. One mutant for each selection was subjected to whole‐genome sequencing to identify the underlying mutations. In one of the mutants , a ybeC mutation was detected. Thus, we tested the remaining mutants for the presence of mutations in ybeC. Strikingly, four out of the eight mutants had acquired mutations in ybeC. These mutations resulted in the production of truncated and therefore possibly inactive YbeC proteins or in an in‐frame deletion of 236 amino acids (in GP3050). The identification of multiple suppressor mutants affecting YbeC strongly supports the crucial role of YbeC in the resistance to serine.The targeted analysis of potential amino acid transporters identified YbeC as the only candidate serine transporter. In an attempt to identify more genes involved in serine toxicity, we cultivated the ybeC mutation, two strains derived from the wild type strain 168 had a duplication of about 16 kb yokD‐thyB chromosomal region. Interestingly, this region contains the ilvA gene encoding threonine dehydratase involved in the biosynthesis of isoleucine from threonine. The remaining three mutants  was fused to a promoterless lacZ gene. The resulting strain, GP2965, was cultivated in minimal in the presence and absence of serine as well as in complex (LB) medium. With very similar β‐Galactosidase activities , this fusion was similarly expressed irrespective of the presence of serine in the medium thus indicating constitutive expression of ybeC.The serA ybeC mutants in the suppressor screen (Screen #2 above) suggested either that the mutant YbeC proteins retained some transport activity or that YbeC is not the only transporter for serine. To resolve this issue, we deleted the ybeC gene in the serA mutant, which is auxotrophic for serine. The resulting double mutant GP2941 depends on serine uptake for viability. Analysis of growth of these mutants demonstrated that both the serA mutant and the serA ybeC double mutant were unable to grow in the absence of serine (C‐glucose medium). In contrast, the strains lacking the ybeC gene were able to grow in minimal medium supplemented with serine  was still able to grow on minimal medium in the presence of serine . The deletion of bcaP alone or in combination with ybeC resulted in improved growth both at 0.04 and 4 mM threonine as compared with the single thrC mutant  is still able to grow in the presence of threonine suggesting the existence of at least one additional threonine transporter . The inactivation of the ybeC gene to prevent serine uptake or the addition of several individual amino acids such as threonine overcomes serine toxicity  and yloU (BKE15830) that suppressed serine toxicity due to overexpression of the sdaAB‐sdaAA operon. These strains have their antibiotic cassettes with the strong outwardly facing promoter immediately upstream of sdaAB‐sdaAA, indicating that their overexpression suppresses serine toxicity  identified overexpression of the hom‐thrC‐thrB operon as relieving serine toxicity.Two different loci related to threonine metabolism were identified in our screens. First, the suppressor screen identified a duplication of the 16 kb yokD‐thyB genomic region encompassing ilvA in two suppressor strains. This observation implies that IlvA may become limiting in the presence of serine or contribute to scavenging excess serine. If IlvA is inhibited by serine, this could be compensated by overexpression of ilvA gene (due to genomic duplication) or by increased synthesis of ThrC with its moonlighting activity as threonine dehydratase .The threonine dehydratase IlvA uses threonine in the initial step of isoleucine biosynthesis. We observed a duplication of the approximately 16 kb hom‐thrC‐thrB as relieving serine toxicity. The suppressor screen (Selection #2) identified a mutation in thrR and a mutation upstream of the hom‐thrC‐thrB operon. The inspection of the mutation in the hom upstream region revealed that this mutation did affect the ThrR binding site  resulted in a frameshift and translation stop after 35 amino acids. This truncation has been observed previously in a different context. It results in an inactive ThrR protein : The screen identified a strain with a thrR deletion and as well as overexpression of the hom‐thrC‐thrB operon originating from yutH, which is adjacent to the hom‐thrC‐thrB operon as relieving serine toxicity . For B. subtilis, only recently significant effort has been put into the elucidation of resistance mechanisms that allow the bacterium to cope with toxic metabolic intermediates and substrates . For example, BcaP alone would be sufficient to transport at least four amino acids. Thus, genes encoding additional transporters for these amino acids (including ybeC) can be deleted as well as the corresponding biosynthetic pathways. It seems that nature has already put this reduction of amino acid acquisition to very few transporters into reality: the highly genome‐reduced Mycoplasma species have lost the ability to produce amino acids and therefore depend completely on their uptake from the medium. Due to the fast evolution of this group of bacteria, it has so far not been possible to identify amino acid transporters based on sequence similarity. However, the independent life of the artificial genome‐reduced organism Mycoplasma mycoides JCVI‐syn3.0  the rapid conversion of serine to other metabolites, mostly pyruvate and (ii) the overexpression of genes involved in the synthesis of threonine (the hom‐thrC‐thrB operon). The serine deaminase complex SdaAA‐AB converts serine to pyruvate and ammonia, thus detoxifying excess serine as well as allowing cells to use serine as carbon and nitrogen source. It is therefore not surprising that removal of this enzyme activity was attempted to increase the yield of serine production in E. coli . Biochemical analysis with purified B. subtilis homoserine dehydrogenase would provide clear evidence for this hypothesis. We attempted to purify B. subtilis homoserine dehydrogenase from hom overexpressing E. coli strain but failed to get active enzyme. It is tempting to speculate that the increased expression of ilvA upon the duplication the yokD‐thyB genomic region is the major determinant for serine‐resistant phenotype in this suppressor mutant since we observed that overexpression of ilvA phenocopied it, even though only partially  medium, SP (sporulation) medium and in C minimal medium containing glucose and ammonium as basic sources of carbon and nitrogen respectively  and amino acids as indicated. Plates were prepared by the addition of 17 g Bacto agar/l (Difco) to the liquid medium. Escherichia coli DH5α and JW3060 . The growth was compared after incubation of the plates at 37°C for 48 h.All E. coli were performed using standard procedures  was used for the polymerase chain reaction as recommended by the manufacturer. DNA fragments were purified using the Qiaquick PCR Purification kit . DNA sequences were determined using the dideoxy chain termination