Electronic phase‐change memory devices take advantage of the different resistivity of two states, amorphous and crystalline, and the swift transitions between them in active phase‐change materials (PCMs). In addition to these two distinct phases, multiple resistive states can be obtained by tuning the atomic disorder in the crystalline phase with heat treatment, because the disorder can lead to the localization of the electronic states and, thus, hamper the electron transport. The goal of this work is to achieve and explore multiple disordered configurations in PCMs by applying high pressure. Large‐scale ab initio molecular dynamics simulations demonstrate that pressure can lower the energy barrier for the antisite migration in crystalline PCMs. The accumulation of these antisite atoms largely increases the compositional disorder, adding localized electronic states near the conduction band. The disorder‐induced electron localization triggered by pressure is a novel way to modulate the properties of materials. Furthermore, the random distortion of the lattice induced by the compositional disorder provides a new mechanism that contributes to the amorphization of crystalline PCMs at high pressure. It can be associated, for example, to the random distribution of vacancies, the alloying of different types of elements, or the occupation of antisites, e.g., sites usually reserved for other elements. The degree of disorder is often governed by thermodynamic laws. Entropy always favors disorder, driving the atomic arrangement to be as disordered as possible. However, usually such chemical disorder is discouraged by the concomitant enthalpy rise, caused by the formation of homopolar bonds. Disorder can induce localization of electronic wavefunctions  take advantage of the fast transformations and large property contrast between the amorphous and the crystalline states.c‐GST) with different levels of electrical resistivity. In this phase, one sublattice contains Te atoms, whereas Ge, Sb, and vacancies occupy the sites of the second sublattice in a random fashion. High annealing temperatures induce the ordering of the vacancies in c‐GST, which gradually evolves into a metallic hexagonal phase (h‐GST) with all vacancies diffusing into layers. Ab initio simulationsTo manipulate the disorder in data storage media, Siegrist et al. have modified the atomic arrangement in crystalline PCMs such as Ge–Sb–Te (GST), a prototype of PCMs, by annealing.c‐GST by lowering the migration barrier. Accumulation of these antisites leads to severe atomic distortions. The resulting strong misalignment of bonds may trigger the loss of the long‐range order in the crystalc‐GST under high pressure, as observed in experiments at 15 GPa.c‐GST and open a new avenue to control the disorder, and hence the transport properties in PCMs.In this article, we report that the compositional disorder in PCMs can also be tuned by pressure in lieu of the thermal treatment. Large‐scale ab initio molecular dynamics (AIMD) simulations reveal that pressure can expedite the antisite hopping in the vacancy‐ridden 22.1c‐GST containing 1008 atoms with and without pressure after 100 ps of an AIMD run in Figurec‐GST at ambient pressure because each antisite Te creates five Te–Te homopolar bonds, which have much higher energy than the heteropolar Ge–Te and Sb–Te bonds. Under high pressure, however, Te atoms shift into the neighboring vacant sites to release the strain energy of the compressed heteropolar bonds.We plot the atomic structure of Even though these Te atoms frequently hop into adjacent vacancy sites, the resulting antisite Te configurations are rather unstable. Interestingly, some of the Te atoms move back swiftly, while others are stabilized by a neighboring Sb atom, which jumps into the vacant spot the Te atom has left behind. This is the reason why antisite Sb and Te atoms always appear in pairs in Figure rmax (the length of the maximum heteropolar bond when the system is subject to zero stress), this atom is then considered to enter the antisite region. rmax is located in the first minimum of the pair distribution functions (PDF) of c‐GST at the ambient pressure . In other words, if the migration does not lead to the breaking of bonds (most of its bond lengths are shorter than rmax), then we treat this movement as a regular vibration instead of an antisite hopping. Figure To quantify the number of antisite Sb and Te pairs (ASPs), one has to distinguish the antisite hopping from the distortion due to the thermal vibrations. We select the “cutoff” for the atomic migration in such a way that, if the movement of an atom toward the vacancy site makes all of its original bonds longer than FigureTo gain a better understanding of this anomalous migration behavior, three questions need to be addressed: 1) why is the single hopping of Te atoms unstable? 2) Are ASPs indeed metastable? And 3) why is Ge not involved in the cooperative migration? To this end, we adopt the nudged elastic band (NEB) methodFigure However, when Sb cooperates with Te and participates in an antisite hopping event, the energy penalty can be significantly reduced. Figure 2.2Figurep electrons to maintain resonant bonding.c‐GST samples, excess vacancies at cation sites are present and act as dopants. Hence, the Fermi level moves toward the valence band, rendering them p‐type semiconductors.The localization of electronic states often stems from compositional disorder that is introduced by defects, which entails impurity states within the band gap of semiconductors,c‐GST,The ASPs can be viewed as point defects: they generate several homopolar bonds, which introduce some defect states within or near the band gap. On the other hand, ASPs add compositional disorder to the lattice, enhancing the electron localization. This disorder‐induced electron localization =∑i|φα,i|4/2, where φα,i are the expansion coefficients of the Kohn–Sham eigenstates α with respect to the localized Gaussian‐type orbitals (GTOs) forming the basis set and i is counted over all the GTOs. Theoretically, the IPR of an extended state tends to zero and has a finite number for a localized state. For finite (or periodic) systems, the size of the unit cell determines the minimum value of the IPR.In order to quantify the degree of localization of electronic wavefunctions, we use the inverse participation ratio (IPR),c‐GSTs with and without antisite disorder as a function of the energy of electronic states. Both structures are quenched down to 0 K and fully relaxed at 0 GPa (by increasing the box size). Since the ASPs are metastable, most of them are able to survive in such nonthermal relaxations. Figure c‐GST containing no antisite atoms, while Figure 2Te4 box.Figure Electron localization can be observed on the top of valence band (near 0 eV) in both configurations, due to random distribution of vacancies on the sublattice.2.3r‐GeTe), where Ge and Te atoms occupy separate layers along [111] direction, the spacing between layers is not equal, one smaller and every other larger,c‐GST in which Ge/Sb/vacancies are randomly distributed. Due to the random displacement of the atoms, the local structure of c‐GST is not as well defined as that in the ordered crystal, but the long‐range order is still maintained.Distortions may exist both in ordered and disordered systems, but have different forms. In ordered systems such as rhombohedral GeTe (g(r), in which the first peak denotes the bond length. The sharper the peak is, the more well defined the local structure is. On the contrary, a broadened first peak corresponds to a randomly distorted local structure. However, c‐GST has large disorder in the cation site and the atoms are intrinsically distorted, a small fraction (less than 10%) of ASPs may not be visible on the overall PDF. To observe the distortion caused by the antisite hopping, we devised a partial PDF, which illustrates the radial distribution of first‐nearest neighbors around ASPs. In Figurec‐GST configuration without ASPs, whereas the partial PDF was calculated by quenching several AIMD models (<9 GPa), which still preserve various amounts of ASPs, to zero pressure. Obviously, the partial PDF is broader than the overall one, suggesting that ASPs introduce further distortions. The first peak of the partial PDF is located around 2.94 Å, corresponding to the Ge–Sb and Sb–Sb bonds, and the shoulder near 3.18 Å is due to the longer Te–Te bonds. The distortion may be induced by the antisite atoms because the resulting homopolar bonds have different stable bond lengths than the heteropolar bonds  we can barely distinguish layers anymore, and the crystal presumably starts to evolve into an amorphous system . A new perspective of these results is that, the crystalline lattice is able to survive a large fraction of ASPs (≈50%), enabling us to manipulate the disorder in c‐GST by increasing the number of ASPs , but with high pressure, it may require much less disorder to become amorphous. This is caused by a further reduction of the energy cost for atomic migration upon increasing pressure, which directly leads to some irreversible distortions in the lattice when the pressure is sufficiently high. For example, Caravati et al. found Te atoms hop into vacancies and fail to move back at about 14 GPa.c‐GST for pressures approaching 15 GPa.Previous ab initio work by Kolobov et al. has demonstrated that the random misalignment of the atoms in crystalline GST may trigger the loss of long‐range order.s Figure . This dis Figure . Such di3c‐GST under various pressures using large‐scale AIMD simulations. A number of antisite hops is observed at medium pressure, with one Te atom hopping into the vacant cation site first, followed by a Sb atom filling the remaining empty Te site. This cooperative hopping has increased the compositional disorder in the crystal lattice, producing several interesting consequences for the atomic and electronic structure of c‐GST: 1) the atomic disorder leads to the localization of electrons. As revealed by IPR, several localized states found near the mobility gap are induced by these ASPs, in addition to those due to vacancy disorder. This interesting feature may be employed to tune the electrical properties in the memory devices using high pressure. 2) The compositional disorder can randomly distort the lattice of c‐GST. Such random distortion may eventually contribute to the instability of the lattice and amorphize the crystal at higher pressure.To summarize, we have studied the atomic migration of 44.12Te3 in the ternary phase diagram.GSTs lie on the tie‐line between GeTe and Sba‐GST: Amorphous GST can be obtained from 1) as‐sputtered film, 2) melt‐quenching the c‐GST, or 3) compressing the c‐GST to ≈15 GPa. The as‐sputtered and melt‐quenched a‐GST have a similar structure, in which atoms are mostly octahedral‐coordinated (p‐bonding) with 17% of voids (or vacant open space) percolated over the glass.a‐GST is found to have more tetrahedral Ge than the melt‐quenched one.a‐GST at ≈15 GPa is also dominated by the octahedral arrangement, yet the voids are largely squeezed out by pressure.c‐GST: Metastable cubic GST bears a rocksalt‐like structure. Te atoms occupy one fcc sublattice while Ge/Sb/vacancies occupy the other.x(Sb2Te3)x1− compositions.2Te4 which has 25% vacancies on the Ge/Sb sublattice. Te layers and Ge/Sb/vacancies layers alternately stack along [1 1 1] direction, and we build our supercell in such a way as to better evaluate the compositional disorder: a and b are two perpendicular lattice vector inside the (1 1 1) plane and c is oriented along the [1 1 1] direction  were built with Te occupying the anion sites, while Ge/Sb/vacancies fill the cation sites. We optimize the initial configuration (before the jump) and final configuration (after the jump), and then applied the NEB method to find the minimum energy path (MEP). Several possible transition points (“images”) are first interpolated between the initial and the final states, and the elastic band method added suppositional spring forces between neighboring images to maintain reasonable intervals between them. The calculations will converge when MEP is found. We calculated several paths for each pattern , and averaged the energies to obtain Figure The NEB calculationsAs a service to our authors and readers, this journal provides supporting information supplied by the authors. Such materials are peer reviewed and may be re‐organized for online delivery, but are not copy‐edited or typeset. Technical support issues arising from supporting information (other than missing files) should be addressed to the authors.SupplementaryClick here for additional data file.


Apcmin716/+ mice expressing a mutant gene encoding an adenomatous polyposis coli protein truncated at amino acid 716. Ultrasound image‐based spleen size measurement precisely mirrors splenomegaly development in vivo in the tumor‐laden Apcmin716/+ mice. Moreover, the spleen dimensions extracted from the ultrasound sonograms are positively correlated with normalized spleen weight and the number and area of colon tumors. Hence, we propose measuring the spleen size in vivo by ultrasound imaging as a novel approach to estimate splenomegaly development and to indirectly monitor colon tumor development in Apcmin716/+ mice. The widespread use of ultrasound machines in the laboratory setting, coupled with the fact that it is a noninvasive method, make it a straightforward and useful tool for monitoring the experimental progress of colon cancer in mice and determining end points without killing animals strictly for diagnostics purposes.Animal models of colon cancer are widely used to understand the molecular mechanisms and pathogenesis of the disease. These animal models require a substantial investment of time and traditionally necessitate the killing of the animal to measure the tumor progression. Several in vivo imaging techniques are being used in both human clinics and preclinical studies, albeit at high cost and requiring particular expertise. Here, we report that the progression of splenomegaly coincides with and positively correlates to colon tumor development in  ApcMin/+ mouse model of Familial Adenomatous Polyposis (FAP) is similar in phenotype to the human disease APC) gene, cells within these mice are prone to spontaneously lose the remaining full‐length copy of the oncogenic APC gene, leading to tumor formation. APC regulates the levels and activity of β‐catenin within cells, and upon losing both functional copies of APC gene, the cell experiences constitutive activation of β‐catenin. The following dysregulation of Wnt signaling leads to the expression of proliferative genes ApcMin/+ mice also develop splenomegaly of yet unknown origin Colon cancer is among the most prevalent forms of cancer worldwide and a major cause of cancer death Apcmin716/+ mice that express a mutant gene encoding an adenomatous polyposis coli protein truncated at amino acid 716 Apcmin716/+ mice, providing researchers the ability to more easily and noninvasively monitor the colon tumor development in vivo.Monitoring tumor formation in humans relies on the use of scanning technologies including Positron Emission Tomography (PET), X‐ray Computed Tomography (X‐ray CT), Magnetic Resonance Imaging (MRI), and others, most of which have been adapted for use in animal research of disease Apcmin716/+ mice Apcmin716/+ male with wild‐type (Apc+/+) females. Mice were maintained in a specific pathogen‐free facility and fed autoclaved food and water ad libitum.All animal experiments were performed in accordance with Johns Hopkins University's Animal Care and Use Committee under the protocol MO13H349 and in direct accordance with the NIH guidelines for housing and care of laboratory animals. Colon adenoma staining and quantification were performed as previously described At the indicated time points, the body weight of indicated mice was determined prior to killing. After killing the mice, the spleen was gently excised under aseptic conditions, and spleen weight was measured by an analytical balance and normalized to body weight of individual mouse.