method  . Bacillus subtilis was transformed with plasmid or chromosomal DNA according to the two‐step protocol described previously , kanamycin (Km 5 μg ml−1), spectinomycin (Spc 150 μg ml−1), or erythromycin plus lincomycin (Em 25 μg ml−1 and Lin 25 μg ml−1).Standard procedures were used to transform B. subtilis, amylase activity was detected after growth on plates containing nutrient broth (7.5 g L−1), 17 g Bacto agar/L (Difco) and 5 g hydrolyzed starch/L (Connaught). Starch degradation was detected by sublimating iodine onto the plates.In lacZ expression in B. subtilis were performed as follows: cells were grown in LB medium or in C glucose medium supplemented with serine as indicated. Cells were harvested at OD600 of 0.6 to 0.8. β‐Galactosidase specific activities were determined with cell extracts obtained by lysozyme treatment as described previously  library was arrayed in 384‐well plates using a Biomek FX liquid handling robot (Beckman Coulter) and stored as glycerol stock. To screen the whole BKE library, cells were pinned from glycerol stocks onto rectangular LB agar plates in 384‐format using a Singer Rotor robot, then four 384‐format plates were combined and pinned to 1536‐format. For each screen, exponentially growing cells in 1536‐format were then pinned to glucose minimal agar plates (growth control) and glucose minimal plates supplemented with three different concentrations of L‐serine . Then, plates were incubated at 37°C in a humidified incubator for about 24–44 h. Plates were imaged using a Powershot G10 camera (Canon) and serine‐resistant mutants were identified by their position in the plates. Each mutant was confirmed by sequencing of their barcodes.The screen was carried out as described previously , pGP2295 (sdaAB), pGP2294 (sdaAB*) and pGP2296 (hom*).Plasmid pAC5 (Martin‐Verstraete E. coli, we constructed plasmid pGP2987. For this purpose, the ybeC gene was amplified using chromosomal DNA of B. subtilis as a template. The PCR product was digested with BamHI and SalI and cloned into the expression vector pWH844 (Schirmer et al., For the expression of YbeC in B. subtilis, plasmid pGP2289 was constructed by cloning a DNA fragment covering the ilvA gene between the BamHI and SalI restriction sites of the overexpression vector pBQ200 (Martin‐Verstraete et al., For the expression of the threonine dehydratase IlvA in Table S1 Known and potential amino acid transporters in B. subtilisTable S2. Bacillus subtilis strains used in this study.Click here for additional data file.


Patients diagnosed with cancer often experience considerable challenges with mental health, and those who had more intense psychiatric care prior to their cancer diagnosis have a higher risk of mortality. As prior research demonstrated a survival benefit among patients screened for symptoms using the Edmonton symptom assessment system (ESAS), this study aims to examine the association between being ESAS‐screened and the risk of mortality across varying intensity levels of pre‐diagnosis psychiatric care utilization.We conducted a retrospective matched cohort study using population‐wide administrative databases. All patients diagnosed with cancer in Ontario, Canada, from January 2007 to December 2015 were identified. Propensity score matching was used to pair ESAS‐screened individuals to those not screened. Pairs were also hard matched on a pre‐diagnosis psychiatric care utilization gradient. A multivariable Cox proportional hazards regression model was implemented to estimate the association between ESAS and mortality, for each intensity level of pre‐diagnosis psychiatric care.p‐value <0.0001). This association was similar across all levels of prior psychiatric use, however, there was no evidence of a differential impact.The matched cohort consisted of 119,806 patient pairs (ESAS‐screened and not screened), of whom 54,468 (45.5%) pairs had prior outpatient psychiatric care and 2249 (1.8%) pairs had experienced emergency department visits or had been hospitalized for psychiatric care. Overall being exposed to ESAS was significantly associated with a 51% decrease in the hazard of mortality (HR 0.49, 95%CI 0.48–0.50, In addition to routinely monitoring symptom severity, including depression, among patients with cancer, it is also important to identify those with preexisting psychiatric comorbidities at the time of diagnosis. This information can be used to ensure that timely and appropriate psycho‐oncology services and psycho‐social supports are offered to help the patient and their family cope during the cancer disease trajectory. Being screened for symptom burden, including depression, lowers the risk of mortality across varying intensity levels of pre‐diagnosis psychiatric care utilization among patients with cancer. In addition to routinely monitoring symptom severity, it is also important to identify those with pre‐existing psychiatric comorbidities at the time of cancer diagnosis. This information can be used to ensure that timely and appropriate psycho‐oncology services and psycho‐social supports are offered to help the patient and their family cope during the cancer disease trajectory. Routine use of PROs in clinical cancer care can improve longitudinal symptom monitoring, quality of life, and communication among the patient–provider team.There has been growing evidence indicating that routine use of PROs improves survival.22.1We conducted a retrospective matched cohort study using population‐wide administrative databases. All patients diagnosed with cancer in Ontario from January 2007 to December 2015 were identified using the Ontario Cancer Registry (OCR), which captures all incident cancers in Ontario.2.2We linked health administrative databases held at the ICES . Symptom screening with ESAS was captured using the Symptom Management Reporting Database.2.3The primary exposure was being screened for symptoms with ESAS. Patients diagnosed with cancer who were subsequently screened with ESAS at least once were considered the ESAS‐exposed patients. The index date for the ESAS‐exposed patients was the first ESAS assessment date after their cancer diagnosis. We 1:1 matched each ESAS‐exposed patient to an ESAS‐unexposed patient (diagnosed with cancer but had not been exposed to ESAS). Both hard‐ and propensity score matching were utilized to create this matched cohort. Patients were hard matched on the following criteria: history of psychiatric utilization in the 5 years prior to cancer diagnosis, year of birth (±2 years), date of cancer diagnosis (±1 year), cancer type, and sex. Similar to recent work, psychiatric utilization in the 5 years prior to cancer diagnosis was defined using a gradient with 4‐levels: no psychiatric utilization; outpatient psychiatric care ; emergency department (ED) visit for psychiatric care; and hospital admission for psychiatric care.Logistic regression was used to calculate the propensity of being screened with ESAS. The regression model included: patient characteristics , cancer characteristics , treatments within 6 months of diagnosis , various measures of comorbid conditions in the 2 years prior to cancer diagnosis  between their diagnosis date and dummy index date was the same as the gap time between the corresponding exposed patient’s diagnosis date and first ESAS date. Patients were followed from their index date until death, diagnosis of a new cancer, 5‐year observation mark, or the end of study at December 31, 2015, whichever came first. Moreover, follow‐up was terminated on unexposed individuals if they had exposure to ESAS after their dummy index date.2.4p‐values) were used to establish whether covariate distributions were balanced between exposed and unexposed groups; a standardized difference (SD) <0.1 indicated balance.The distributions of baseline characteristics were compared among patients exposed and unexposed to ESAS, stratified by the four levels of prior psychiatric utilization. Medians and interquartile ranges were used to describe continuous measures, and frequencies and proportions were used to describe categorical measures. Due to the large cohort size, standardized differences ; number of visits to a family physician or radiation/medical oncologist between the index date and end of follow‐up was (included as a counter time‐varying covariate); and experiencing surgery after diagnosis (included as a binary time‐varying covariate that turned “on” once surgery was received). As defined in prior work, phase of care was measured to account for different periods of cancer management across the disease trajectory.3Each pair in our matched cohort consisted of one patient who was exposed to ESAS screening and one patient who was not. The overall matched cohort consisted of 119,806 patient pairs, of whom: 63,089 (52.7%) pairs had no psychiatric utilization in the 5 years prior to cancer diagnosis; 54,468 (45.5%) pairs had prior outpatient psychiatric care; 1480 (1.2%) pairs had experienced prior emergency department visit for psychiatric care; and 769 (0.6%) pairs had been hospitalized for psychiatric care. The distribution of (selected) baseline characteristics among cancer patients with and without ESAS exposure is presented in Table Figure p‐value <0.0001). There was a gradient in the association between prior psychiatric care utilization and mortality. Compared to patients without any prior psychiatric care utilization, those with the highest level of psychiatric care utilization prior to diagnosis had a 25% higher hazard of mortality , whereas those with prior outpatient psychiatric care only did not significantly differ in their hazard of mortality . Compared to patients in the continuing phase of care, those in the palliative phase of care had a 29‐fold higher hazard of death . Once surgery was received, the hazard of mortality notably decreased by 43% .Table Table 4This population‐based matched cohort study among patients diagnosed with cancer examined the association between symptom screening with ESAS and the risk of mortality across varying intensity levels of pre‐diagnosis psychiatric care utilization. We found a strong relationship between ESAS screening and survival. Use of ESAS was associated with a decreased risk in mortality, and this significant reduction was consistent across the intensity gradient for pre‐diagnosis psychiatric care utilization. Although patients with higher levels of prior psychiatric use had a greater risk of mortality, the impact of ESAS on mortality was similar across each level.Our results are consistent with previous studies assessing prior psychiatric comorbidities and mortality among patients with cancer. Klassen et al. demonstrated that higher intensities of pre‐cancer diagnosis psychiatric utilization were associated with poorer survival.We demonstrated that screening for severity of symptoms, including depression, using ESAS was associated with an improvement in survival among all patients, including those with higher intensities of pre‐diagnosis psychiatric care utilization. Randomized studies have also indicated that routine symptom monitoring in cancer patients with solid tumors on chemotherapy was associated with a decreased mortality risk compared to those who were not being routinely monitored for their symptoms.Like other studies, we recommend PROs such as ESAS be administered near the time of a patient’s cancer diagnosis and continue to be used routinely thereafter for screening and management of symptoms, including depression. The impact of ESAS screening on survival was shown to be strongest during the phases of initial / active treatment and palliative care,Our study has numerous strengths. We used population‐based health administrative data to create a matched cohort (ESA‐screened vs. not) of nearly 120,000 pairs of patients, accounting for varying intensities of psychiatric care prior to the cancer diagnosis. To minimize confounding both hard‐ and propensity score matching techniques were implemented, resulting in the distributions of patient characteristics to be well balanced at baseline. Changes in measures such as receipt of surgery occurring after diagnosis were appropriately accounted for as time‐varying characteristics. The results from this study are likely generalizable to other populations of cancer patients receiving universal healthcare, and add to the literature on real world evidence surrounding the impact of routine use of PROs in clinical cancer care. However, this study also has several limitations. We were not able to measure other clinical prognostic variables such as performance or functional status. Information on specific chemotherapy regimens and medications for dealing with symptoms such as depression were not available. It is also unclear if our findings could be generalized to cancer populations with access to private healthcare.To our knowledge, this is the first study to assess the association between symptom screening and mortality across varying levels of pre‐cancer diagnosis psychiatric care utilization. Improvements in survival for those screened with ESAS, seen across the intensity gradient for psychiatric use, highlight the importance of routinely using PROs in clinical cancer. This study also emphasizes the need for patients with cancer to be cared for by a diverse team of providers who can offer supportive cancer care to reduce stress and improve mental well‐being.The authors declare that they have no conflict of interest.All authors had roles in design and conduct of the study. RS and QL planned and executed the statistical analyses. All authors had roles in the interpretation of the results, as well as preparation and approval of the Article.This study involved secondary data analyses only and was thus exempt from requiring REB approval because ICES is a designated “45.1 entity” under the Personal Health Information Protection Act (PHIPA) enabling the use of personal health information.