® High‐Resolution Imaging System  following the manufacturer's instructions. Briefly, all fur was removed from the abdomen of mice using depilatory cream (Nair) and skin was washed with water to remove excess lotion. Mice were maintained anesthetized for the duration of the imaging and a heat lap was kept over the mice at all times to preserve body temperature. With a generous amount of warmed ultrasound gel applied to the skin, the mouse was restrained on the heated imaging platform with surgical tape and ultrasound images were taken of its abdomen using the RMV 704 scanhead. The sonograms were analyzed and the diameter, both along the shortest part as well as the widest part of the spleen, and the area was determined using ImageJ software .Mice spleens were imaged by ultrasound using a Vevo 770P < 0.05; **P < 0.01; and ***P < 0.001 by unpaired Student's t‐test.All statistical analysis was performed using GraphPad Prism version 6.0 . Standard errors of means (S.E.M.) were plotted in graphs. Significant differences were considered: n.s., nonsignificant difference; *Apcmin716/+ mice develop a large number of adenomas in the colon and exhibit a reduced life span (~6 months), thus modeling human colon cancer to certain extents. In order to examine the tumor development present within the colon, Apcmin716/+ mice and their wild‐type (Apc+/+) littermates were aged according to the schematic in Figure Apcmin716/+ mice spontaneously developed adenomas between 10 and 20 weeks of age, with majority of adenomas present within the final 2 cm of the distal colon, some in the cecum, and occasionally some within the proximal colon , which suggests that the differences in spleen size are not caused by an increase in body weight. Instead, the increases in spleen size and tumor burden in aged Apcmin716/+ mice may provide additional morphological and pathological markers to evaluate colon tumor development.It was previously reported that the spleens were enlarged in tumor‐laden ApcMin/+ mice Apcmin716/+ mice versus 10‐week‐old ones . Hence, imaging the spleen size in vivo by ultrasound may serve as a unique tool to monitor and estimate the colon tumor development in Apcmin716/+ mice.The established positive correlation between spleen size and colon tumor number and tumor load in ges Fig. D–E suggeely Fig. A. To ascely Fig. A, which ely Fig. B. When tely Fig. C–E, suppely Fig. D–E, the ApcMin/+ mice Apcmin716/+ mouse model of colon cancer. As expected, the number and load of colon tumors spontaneously increases in Apcmin716/+ mice over time, which most likely facilitates the accumulation of further mutations and the complete loss of Apc gene activity. Interestingly, in parallel to the increased number and load of colon tumors, the dimensions and weight of the spleen increased in Apcmin716/+ mice of varying ages, which is unrelated to the animals' body weight growth over time. The divergence between the spleen size from Apc+/+ and Apcmin716/+ mice is exhibited more profoundly in older animals where colon tumors are fully developed. The significance of the correlation between splenomegaly and tumor development in Apcmin716/+ mice across ages provides the rationale for measuring spleen size as a novel approach to monitor colon tumor development in vivo.Splenomegaly has been recognized in the tumor‐laden Cancer development is believed to be a chronic and gradual process, with the formation and progression of tumors needing substantial amount of time. Hence, monitoring tumor development in cancer animal models requires striking a careful balance between allowing enough time for tumor growth and capturing the best time windows to reach biological significance. This makes the study of internal cancers particularly challenging without access to methods to observe tumor progression directly. The advancement in imaging techniques and tools has bettered our understanding of the molecular events surrounding tumor formation and progression None declared.


SARI) is important for setting national influenza surveillance and vaccine priorities. Estimating influenza‐associated SARI rates requires hospital‐based surveillance data and a population‐based denominator, which can be challenging to determine.Understanding the burden of influenza‐associated severe acute respiratory infection  including hospital admission survey (HAS) methods for estimating the burden of influenza‐associated SARI, with lessons learned to help others calculate similar estimates.We present an application of the World Health Organization's recently developed manual (SARI surveillance platform in Cambodia, we counted influenza‐associated SARI cases during 2015 at one sentinel surveillance site in Svay Rieng Province. We applied WHO Manual‐derived methods to count respiratory hospitalizations at all hospitals within the catchment area, where 95% of the sentinel site case‐patients resided. We used HAS methods to adjust the district‐level population denominator for the sentinel site and calculated the incidence rate of influenza‐associated SARI by dividing the number of influenza‐positive SARI infections by the adjusted population denominator and multiplying by 100 000. We extrapolated the rate to the provincial population to derive a case count for 2015. We evaluated data sources, detailed steps of implementation, and identified lessons learned.Using an existing We estimated an adjusted influenza‐associated 2015 SARI rate of 13.5/100 000 persons for the catchment area of Svay Rieng Hospital and 77 influenza‐associated SARI cases in Svay Rieng Province after extrapolation.Methods detailed in the WHO Manual and operationalized successfully in Cambodia can be used in other settings to estimate rates of influenza‐associated SARI. It outlines how to use the HAS, catchment population, and SARI sentinel surveillance data to calculate the burden of influenza‐associated SARI.2.2Existing surveillance, hospital, and population data were evaluated for suitability to estimate the rate of influenza‐associated SARI.2.2.1We used data previously collected via C‐CDC/MOH's SARI sentinel surveillance at SRPH to count the number of SARI cases and influenza‐associated SARI cases in Svay Rieng Province in 2015  to assess for under‐reporting of SARI cases  to the SARI surveillance system Figure : Step 2.2.2.3We reviewed admission and discharge registers at all public and private hospitals within the catchment area of SRPH to count the number of hospitalizations for any respiratory illness by age group for each hospital Step 3. We identified the catchment area, which is the geographic area where most case‐patients seeking care at the sentinel site resided. The WHO Manual recommends that the catchment area for a sentinel site should include the administrative divisions where ≥80% of the SARI case‐patients reside for the site. We used address data from the SARI surveillance system to determine the districts within the province where the majority of SARI case‐patients lived.Step 4. We evaluated respiratory diagnoses to capture the most applicable hospital admissions. While the WHO Manual recommends using a diagnosis of pneumonia to determine the number of respiratory hospital admissions, we were concerned that using one specific definition might result in missing some SARI‐related admissions. None of the hospitals within the catchment area used International Classification of Diseases (ICD) coding for admission and discharge diagnoses, so we evaluated a comprehensive list  × 100 000Step 8. We multiplied resulting rates by the age‐specific provincial population data to obtain a provincial estimate of influenza‐associated SARI cases for SRPH in 2015  of SARI case‐patients in the catchment area  and identified 216 with evidence of fever. Of those, we identified 41 (19%) patients who met the C‐CDC/MOH SARI case definition of a hospitalized patient with measured temperature ≥38°C or self‐reported fever with symptoms of cough or sore throat, and shortness of breath or difficulty breathing within 10 days of hospital admission. Using the WHO case definition, which does not require evidence of difficulty breathing, we identified 101 SARI case‐patients. During those same 6 weeks, the surveillance system identified 50 SARI case‐patients. The ratio of cases identified during the chart review compared to those identified through the surveillance system was 41/50 or 0.8 using the C‐CDC/MOH SARI case definition; using the WHO case definition, the case ratio was 101/50 or 2.0.3.3Of the 41 patients who met the C‐CDC/MOH SARI case definition, 40 (98%) had an admission or discharge diagnosis consistent with a respiratory illness. The most frequently found diagnoses were pneumonia , pharyngitis , bronchiolitis , and asthma . Of the 101 hospital admissions that met the WHO SARI case definition, 90 (89%) had an admission or discharge diagnosis consistent with a respiratory illness. Pharyngitis ; pneumonia, including severe pneumonia and bronchopneumonia ; bronchiolitis ; and asthma  were the most common diagnoses. Of the 11 patients without a respiratory diagnosis, the following diagnoses were observed: neonatal infection (5), hyperthermia (1), dysentery (1), malnutrition (1), enteritis (1), dengue (1), and intoxication (1).3.4Using Svay Rieng Province Health Center Population Data, the Svay Rieng Province population in 2015 was 596 539 and the population within the catchment area was 487 489  were from public district hospitals, 2% (54) from private admitting facilities, and 52% (1442) from SRPH, with differences by age Figure .3.6We calculated the influenza‐associated SARI rate using both SARI case definitions. Using the C‐CDC/MOH case definition, we estimated an influenza‐associated SARI rate for all ages of 6.7/100 000 persons in 2015 within the SRPH catchment population . By adjusting for possible under‐ascertainment of cases by using the WHO case definition and applying the resulting catchment area hospitalization rate to the provincial population, we estimated 77 influenza‐associated SARI cases in Svay Rieng Province in 2015  and surveillance implementation challenges may have resulted in identification and enrollment of fewer case‐patients than met the case definition. We may also have missed a large fraction of the population that either chose not to seek care for their illness  or sought care outside of the province. Our study could not account for these factors. Our estimate was for one province of Cambodia, which may not be representative of Cambodia; this initial estimate was not intended to provide a national estimate. Future work to generate a national estimate is needed to understand the burden of influenza‐associated SARI in Cambodia.The HAS method described by the WHO ManualEach data source used in our estimate presented challenges for use and interpretation. By applying the WHO Manual to Svay Rieng Province, we learned lessons that may be useful to other settings where the WHO Manual is being considered.While the intent of a burden study is not to review and evaluate the surveillance system, such review may inform projects that use the surveillance system and may ensure the quality and reliability of burden estimates, future surveillance methods, and reporting. For this study, we used a sensitivity analysis through a retrospective chart review to evaluate the application of the case definition to hospitalized patients at SRPH and adjusted our estimated number of case‐patients accordingly. The validity of the sensitivity analysis is dependent on the quality of the patient's medical record and the accurate recording of symptoms such as fever, cough, sore throat, and difficulty breathing.In our study, we also evaluated hospital records to allow us to count the number of respiratory hospitalizations with the predetermined diagnoses and to determine the catchment population. The minimum patient record required for an HAS is a hospitalization register that includes admission and/or discharge diagnoses, date, age, gender, district, diagnoses, and patient outcome. Hospital registers provide the ability to count respiratory hospitalizations. Such records must be available for all hospitals in the catchment area; if electronic or paper patient records are not available or organized for a review, an HAS will not be possible.We learned that there may be different sources of hospitalization information that could be identified and reviewed. During our study, we learned that the MOH collects hospitalization data from public and large private hospitals. Other countries may also collect national‐level health data or subnational hospitalization data which may be evaluated and used to estimate burden. When reviewing data sources for suitability, the following should be considered: types of respiratory diagnoses; potential missing data ; age and gender data; protocols and application of reporting; differences between hospitals; and any previous evaluation or validation of data sources.We learned that it is important to review the relevant respiratory diagnoses when conducting an HAS. Our findings suggest that the diagnoses list for HAS data collection should be expanded beyond pneumonia. In Cambodia, it could be limited to small set of diagnoses: pharyngitis, pneumonia, bronchiolitis, asthma, and bronchitis. However, commonly used diagnoses may vary greatly by country and hospital; therefore, an evaluation to optimize the list of included diagnoses is recommended before beginning an HAS.Another lesson learned was the importance of identifying and evaluating all possible data sources, including population data. The HAS methodology requires reliable and accessible population data for relatively small administrative units. The availability and quality of these data must be evaluated before deciding to conduct an HAS. We identified two sources of population data, one of which had data stratified by district, which we were able to use for our provincial estimate.5Using HAS methods derived from the WHO Manual and several pre‐existing data sources, we estimated an influenza‐associated SARI rate of 6.7/100 000 persons for the catchment area of Svay Rieng Hospital; after adjusting for possible decreased case ascertainment using the C‐CDC/MOH case definition, we estimated a rate of 13.5/100 000 persons. We evaluated data sources, detailed steps of implementation, and identified lessons learned. A careful review of all available data sources before beginning data collection will improve the feasibility of the study and quality of the data collected. Health officials may find our operationalization of the WHO Manual methods and detailed steps helpful when working toward similar estimates in similar contexts.We declare that we have no conflict of interests.The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


To assess the association between the prevalence of tongue cyst‐positive and antigen‐positive pigs across different settings in Africa, to evaluate whether examining pigs for cysts could be used as a rapid surveillance tool for identifying geographical areas with a higher probability of high transmission of cysticercosis.Published data were collated from 26 study sites across Africa that reported the prevalence of porcine cysticercosis by both lingual and serological examinations. The study sites were located in 10 countries across Africa.PPV of 100%), although this cut‐off is less reliable at predicting that an area is of low transmission (NPV of 84%).Seroprevalence rates ranged from 4% to 41%. Despite the varied study sites, the relationship between the two variables was highly consistent and suggests identification of tongue cysts may be useful for cysticercosis surveillance. We found that all areas with more than 10% of pigs having cysts in their tongues had at least 30% seroprevalence (Assessing the prevalence of tongue cyst‐positive pigs is a potential rapid epidemiological tool for identifying areas at high risk of cysticercosis, although further refinement and validation is required using standardised data sets. The Food and Agriculture Organization (FAO) has identified cysticercosis as the most important foodborne parasite globally Lingual palpation (or tongue inspection) for cysts is a practice carried out by pig producers, buyers and veterinarians alike to rapidly screen pigs for cysticercosis. However, because it has been shown to have low sensitivity in identifying infected animals (as low as 21%) We undertook a comprehensive literature review of published community studies in Africa that collected both serological  and lingual palpation data for pigs . Only data from household surveys (as opposed to markets or slaughter houses) were included.et al. et al. In total, we identified 26 study sites across 10 countries in Africa Cameroon , 21 condThe sampling framework, if given, varied markedly across studies at each level . For instance, in some studies villages were purposively selected based on certain risk factors such as large numbers of pigs, accessibility and/or willingness to participate Figure In all studies, the prevalence of tongue cyst‐positive pigs was less than the prevalence