There is compelling support for implementing prehabilitation to optimize perioperative risk factors and to improve postoperative outcomes. However, there is limited evidence studying the application of multimodal prehabilitation for patients with breast cancer.To determine the feasibility of multimodal prehabilitation as part of the breast cancer treatment pathway.This was a prospective, cohort observational study. Breast cancer patients undergoing surgery were recruited. They were assigned to an intervention or control group according to patient preference.UK prehabilitation center.A total of 75 patients were referred during the study period. Forty eight patients (64%) did not participate; 20 of those opted to be in the control group. Twenty four patients engaged with prehabilitation and returned completed questionnaires. In total, 44 patients were included in the analysis.The program consisted of supervised exercise, nutritional advice, smoking cessation, and psychosocial support.Feasibility was determined by the center's ability to deliver the program. This was measured by the number of patients who wanted to access the service, compared with those able to. Service uptake, patient satisfaction, and project costs were recorded. Patient‐reported outcomes (PROs) and the use of healthcare resources were also evaluated.A total of 61 patients (81%) wanted to participate; 24 (32%) were able to partake and return questionnaires. Reasons for nonparticipation included surgery within weeks, full‐time commitments, and transportation difficulties. A total of 25 (93%) prehabilitation patients recorded high satisfaction with the program. There was a significant reduction in anxiety among prehabilitation patients. There were no significant improvements in the other PROs. There were no changes to hospital length of stay, readmissions, and complications.Multimodal prehabilitation is a feasible intervention. Logistical challenges need to be addressed to improve engagement. These results are limited and would require a larger sample to confirm the findings. Work on a thorough cost‐benefit analysis is also required. Breast cancer remains the most diagnosed cancer among women globally.Cancer care treatment has traditionally been focused on the postoperative period to rehabilitate and facilitate the patient's recovery.There is a growing focus on developing and implementing interventions earlier in the patient's cancer treatment pathway (immediately following diagnosis).There is already a multipronged innovation project for colorectal and urology cancer patients underway by the prehab team in February 2018, at a district general hospital situated in Kent (England).Currently there are limited published data studying the application of multimodal prehabilitation on patients undergoing breast surgery.This was a prospective, cohort observational study. We used the basic components of the Health Belief Model regarding behavioral change to support the design of the study.Our intervention was modeled on existing prehabilitation programs.Our core project team consisted of an anesthetist and clinical exercise physiologists. The primary role of the anesthetist is to be involved with clinical engagement. Anesthetists are uniquely placed to support prehab as they assess and risk stratify patients for their surgical suitability in the preassessment clinic and form perioperative management plans for patients undergoing surgery. Their role is supported by the clinical exercise physiologists who are involved with designing, implementing, and delivering the prehabilitation program.The prehabilitation program is a multimodal intervention. Three of the four interventions are advisory and ascribed to one face‐to‐face session , whereas exercise involved supervised sessions over the period from diagnosis to operation. Participants were required to attend one or more sessions of supervised exercise. The length of the intervention depended on the length of time to surgery. Each session lasted for 30 minutes and was organized into two sessions per week, until the date of their operation.The supervised exercise sessions are focused on upper body resistance training (RT). RT has been coupled to improve fatigue, muscle strength and shoulder mobility; these limitations are often associated with breast cancer surgery.An initial screening survey was performed by the physiologist to identify patients with unhealthy eating habits . The perioperative nutrition score was used to determine if patients needed clinical nutritional intervention. Nutritional education was provided by the physiologists during individual sessions. Patients were advised to consume adequate amounts of protein from plant‐based and/or animal sources to meet their daily requirements (an average daily intake of 64 g of protein for women). Furthermore, they were advised to consider the quality of their protein, to cut down on processed foods, particularly processed red meat. Protein is essential for tissue repair. Protein deficiency is associated with poor wound healing and increased infectious complications.Patients who were smoking were supported to attend the smoking cessation service. The stop smoking advisors provided these patients with the necessary therapies and advice to help them quit smoking . Preoperative smoking cessation is valuable and reduces the risk of cardiopulmonary complications, wound infections, and improves tissue healing.Anxiety is highly prevalent among breast cancer patients.The feasibility of the service was determined by the center's ability to deliver the program. This was measured by the number of patients who wanted to access the service, compared with those that were able to do so. In addition, we recorded service uptake to assess acceptance of prehabilitation among breast cancer patients. This was measured by the number of patients opting to participate. Patient satisfaction was recorded with service evaluation forms.Three questionnaires were distributed to patients pre‐ and postsurgery. Patients completed the preoperative questionnaires at the time of enlisting for surgery (before undergoing prehabilitation). This formed the baseline assessment. The postoperative questionnaires were collected at 6 weeks postsurgery. This allowed patients to return completed forms at their follow‐up appointment for ease of convenience. These questionnaires involved gathering information on (1) global health status by the Short Form 12 (SF‐12) health survey, (2) mental well‐being by the Hospital Anxiety and Depression Scale (HADS), and (3) shoulder function by the Shoulder Pain and Disability Index (SPADI).The SF‐12 is a screening for quality of life and self‐perceived health status.The HADS contains 14 questions split into two subscales: the anxiety component and the depression component.The SPADI is a validated measure of both shoulder pain and shoulder disability.Length of inpatient hospital stay and hospital readmissions and complications within 30 days for the same condition were registered.P value <.05 was considered statistically significant. Statistical analysis was performed using SPSS software and Windows Microsoft Excel.The responses from the three patient‐reported outcome questionnaires were compared in the surgical breast cancer patients, before and after undergoing surgery, to determine the changes from the baseline assessment. Pre‐ and postsurgery scores were compared between groups using the Kruskal‐Wallis test. Within‐group comparisons were performed using the Wilcoxon signed‐rank test. Data are presented as median (interquartile range). A This service expansion project was registered as an Innovation and Service adaptation with the local Foundation Trust's Quality Improvement and Clinical effectiveness Team. Project approval was granted by the Foundation Trust. Eligible patients were identified and approached about the study during clinic visits. Eligible patients who agreed to participate in prehabilitation provided informed consent and completed presurgery (baseline) questionnaires.A total of 44 patients were included in the analysis of this study. Twenty‐four patients participated in our prehabilitation program. Twelve patients attended ≥4 sessions of supervised exercise training sessions and 12 patients attended 1‐3 sessions. Twenty patients declined to participate but were included in the study as the control group. All patients were female. The median age was 63 years old . The modal American Society of Anesthesiologists grade was 2. A summary of the patients' characteristics is outlined in Table The median program duration was four sessions . A summary of the interventions offered to the prehabilitation cohort is described in Table A total of 61 (81.3%) patients wanted to participate in the prehabilitation program. Over the 6‐month pilot period, 75 patients were invited to attend the program. A total of 14 (18.7%) patients declined to participate because of a lack of interest. Of 61 (81.3%) patients who wanted to attend prehabilitation, only 24 (32%) patients achieved this and returned results. Three patients completed the program but did not complete the questionnaires. The most common reasons for nonparticipation among those who wanted to attend were surgery within 2 weeks (n = 14); full‐time commitments, for example, work/caring responsibilities (n = 12); and transportation difficulties (n = 8). A total of 20 nonparticipating patients consented to participate in our study and were enrolled in the control group.Service evaluation forms were completed postoperatively by the 27 prehabilitation patients (inclusive of the three patients who did not return their questionnaires). A total of 25 (93%) patients regarded the service as “excellent” and a powerful motivator for achieving healthy lifestyle changes. They perceived the service to be beneficial, as part of their cancer treatment, their postoperative recovery, and they would strongly recommend it to other patients. Two (7%) patients regarded the service as “average” and subsequently discontinued prehabilitation, citing muscle soreness (n = 1) and lack of interest (n = 1) as reasons for discontinuation.An Independent Cancer Taskforce Strategy funded a £100 000 grant to set up our prehabilitation unit including exercise equipment, patient‐information materials, and staff fees (project manager and physiologists). The prehabilitation unit served colorectal and urology in addition to breast patients from a single district general hospital. The cost of the intervention was £200 to £500 per patient for all three surgical specialties; the cost was based on the number of sessions attended, which was based on the waiting time to surgery.Pre‐ and postsurgery patient‐reported outcome questionnaires were collected to assess the patients' general health status, mental well‐being, and shoulder pain/disability in the SF‐12, HADS, and SPADI, respectively. Pre‐ and postsurgery scores obtained by all three cohorts of patients are outlined in Table The between‐group differences in the scores before surgery were not statistically significant. Postsurgery differences between groups did not achieve statistical significance either. When analyzing within‐group pre‐ and postsurgery changes, anxiety scores were statistically lower after surgery in both groups participating in prehabilitation. The remaining components analyzed did not demonstrate significant changes.The median length of hospital stay was 2 days/1 night for both the prehabilitation and non‐prehabilitation cohorts. There were no 30‐day complications requiring further hospitalization and no hospital readmissions for the same condition identified in the patients studied.This pilot study has demonstrated that multimodal prehabilitation for breast cancer patients can be delivered in a district general hospital. A total of 75 patients were referred to prehabilitation. Fourteen (18.7%) patients declined to participate because of a lack of interest and 61 (81.3%) patients wanted to participate. Of those 61 patients, only 24 (32%) were able to achieve this and return completed questionnaires. Although the center had availability to meet 100% of participants’ requirements, uptake was limited from 61 to 24 patients owing to the service being delivered at specific scheduled appointments and at only one location. Work is underway to open satellite community centers and “virtual” prehabilitation to improve patient engagement.The patient‐reported outcomes suggest that prehab for patients undergoing breast surgery may not have the same full perceived benefits as compared with those undergoing other forms of major surgery.The final factor to consider is that the interventional period is relatively short. Many of the prehabilitation programs in the literature occur over a longer period, a minimum of 4 weeks.The study was based on a limited number of patients. Their breast cancer treatment including type of surgery, adjuvant/neoadjuvant chemotherapy and/or radiotherapy were not recorded. Patients were not compared to a matched cohort. Patients volunteered into the intervention group providing potential for self‐selection bias. More patients with an American Society of Anesthesiologists classification of 3 declined to participate. The significance of this is unknown with the current data we have but an interesting issue to explore. It is not possible to determine if patents who declined the program would have received greater benefit from prehabilitation. Patient outcomes were also collected via self‐assessment and we could not verify adherence to our interventional recommendations. A functional assessment was not conducted because of the extremely short period of time from joining prehab to surgery. The duration of the intervention was not standardized as we accommodated the intervention in the time between referrals and operation date. We do not have long‐term follow‐up data on the number of patients who have continued to follow our recommendations.Furthermore, patient uptake was limited by time and location availability. The cost benefit of face‐to‐face supervised exercise sessions could be superseded in favor of home‐based or “virtual” programs. Subsequent prehab sessions could be held not only within a hospital setting but also in small groups within the community or even at home via teleconsultations . This has the potential to increase the availability of sessions and user acceptance and reduce costs.Within our sample, there is a high interest (81.3%) among patients to participate. This program is simple to perform and shows potential to be replicated across other breast cancer care units. There was a high level of patient satisfaction with our program; however, uptake was low owing to the rigidity of timing and location of service.Prehabilitation services have already been established in many units to serve patients undergoing major cancer resections.


Target enrichment represents a useful, cost‐effective method for researchers working on the phylogenomics of non‐model organisms . This versatile and powerful approach relies on probes to capture complementary sets of genomic targets from whole genome DNA or cDNA samples using solid‐phase or in‐solution hybridization . In the second step, reads from putative hybrids are mapped to these chosen clade representatives. Differential mapping information is then used to phase hybrid sequences, which can then be placed on a multiply‐labeled tree to identify hybrid origins. The HybPhaser method also has promise for addressing a common issue in target‐capture phylogenetics: the identification of paralogous genes. This builds upon previous work using clade references to identify paralogs  was recently launched (Baker et al., Currently, there is no central data repository specifically tailored to access target enrichment data in a way that is not taxon specific. The Kew Tree of Life Explorer (