of antigen‐positive pigs, an expected outcome given the known sensitivity issues of lingual examination. However, given the data available at present, if the prevalence of tongue cyst‐positive pigs is >10%, then the serological prevalence appears to always be >30%. Tongue cyst‐positive rates >10% varied between 12% and 26%, and suggest that a prevalence >10% would indicate a seroprevalence in pigs of more than 30%, with a positive predictive value (PPV) of 100% (7/7) (i.e. only true positives are identified). If 10% or less of pigs have cysts on their tongues, seroprevalence can vary widely between 4% and 41%, and lingual examination becomes a far less valuable indicator of intensity of infection in the population. From the data available, it seems that this cut‐off would identify seroprevalence rates of 30% or less with a negative predictive value (NPV) of 84% (16/19) . In fact, of the 10 studies with a seroprevalence >30%, three had a tongue cyst prevalence below 10%, although two of these had seroprevalences close to the cut‐off (30.7 and 32.8).Ascaris lumbricoidesIf, as we suggest, the prevalence of pigs with tongue cysts does relate to the prevalence of heavy infection, then its relationship with the prevalence of infection (as assessed by serology) would be predicted to be nonlinear if the distribution of cysts in a pig population is overdispersed (i.e. most pigs have a few cysts and a few pigs have many cysts). These overdispersed distributions in parasite numbers have been observed and quantified for other helminth infections such as T. solium infection T. hydatigena, this appears to be more a problem in parts of Asia, such as Vietnam T. hydatigena in pigs can reach levels in excess of 60%. This contrasts markedly with studies in Africa where T. hydatigena in pigs rarely exceeds a few per cent T. hydatigena can be found at high prevalences in goats in Africa, the prevalence in pigs is consistently low, in the range of 2 to 6% . Although both T. solium and T. hydatigena can be a consequence of bad sanitation and slaughter practices, their transmission and risk factors can be quite different, and as a result, we may not see them at equivalent prevalences in pig populations.The data presented here on lingual and seroprevalence in same settings represent published studies in the international scientific literature to date in Africa. Although there are concerns related to the specificity of the antigen test in diagnosing T. hydatigena does have are either extremely small or consistent across all settings. However, we would call for further data to validate this relationship, particularly in areas of intense transmission . There are likely to be unpublished data within countries as part of ongoing surveillance or research programmes which could complement this data set. Furthermore, the collection of such data should be encouraged in future activities. Data are required from village‐based field surveys, not surveys undertaken in slaughterhouses or markets where pigs may already have been pre‐selected to be tongue cyst free.Indeed, the consistency of the relationship we observe between lingual prevalence and seroprevalence suggests that any modifying effects the presence of The data also need to be collected using standardised sampling frameworks. Various approaches to sampling villages, households and pigs were employed in the published data presented here. Studies that only sample a few households or pigs in a whole village are unlikely to be representative unless villages are highly homogenous in their levels of cysticercosis. We propose a multicountry approach in which villages with a range of pig population sizes and expected prevalences are comprehensively sampled and examined both clinically and serologically. This would help establish whether the NPV of 84% observed using this limited data set (with the possible concerns that a proportion of high‐risk areas could be missed) is still applicable when the data are standardised. Such an activity could form part of the global network for the elimination of cysticercosis proposed by WHO The data presented suggest that if more than 10% of pigs are tongue cyst‐positive in an area, then these areas will be at high risk of cysticercosis with more than 30% of pigs being infected. Although there is a potential for 16% of high‐risk areas to be missed using this 10% lingual prevalence cut‐off, further data and quantification of the relationship between the proportion of pigs with cysts in their tongues and antigen‐positive pigs could provide a cheap and rapid decision‐support tool for identifying target areas for cysticercosis control, and in evaluating and monitoring control efforts.


HF). However, the biological underpinnings of frailty remain unclear and the interaction with HF is complex. Here, we describe the inflammatory pathophysiology that is associated with frailty and speculate that the inflammation that occurs with frailty shares common origins with HF. We discuss the limitations in investigating the pathophysiology of frailty due to few relevant experimental models. Leveraging current therapies for advanced HF and current known therapies to address frailty in humans may enable translational studies to better understand the inflammatory interactions between frailty and HF.Frailty, a clinical syndrome that typically occurs in older adults, implies a reduced ability to tolerate biological stressors. Frailty accompanies many age‐related diseases but can also occur without overt evidence of end‐organ disease. The condition is associated with circulating inflammatory cytokines and sarcopenia, features that are shared with heart failure ( This growth will pose an increasing burden on our healthcare system and resources, particularly as cardiovascular disease in older people overshadows all other age‐related end‐organ diseases including infectious diseases, cancer, and lung diseases. There is thus an urgent need to understand how aging impacts cardiovascular diseases. Among cardiovascular diseases in older people, heart failure (HF) is a major cause of morbidity and mortality. Importantly, people over 65 years of age constitute >80% of patients with HF and the incidence of HF is 10 per 1000 in people aged >65 years of age . Importantly, the induction of inflammation leads to negative feedback pathways to resolve inflammation, via immune‐suppressive cytokines like IL‐10 or resolvins  trial demonstrated favorable outcomes in patients with HFrEF although the effects of exercise training on formal measures of frailty and markers of inflammation were not studied in HF‐ACTION  improve frailty symptoms  or whether improving frailty symptoms prior to resolving the hemodynamics of HF improve outcomes after transcatheter aortic valve replacement . Few studies have examined whether LVAD impact inflammatory cytokine levels, with one revealing that LVADs may reduce circulating IL‐6 and TNF‐α levels 1 month after implantation (Clark As increasing numbers of older frail patients receive advanced options for end‐stage HF, there is a unique opportunity to perform translational research that could inform on the inflammatory biological basis of frailty and how it interacts with HF. LVADs improve cardiac hemodynamics to resolve the poor tissue perfusion that occurs with HF. Thus, investigation of frail patients with HF that receive LVADs could inform on the contribution of end‐organ dysfunction to the frailty clinical and inflammatory phenotypes. Future clinical investigation is required to determine whether resolving the hemodynamic alterations of HF using advanced therapeutic options would improve the systemic inflammatory profile associated with both frailty and HF.Given the anticipated rise in the number of older people with HF and current limited experimental models of frailty, there is a rare opportunity to leverage ongoing clinical practice to yield novel insights as to whether therapies that improve HF resolve the chronic inflammation that occurs in frailty and HF. Such lines of investigation could provide precious information on the biological underpinnings of frailty and end‐organ disease such as HF.Daniel Goldstein has following NIH grant funding: AG050096, HL 130669, and AG028082. Scott Hummel has following NIH grant funding: HL‐K23109176.None declared.


O‐Methyltransferase (COMT) gene on white matter connectivity in healthy adults.Genetic polymorphisms play a significant role in determining brain morphology, including white matter structure and may thus influence the development of brain functions. The main objective of this study was to examine the effect of Val158Met (rs4680) polymorphism of Catechol‐TBSS) analysis to examine white matter structural integrity in intrinsic brain networks on a sample of healthy subjects (N = 82).We used a whole‐brain diffusion‐weighted imaging method with Tract‐Based Spatial Statistics : in males only, Val homozygotes had significantly higher fractional anisotropy (FA) compared to Met‐carriers. Volume‐of‐interest analysis showed a genotype by sex interaction on FA in genu and rostral midbody of CC, whereby Val males demonstrated higher FA than Met females.Results revealed a sex‐specific effect of These results demonstrate the key effect of genes by sex interaction, rather than their individual contribution, on the corpus callosum anatomy. Developmental studies showed that dopamine (DA) is one of the earliest neuromodulators expressed in the developing brain that plays a role in the neuronal maturation and myelination  gene located within the q11 of the 22nd chromosome , a functional single‐nucleotide polymorphism that codes for a substitution of methionine (Met) for valine  at codon 158. Previous studies have shown that this Met substitution reduces the activity of COMT enzyme to one‐quarter of what is originally encoded by the Val allele  signal in people performing working memory tasks  spatial convergence of imaging genetics findings on this association . Shimony et al.  in a group of 40 children (aged 9–15). The authors reported a significantly higher FA in Val‐allele homozygotes  in the genu of corpus callosum and anterior thalamic radiation, respectively. Based on animal studies showing increase in DA availability due to inhibition of COMT functionality  had lower FA values in the prefrontal white matter tracts.As well as studying the effect of y et al.  used quay et al.  examinedu et al.  who emplCOMT was not replicated in a study of Kohannim et al. , neurotrophic tyrosine kinase receptor‐type 1 (NTRK1), and the hemochromatosis gene (HFE) which explained ∼6% of the variance in the average FA of the corpus callosum including the genu, body, and splenium in young, healthy individuals. Although adding to the combined effect of other SNPs, there was no significant independent effect of COMT Val158Met polymorphism on FA.However, the main effect of m et al. . This voCOMT functioning. In particular, COMT activity in human prefrontal cortex is 17% higher in men than women  due to lower activity of Val polymorphism and putatively higher DA availability in females. In order to make our study comparable with the studies reviewed as above, we chose to group COMT genotypes according to the presence or absence of the Met allele .To summarize, the studies reviewed above demonstrated negative associations between COMT polymorphism on the intrinsic brain networks in a sample of healthy adults. We chose FA as the measure of white matter structure, as it has been shown to have higher heritability than other DWI parameters, such as radial and axial diffusivity  tractography method with Tract‐Based Spatial Statistics (TBSS) analysis to examine influence of 22.1The study included 82 right‐handed, White Caucasian, healthy volunteers . The White Caucasian ancestry has been established by participants' self‐report. Exclusion criteria comprised the neuropsychiatric disorders in the participants or their first‐degree relatives, screened out by the Structured Clinical Interview for DSM‐IV . The genotype of the COMT Val158Met (rs4680) SNP was determined by allelic discrimination assay (C__25746809_50) based on fluorogenic 5′ nuclease activity: a TaqMan SNP genotyping assay was performed using an ABI Prism 7900HT and analyzed with Sequence Detection System software according to the manufacturer's instructions . There was no statistical deviation from Hardy–Weinberg equilibrium for all the polymorphisms. The COMT Val/Val homozygosity was detected in 19 participants  and 63 participants were Met‐carriers .Cheek swab samples were collected and DNA extracted using the protocol developed at the Social, Genetic and Developmental Psychiatry Centre  .We acquired DWI that uses the water diffusion properties to investigate the microstructural architecture of white matter fibers  . TBSS is a useful tool for analyzing FA data as it improves sensitivity, objectivity, and interpretability through nonlinear registration with an alignment‐invariant tract representation   was applied to voxelwise statistics on skeletonized FA data for all subjects. A design and a contrast matrix were performed using General Linear Model . Next, randomization procedure produced statistical maps so that each pixel value refers to the COMT  and sex, as well as interactions of COMT x sex. The age was considered as a covariate.The GLM analysis was performed where we have modeled main effects of the 2.6Although TBSS has been very popular approach for analyzing DWI data, the investigators also reported potential inaccuracies that are inherent in the FA skeleton projection and the substantial bias that it can introduce , with FA in male Val/Val > male Met‐carriers in the following major white matter tracts: the corpus callosum (CC)  and the superior posterior portion of the left superior longitudinal fasciculus (SLF). The latter included horizontal fibers that connect superior parietal lobe (SLF‐I), angular gyrus (SLF‐II), and supramarginal gyrus (SLF‐III) with ipsilateral frontal and opercular areas. Significant differences were also observed in the internal capsule which may correspond to the inferior fronto‐occipital fasciculus (IFOF) and/or the uncinate fasciculus, in the superior part of the cortico‐spinal tract (CST), and the anterior, posterior, and superior parts of the corona radiata . Results of TBSS are shown in Figure The GLM has not produced significant main effects of 3.2Val homozygotes and Met‐carriers in the following regions of CC: genu and rostral midbody, anterior midbody, posterior midbody, and isthmus. Post hoc tests (Mann–Whitney) demonstrated that in all these contrasts, male Val homozygotes had higher FA values compared with male Met‐carriers , Kohannim et al.  as proposed by Keller .Val homozygotes was higher than in male Met‐carriers in corpus callosum, SLF, IFOF, corona radiata, and CST at p < .05.The additional analysis supported our original results, that is, FA in male What are the implications of our finding of genotype‐ and sex‐related effects on CC fractional anisotropy? Corpus callosum contains WM fibers that connect the two hemispheres, and is involved in interhemispheric communication  due to the impact of estrogen.Our data showed that the difference between e et al.  showed dCOMT polymorphism in males and in females might contribute to the inconsistencies in the literature on the association of COMT genotype with some behavioral phenotypes. In particular, COMT Val carriers demonstrated an impaired performance and higher number of errors in the Wisconsin Card Sorting Test compared to Met/Met individuals  performed poorer compared to COMT Met‐carriers (and wild‐type mice) , it would be interesting to further examine whether these discrepancies potentially might be explained by sex effect on COMT functionality.A differential effect of 4.1Although our sample size was reasonably large, there were small numbers in some genotype groups, for example, Val homozygotes were represented by 12 males and 