Corals have evolved a variety of stress responses to changing conditions, many of which have been the subject of scientific research. However, polyp bailout has not received widespread scientific attention, despite being described more than 80 years ago. Polyp bailout is a drastic response to acute stress in which coral colonies break down, with individual and patches of polyps detaching from the colony and the calcareous skeleton Polyps retain their symbiotic partners, have dispersal ability, and may undergo secondary settlement and calcification. Polyp bailout has been described worldwide in a variety of anthozoan species, especially in Scleractinia. It can be induced by multiple natural stressors, but also artificially. Little is known about the evolutionary and ecological potential and consequences of breaking down modularity, the dispersal ability, and reattachment of polyps resulting from polyp bailout. It has been shown that polyp bailout can be used as a model system, with promise for implementation in various research topics. To date, there has been no compilation of knowledge on polyp bailout, which prompted us to review this interesting stress response and provide a basis to discuss research topics and priorities for the future. The present review addresses the stress response polyp bailout, including the current state of research and theoretical aspects of the evolutionary and ecological consequences. Furthermore, the review deals with the possible use of polyp bailout in future research. The cold‐water corals 2.5Oculina patagonica and Pocillopora damicornis, tissue‐specific apoptosis was responsible for the dissolution of the coenosarc. Using a protein activity assay, this link between tissue‐specific apoptosis and polyp bailout was established for the first time. In addition, it was shown that high caspase activity was most likely responsible for the apoptotic processes leading to coenosarc dissolution  and transmission electron microscopy (TEM) can provide insights if detached polyps differ from healthy polyps or multicellular ball‐like aggregates formed in primary cultures of Interestingly, the current boundaries between polyp bailout, asexual reproductive processes, and reproduction are blurred. Although it has been suggested that asexual reproductive processes are more important and even increase under unfavorable conditions Fautin, , others Although there is an overlap with asexual reproduction, published work to date indicates that polyp bailout is a stress response. Previous studies suggest that parts of the processes during polyp bailout bear similarities to those of reverse development mechanisms that are described in stressful situations in corals  Polyp bailout permits polyps in a modular colony to escape local detrimental factors  and hence decreases the risk of mortality of the genets . Even though the chances of survival of individual ramets may be low, the number of modules increases the chances of survival of the genet since only a small fraction of the modules need to survive  can improve conditions to such an extent that the polyps can resettle, as stressors are often not uniformly pronounced on the whole reef system  Polyp bailout may increase fitness by producing many ramets of the identical genetic lineage, capable of survival, and reproduction Hageman, . The detPorites spp., Potts et al., 6 polyps  warming events have caused extensive mortality of reef‐building corals and altered colony size distribution in the Galápagos Islands, suggesting that the colonies regrew from survivors of the 1997/98 ENSO .Sammarco  described et al.  with P. Whether all of these observations are due to increased sexual reproduction, other modes of asexual reproduction, or maybe a stress response like polyp bailout that creates a lot of potential new ramets cannot be fully answered here. It should not be ruled out that polyp bailout plays a role in shaping the genetic structure of local reefs after stress events, which also implies that surviving recruits after severe stress periods may not be better adapted to future stress events, but may be just as vulnerable as the previous coral community.5The modular structure and shared life‐history traits of sessile colonial invertebrates, comparable to higher plants, offer a chance to establish model systems for experimental work. Species whose modules are easily propagated provide powerful models for experimental investigations. An approach to create these micropropagates via the break‐up of modularity could be polyp bailout, as demonstrated by Shapiro et al. .So far in cnidarians, valuable insights into physiological processes such as calcification and symbiosis have relied mostly on the use of cell or tissue cultures ; Data curation ; Formal analysis ; Funding acquisition (supporting); Investigation (lead); Methodology ; Project administration ; Visualization ; Writing‐original draft ; Writing‐review & editing . Fabian Gösser: Conceptualization ; Data curation ; Formal analysis (supporting); Funding acquisition (supporting); Investigation ; Methodology ; Visualization ; Writing‐original draft ; Writing‐review & editing . Ralph Tollrian: Conceptualization ; Data curation (supporting); Formal analysis (supporting); Funding acquisition ; Investigation (supporting); Methodology ; Project administration ; Writing‐original draft (supporting); Writing‐review & editing .


Exosomes are a subset of extracellular vesicles essential for cell–cell communication in health and disease with the ability to transport nucleic acids, functional proteins and other metabolites. Their clinical use as diagnostic biomarkers and therapeutic carriers has become a major field of research over recent years, generating rapidly expanding scientific interest and financial investment. Their reduced immunogenicity compared to liposomes or viral vectors and their ability to cross major physiological barriers like the blood–brain barrier make them an appealing and innovative option as biomarkers and therapeutic agents. Here, we review the latest clinical developments of exosome biotechnology for diagnostic and therapeutic purposes, including the most recent COVID‐19‐related exosome‐based clinical trials. We present current exosome engineering strategies for optimal clinical safety and efficacy, and assess the technology developed for good manufacturing practice compliant scaling up and storage approaches along with their limitations in pharmaceutical industry. Anderson Cancer  investigates the use of mesenchymal stem cells‐derived exosomes for the treatment of stage IV pancreatic cancer patients with the presence of KrasG12D mutation where patients are injected with KrasG12D‐specific siRNA‐loaded exosomes targeting the oncogenic 3.2Exosomes are promising delivery agents to treat inflammatory disorders due to their low immunogenicity, intrinsic anti‐inflammatory properties and drug delivery potential. For instance, mesenchymal stem cell‐derived exosomes were administered to patients with graft versus host disease and allowed to reduce the pro‐inflammatory cytokine response . It is derived from human amniotic fluid, highly enriched in exosomes and consisting of various growth factors, pro‐inflammatory cytokines potentially able to act as a suppressor of the cytokine storm observed in COVID‐19 patients.Interestingly, various exosome‐based studies and clinical trials associated with COVID‐19 have been initiated. These trials aim to treat severe acute respiratory complications associated with COVID‐19. They include trials  built on previous studies highlighting the immunomodulatory role of adipose tissue‐derived mesenchymal stem cells and its secretome for the treatment of pulmonary injuries  adjunction to the outer membrane of exosomes can act as a shield to protect vesicles from clearance  is observed in mesenchymal stem cell‐derived exosomes, which after interaction with death receptors 4/5 (DR4/TNFRSF10A: DR5/TNFRSF10B) mediates apoptosis specifically in cancer cells ‐15 show specific tropism towards human cancer cells but can also trigger a cytotoxic effect  and via induction of apoptosis  cells exhibit therapeutic effect by activating T cell responses and displaying anti‐tumour effects 5Exosome are defined by their cells of origin and their engineered properties. However, their efficient and reliable production is controlled by their microenvironment, culture and dissociation systems. Further downstream steps in their manufacturing are also required involving isolation and characterisation. This process is generally divided into three steps:‐ (i) removing of cells and cell debris, (ii) concentration of condition medium and (iii) purification  awarded jointly with Evox Therapeutics.