7 females. We have ensured that the Type 1 error has been controlled for by most rigorous two‐stage statistics, that is, the whole‐brain TBSS with subsequent nonparametric VOI analysis.COMT activity have been based on existing literature.Another limitation of this study is that the individual plasma levels of estrogen were not assessed; therefore, we were unable to exclude any individual variation in estrogen levels. We assumed that in our group of healthy women (aged from 19 to 54), the levels of estrogen were within healthy range. Our conclusions on the inhibitory effect of estrogen on 5COMT polymorphisms on white matter connectivity in healthy adults. We found sex‐specific effect of COMT on brain white matter (CC): male Val homozygotes had significantly higher white matter integrity compared with Met‐carriers. This effect was absent in females where Val and Met groups had almost similar FA values in CC.To the best of our knowledge, this is the first study to examine the effects of sex and COMT on neuroanatomical structures.We believe that the importance of our results lies in highlighting the often overlooked joint effect of gene and sex on integrity of white matter tracts. Further research on larger samples is warranted that may shed more light on the sexually dimorphic effect of


The prescription of optimal medical therapy for heart failure is often delayed despite compelling evidence of a reduction in mortality. We calculated the absolute risk resulting from delayed prescription of therapy. For comparison, we established the threshold applied by clinicians when discussing the risk for death associated with an intervention, and the threshold used in official patient information leaflets.UK patient information leaflets to establish the magnitude of risk considered sufficient to be stated explicitly showed that leaflets begin to mention death at a ∼18 000‐fold lower mortality risk of just 0.0007 in 100 patients.We undertook a meta‐analysis of randomized controlled trials to calculate the excess mortality caused by deferral of medical therapy for 1 year. Risk ratios for angiotensin‐converting enzyme inhibitors, beta‐blockers and aldosterone antagonists were 0.80, 0.73 and 0.77, respectively. In patients who might achieve a 1‐year survival rate of 90% if treated, a 1‐year deferral of treatment reduced survival to 78% . This corresponds to an additional absolute mortality risk per month of 1%. A survey of clinicians carried out to establish the risk threshold at which they would obtain written consent showed the majority (85%) sought written consent for interventions associated with a 12‐fold lower mortality risk: one in 100 patients. A systematic review of Deferring heart failure treatment for 1 year carries far greater risk than the level at which most doctors seek written consent, and 18 000 times more risk than the level at which patient information leaflets begin to mention death. Effective therapies for heart failure exist, but audit reveals their under‐utilizationPrevious work shows that clinicians engage in asymmetrical behaviour when discussing medical therapy for heart failure.Discussing absolute risk with patients for any health care decision is only relevant if clinicians regard the risk as sufficiently high to warrant its discussion with patients. If the risk of death is very small, doctors may wish to avoid burdening their patients with a very remote possibility. When the risk is higher, a patient might reasonably expect to be warned. It is not known whether, as a group, clinicians have any consistent threshold for mentioning the possibility of death when discussing an intervention with a patient, and, if so, where this threshold lies.In this study, we calculated, by meta‐analysing the cumulative RCT experience, the absolute risk of deferring heart failure therapy for 1 year. We surveyed clinicians to establish whether their perceptions of this risk are accurate, and whether the risk exceeds their thresholds for mentioning a risk for death during decision making with patients. For comparison, we reviewed official UK National Health Service (NHS) patient information leaflets for common interventions in order to establish what levels of risk for death are deemed sufficiently high to warrant discussion.Our study involves three components. First, we conducted a meta‐analysis to estimate the respective effect sizes of the use of angiotensin‐converting enzyme (ACE) inhibitors, beta‐blockers and aldosterone antagonists to calculate the levels of risk associated with deferring therapy for 1 year. Second, we surveyed clinicians treating heart failure patients to establish: (i) whether their estimates of the risk arising from deferring heart failure therapy are accurate, and (ii) whether there is agreement on the level of risk for death that is considered sufficient to warrant discussion with patients. Third, we reviewed NHS patient information leaflets to establish the levels of risk deemed sufficient to warrant their presentation in official documentation.ACE inhibitors: PubMed search: (Heart failure [Title/abstract] OR congestive [Title/Abstract]) AND angiotensin‐converting enzyme (inhibitor OR inhibition OR blocker OR blockade) OR ACE (inhibitor OR inhibition OR blocker OR blockade) OR captopril OR enalapril OR lisinopril OR ramipril OR quinapril; filters: randomized controlled trial; publication date from 1 January 1994 to 1 January 2016; humans; (ii) beta‐blockers: PubMed search: (Heart failure [Title/abstract] OR congestive [Title/Abstract]) AND (adrenergic beta‐antagonist OR beta‐adrenergic OR beta‐blocker OR beta‐blockade OR carvedilol OR metoprolol OR bisoprolol OR bucindolol OR nebivolol); filters: randomized controlled trial; publication date from 1 April 2012 to 1 January 2016; humans; (iii) aldosterone antagonists: PubMed search: (Heart failure [Title/abstract] OR congestive [Title/abstract]) AND aldosterone receptor (antagonist OR blocker OR blockade OR blocking agent) OR canrenoate OR canrenone OR canrenoic acid OR spironolactone OR eplerenone OR RN 52‐01‐ OR RN 107724‐20‐9 OR Aldactone OR Inspra; filters: randomized controlled trial; publication date from 1 January 2008 to 1 January 2016; humans.We carried out a meta‐analysis of the three major drug classes used in chronic systolic heart failure. We identified the most recent meta‐analysis for each drug classRandomized controlled trials studying chronic heart failure with reduced ejection fraction were included, as long as they utilized a placebo‐controlled arm rather than non‐placebo ‘usual care’. Any RCTs specifically investigating heart failure with preserved ejection fraction or acute heart failure in specific scenarios were excluded from our analyses.Manuscripts of included RCTs were independently reviewed by two authors to confirm sample size, numbers of deaths in the control and treatment arms, and follow‐up period. If manuscripts were unavailable for an RCT, we included data for that RCT quoted in previous meta‐analyses.We conducted random‐effects meta‐analyses of RCTs for all three drug classes. The primary endpoint was all‐cause mortality. Statistical analysis was undertaken in R  using the metafor packageWe reviewed data for annual mortality in contemporary registries of heart failureWe assumed the effect size would be constant over the time period studied. The mortality attributable to deferral is dependent on the baseline risk of the population, which can vary widely in heart failure.TableOne way to assess survival in a heart failure population treated with all three agents is to consider the treatment arm of a contemporary aldosterone antagonist RCT, in which