N = 269) of 18‐ to 59‐month‐old children completed measures of both dimensions of perceived parenting competence  and of controlling  and positive  food parenting practices. Relationships were found between perceptions of competence and use of food parenting practices. Self‐efficacy and satisfaction with parenting were positively associated with the use of most positive food parenting practices. Greater parenting satisfaction, but not parenting efficacy, was associated with lower use of some of the potentially detrimental controlling food parenting practices. Neither parenting self‐efficacy nor satisfaction with parenting were related to mothers' reported use of pressure to eat. In conclusion, supporting and promoting greater maternal self‐efficacy and satisfaction with parenting may be a useful target for public health interventions and for professionals working with families with the aim of promoting optimal parenting to support children's development of healthy eating habits. Future research should seek to further elucidate the current findings with a longitudinal design.Perceptions of parenting competence are composed of self‐efficacy and satisfaction with parenting. Parenting competence is linked to differential outcomes across numerous parenting domains. To date, few studies have explored the relationships between maternal self‐efficacy and food parenting practices, deploying different measures and age ranges, and yielding conflicting findings. Therefore, the current study sought to explore relationships between the two dimensions of perceived parenting competence and the use of controlling and positive food parenting practices. UK mothers ( Perceived parenting competence is related to the use of food parenting practices in mothers of 18‐month‐old to 5‐year‐old children.Mothers reporting greater parenting self‐efficacy and parenting satisfaction used various positive, health‐promoting food parenting practices.Mothers who felt more satisfied with their parenting used fewer controlling food parenting practices.Parenting competence was unrelated to use of pressure to eat or restriction for weight.Parenting competence—specifically self‐efficacy and satisfaction—could be important to target in future interventions and by professionals seeking to support the development of children's healthy eating habits and weight.1Parents have a key role in shaping their children's healthy development and cognitions about their parenting could impact children's health outcomes. One such cognition is parents' perception of their competence, which incorporates both parenting self‐efficacy (described as the degree to which parents feel competent and confident in handling problems with their child) and satisfaction with parenting  of children aged between 18 and 59 months  participated. Mothers' age ranged from 20 to 46 years . Most reported their ethnicity as White British/White other (n = 258) with five mothers identifying as mixed ethnicity, four as Asian/Asian British, one as Black/Black British, and one as a different ethnicity, which was not specified. The majority of mothers were educated at university level (n = 190), and more of the children were male (n = 151) and first‐born (n = 174).Mothers .The Parenting Sense of Competence Scale (PSOC) was used to assess mothers' sense of competence in their parenting. The 16‐item measure is composed of two subscales. One subscale (seven items) assesses mothers' Efficacy, defined as their competence, capability levels, and problem‐solving abilities in their parental role. The other subscale, Satisfaction, examines mothers' parenting‐related anxiety, motivation, and frustration (nine items). Items are responded to on a 6‐point Likert scale ranging from 2.3.2never to always or from disagree to agree. Mean scores are generated for each subscale, with higher scores indicating greater use of the feeding practice. This measure has been validated among a similar sample , with the exception of Encouraging Balance and Variety (α = 0.49); therefore, results pertaining to this subscale are treated with caution.Mothers' food parenting practices were measured using 11 subscales of the Comprehensive Feeding Practices Questionnaire, which assesses different feeding practices. Five of these are controlling  and six are positive practices . Items are responded to on a 5‐point Likert scale with responses ranging from 2.4p < 0.01 was adopted to account for multiple statistical comparisons conducted.Data were analysed using IBM Statistical Package for the Social Sciences, version 24. Kolmogorov–Smirnov tests revealed that none of the variables were normally distributed; therefore, nonparametric analyses were used to test the study hypotheses. Preliminary analyses (data not shown) indicated that there were no significant differences between mothers of girls and mothers of boys on any study variables but that maternal and child age significantly correlated with some of the study's variables. Therefore, two‐tailed partial Spearman's correlations  were used to investigate associations between the two dimensions of maternal competence  and each of the 11 food parenting practices included in the study. A more stringent alpha of 33.1Descriptive statistics for the study variables can be seen in Table 3.2Partial correlations to test the study hypotheses are in Table 4The present study sought to explore the relationships between mothers' perceptions of parenting competence and their use of controlling and positive food parenting practices with their young children. Both self‐efficacy and satisfaction with parenting were hypothesised to be related to lower use of controlling food parenting practices and greater use of positive food parenting practices. These hypotheses were partially supported as greater perceived self‐efficacy and satisfaction with parenting were both associated with greater use of almost all of the positive food parenting practices. Moreover, greater satisfaction with parenting was associated with lower use of three controlling food parenting practices.In the current study, mothers who reported higher levels of self‐efficacy and satisfaction with parenting also reported greater use of several positive food parenting practices, namely, encouraging balance and variety, providing a healthy home environment, modelling, and teaching about nutrition. This suggests that feeling more confident about parenting in general is associated with the use of more health‐promoting food parenting behaviours with young children. The current study is the first to explore relationships with positive food parenting practices in a western sample and so our findings support and extend previous research from Iran, which identified that self‐efficacy was associated with greater encouragement of balance and variety and greater modelling , it might be more challenging to implement in mothers who feel less efficacious in the parenting role. Similarly, mothers reporting higher parenting self‐efficacy also reported more monitoring of their children's food intake, but monitoring was not linked to parenting satisfaction. This finding extends the work of Duraccio et al. , with thParenting competence was related to the use of three of the five controlling food parenting practices. Specifically, mothers who reported greater satisfaction with parenting also reported lower use of food for emotion regulation, food as a reward, and restriction for health, while maternal self‐efficacy was not significantly related to the use of any controlling food parenting practices. The food parenting practices of using food for emotion regulation and as a reward are typically used outside of a mealtime, as a way to respond to or manage children's behaviour. It therefore follows that parents who feel more satisfaction with their parenting role might feel less likely to need to use such practices in their everyday parenting interactions. An alternative explanation for these findings is that parents might feel less confident in their parenting if their child's behaviour is harder to manage and so these parents may use food—and these controlling food parenting practices—as a mechanism through which to do so. Given that these three food parenting practices have been linked to children eating in the absence of hunger  food parenting practices, and greater parenting satisfaction is also associated with lower use of some potentially detrimental controlling food parenting practices. These findings suggest that supporting greater maternal self‐efficacy and satisfaction with parenting may be a useful target for public health interventions and for professionals working with families with the aim of promoting optimal parenting to support children's development of healthy eating habits and weight. This support could come in the form of education programmes that aim to inform parents about typical pitfalls associated with child feeding and that share evidence‐based strategies to promote children's healthy eating. Such an intervention has already been shown to be effective at improving food parenting practices and reducing general feelings of anxiety in mothers of preschool age children (Haycraft et al., The authors declare that they have no conflicts of interest.CEH and EH designed the research study, conducted the research, and wrote the paper. CEH analysed the data. Both authors approved the final submission.


Bos mutus was believed to be regionally extinct in Nepal for decades until our team documented two individuals from Upper Humla, north‐western Nepal, in 2014. The International Union for Conservation of Nature (IUCN) seeks further evidence for the conclusive confirmation of that sighting. We conducted line transects and opportunistic sign surveys in the potential wild yak habitats of Humla, Dolpa, and Mustang districts between 2015 and 2017 and collected genetic samples (present and historic) of wild and domestic yaks Bos grunniens. We also sighted another wild yak in Upper Humla in 2015. Phylogenetic and haplotype network analyses based on mitochondrial D‐loop sequences (~450 bp) revealed that wild yaks in Humla share the haplotype with wild yaks from the north‐western region of the Qinghai‐Tibetan Plateau in China. While hybridization with domestic yaks is a major long‐term threat, illegal hunting for meat and trophy put the very small populations of wild yaks in Nepal at risk. Our study indicates that the unprotected habitat of Upper Humla is the last refuge for wild yaks in Nepal. We recommend wild yak conservation efforts in the country to focus on Upper Humla by (i) assigning a formal status of protected area to the region, (ii) raising awareness in the local communities for wild yak conservation, and (iii) providing support for adaptation of herding practice and pastureland use to ensure the viability of the population.The wild yak  Our study carries a global relevance as it presents phylogenetic and haplotype network analyses of wild and domestic yak samples to reveal that the wild yaks in Humla, Nepal, share the haplotype with wild yaks from the north‐western region of the Qinghai‐Tibetan Plateau in China, providing validation to the wild yak rediscovery in Nepal that was based on morphology and behavior of the sighted animals. We also derive phylogeographical inference for the wild yaks in the Nepalese Transhimalayas and discuss their hybridization status while also outlining the conservation implications for the wild yaks that are critically endangered in the country. This allows seasonal movement of wild yaks from TAR into northern Nepal . The herders and their domestic livestock threaten the wild yaks further through habitat encroachment and displacement  by livestock herders to prevent hybrid offspring and abductions of female domestic yaks  Harris, , while t Harris, . IllegalIn 2014, we sighted two wild yaks in the remote Transhimalayan valleys of Upper Humla in north‐western Nepal, leading to the rediscovery of the species in the country  Bos spp., horses Equus ferus coballus, goats Capraaegagrus hircus, and sheep Ovies aries in the alpine pastures during spring and summer seasons. They shift the livestock herds among pasturelands and bring the animals down to the villages during winter , 7,517 in Dolpa , and 2008 in Mustang District  , and Upper Mustang lies entirely within the Annapurna Conservation Area (ACA). All the three study areas share an international border with the TAR of China. Elevation in the study areas ranged between 3,600 and 5,600 masl, and the vegetation is characterized by alpine grasslands and steppes interspersed with patches of shrubland , 21 of presumed domestic yak: , and one unknown dung sample. We obtained genetic data from 25 samples, while two bone samples of suspected wild yaks and one hair sample of domestic yak failed possibly due to poor sample quality (see Table 2.3n = 34) and domestic (n = 96) yaks from QTP from NCBI GenBank (See Table Bisonbison sequence (GenBank accessions: U12936) as an outgroup to root all yak D‐loop haplotypes. We performed two parallel runs of four chains (three heated and one cold) for 3,000,000 generations, with sampling done at every 500th generation. We diagnosed the convergence of the Bayesian posterior probabilities of four chains in Tracer v1.7.1  sequences of the mitochondrial genome using self‐designed primers (YAK_Dloop2_F: 5′‐ GAGCCTCACCAGTATTAAATTT‐3′ and YAK_Dloop2_R: 5′‐ACAGTTATGTGTGAGCATGGGC‐3′). Details on the laboratory methods are provided in the supplementary information. We retrieved a subset of reference sequences of wild  in Nepal and 130 yak sequences  in China  which are shared by domestic and wild yaks with the majority representing domestic yaks in terms of frequency Figure . The top44.1Wild yaks evolved into three allopatric lineages in different regions during the Pleistocene glaciation events  and reunited into a single gene pool during a postglacial population expansion and subsequent migrations before multiple domestications began across QTP in the Holocene   were found to be identical to a haplotype belonging to an endemic haplogroup of wild yaks sampled in north‐western QTP by Wang et al. . This paThe other two haplotypes of presumed  wild yaks collected from Humla  and Dolpa  are identical to contemporary haplotypes belonging to domestic yaks in haplogroups A and D. Both of these haplogroups consist of haplotypes shared by both wild and domestic yaks, the majority of which belong to the domestic yak gene pool. Similarly, the haplotype of the unknown yak from Humla (dung) is associated within the haplogroup C which consist of haplotypes shared by both wild and domestic yaks with the majority belonging to wild yak gene pool. However, the haplotype shows a more direct affinity with domestic haplotypes within the haplogroup suggesting that it is the most likely to be of a domestic origin. These inferences clearly show the extent of hybridization across the wild yak range since the historic past. The other haplotypes of domestic yaks from Mustang, Dolpa and Humla are unevenly distributed among haplogroups A, C, and D irrespective of their geographic locations. These results corroborate the previous findings of Guo et al.  and WangBubalus arnee whose wild population face serious threats due to hybridization with domestic water buffaloes Bubalus bubalis . Anecdotal reports like these motivated deeper investigations into the matter and the present research. During our observations of wild yaks in 2014 and 2015, the animals were extremely shy of humans. This behavior may reflect the intense hunting pressure they face from humans. The large amount of meat resulting from a hunted wild yak and the high price of wild yak heads  in the nearby illegal markets of TAR (Tibetans have a tradition of hanging a wild yak head by the entrance of their houses as a status symbol) act as incentives for killing the animals. The construction of motor roads in the Tibetan Plateau has further intensified the poaching risk ; data curation (lead); formal analysis ; methodology ; writing‐original draft (lead); writing‐review & editing . Prajwol Manandhar: Conceptualization ; data curation ; formal analysis (lead); methodology ; writing‐original draft ; writing‐review & editing . HelenSenn: Methodology ; writing‐review & editing . Jyoti Joshi: Investigation ; writing‐review & editing . MuhammadGhazali: Methodology ; writing‐review & editing . Krishna DevHengaju: Investigation ; writing‐review & editing . Sanej Prasad Suwal: Investigation ; writing‐review & editing . Tshiring Lhamu Lama: Investigation ; writing‐review & editing . Laxman Prasad Poudyal: Resources ; writing‐review & editing . Madhuri Thapa: Resources ; writing‐review & editing . GeraldineWerhahn: Conceptualization ; methodology ; writing‐original draft ; writing‐review & editing .Supplementary MaterialClick here for additional data file.