the vast majority of patients were also treated with ACE inhibitors and beta‐blockers. This shows treated 1‐year survival of 93%.Unwarned clinical doctors were approached during teaching sessions, lectures or in person and invited to answer a series of questions. Participants were told the questions were part of a research project and were asked to provide verbal consent. Responses were anonymous and no patients were involved; therefore verbal consent was considered proportionate and reasonable. In addition, participants' willingness to fill in the survey proforma voluntarily was taken to indicate consent. Guidance indicated that research ethics committee approval is not required for such a study. The project was supported by management at our institution.What level of absolute risk for death from a clinical decision makes that risk worth mentioning?Your patient with heart failure is not prescribed an ACE inhibitor. By how much will their absolute risk of death over 1 year be increased?Your patient with heart failure is not prescribed a beta‐blocker. By how much will their absolute risk of death over 1 year be increased?Your patient with heart failure is not prescribed an aldosterone antagonist. By how much will their absolute risk of death over 1 year be increased?The questions were:For each of these questions, clinicians were able to choose from a series of options .The NHS website (NHS Choices) includes a centralized patient information leaflet repository.TablesAppendixWe identified 70 RCTs for inclusion . The characteristics of the RCTs used in this analysis are shown in the supplementary material online, P = 0.002] . There was no evidence of heterogeneity .The analysis included 38 RCTs. There was a significant reduction in mortality with ACE inhibitors [risk ratio (RR) 0.80, 95% confidence interval (CI) 0.70–0.92;  Figure A. ThereP < 0.001) . There was evidence of moderate heterogeneity .The analysis included 21 RCTs. There was a significant reduction in mortality with beta‐blocker therapy  . There was no evidence of heterogeneity .The analysis included 11 RCTs. There was a significant reduction in mortality with aldosterone antagonist therapy .The thresholds at which individual clinicians include reference to death when taking verbal consent for a clinical decision were highly correlated with their behaviour when taking written consent  referred to death or a combination of death and another complication. The risk of death quoted varied from one in 28.6 (death in the first year after pancreas transplant) to one in 150 000 . The median risk was one in 300 (interquartile range: one in 75 to one in 1000). The risk of death in these patient information leaflets was usually lower than is associated with the deferral of treatment with any individual drug class in heart failure patients with 1‐year treated survival of 90%. Every leaflet quoted a risk of death that was lower than the risk arising from the deferral of ACE inhibitor therapy for 1 year (one in 22) or deferral of beta‐blocker therapy for 1 year (one in 21). Twelve of 13 (92%) leaflets quoted a risk of death that was lower than the risk arising from the deferral of aldosterone antagonist therapy for 1 year (one in 33). Every leaflet quoted a risk of death lower than the risk associated with the deferral of medical therapy with all three drug classes in combination for 1 year (one in eight).Table In this study, we show that when medical therapy for heart failure is deferred even for 1 month in a low‐risk patient, the absolute increase in risk of death (∼1%) substantially exceeds the threshold at which most clinicians would take written consent for risk of death arising from a procedural intervention. As Why is the risk of deferring effective medical therapy for a patient with heart failure approached differently from procedural risk? One explanation may be that, for a procedure, the risk is concentrated in a shorter time period. Once the decision to undertake a procedure has been made, it cannot usually be reversed. In contrast, a decision to defer prescribing a tablet may in theory be revised, although our experience is that patients risk either being left untreated or being treated with smaller doses than have been shown to be beneficial in RCTs. If additional repeat appointments for patients not taking life‐prolonging therapy led reliably to reconsideration or up‐titration, they might be a surprisingly effective intervention. For the minority of patients who refuse therapy, one way of allowing them to reverse their decision independently may be a prescription from the initial consultation, which can be used to embark on therapy without the need for further consultation. This approach has been shown to be of value in other scenarios.Another explanation for differing attitudes to risk may be that clinicians (and perhaps patients) view risk associated with an intervention differently from risk arising from a lack of intervention. When a procedural complication arises, causality is usually clear. When it arises after the deferral of an intervention, it is impossible to know for that individual patient whether it was caused by the deferral of effective therapy or would have happened regardless due to the condition itself.However, in a given population, it is possible to calculate the chance that a death is attributable to deferral. In patients with treated 1‐year survival of 90%, the 10% mortality risk increases to 12.8% with the deferral of an aldosterone antagonist. It follows that 23% (2.8 of the 12.8 percentage units) of deaths over the first year are attributable to the deferral of aldosterone antagonist treatment. In a similar way, in patients with treated 1‐year survival of 90% in which both aldosterone antagonist and beta‐blocker treatment are deferred, 44% (7.8 of 17.8) of deaths arise from deferral. In patients with a treated 1‐year survival of 90% in which all three drug classes are deferred, 55% (12.2 of 22.2) of deaths over the first year will be attributable to the deferral of therapy.We believe the decision on whether to discuss the risk of death with a patient should depend on the magnitude of risk, rather than whether it arises from an intervention or from the deferral of the intervention. Similarly, it is illogical to decide whether a patient should be made explicitly aware of the risk based on whether it occurs in an operating theatre or at home, or whether there is a theoretical option of reversal. We propose that, given the magnitude of risk involved, the early initiation and up‐titration of medical therapy are of critical importance. If patients wish to decline or defer therapy, it may be appropriate to take written consent.The act of taking written consent for the deferral of treatment may have a hidden therapeutic value if it helps the patient to focus on the implications of his or her decision. Further therapeutic advances in heart failure are likely to be hard‐won: a new class of treatment has required almost 20 000 patient‐years of follow‐up to demonstrate a ∼1% reduction in annual mortality.Although the manuscripts for the majority of RCTs identified from previous meta‐analyses were reviewed manually, some manuscripts were unavailable. In such cases, the numbers of patients and deaths in control and treatment arms were extracted from abstracts or existing meta‐analyses. Ideally, our meta‐analysis would have used hazard ratios, but these were unavailable and we therefore used risk ratios instead.One unavoidable limitation is that our calculation is based exclusively on data from RCTs, which provide the only bias‐resistant measurement of therapeutic effect size.TableAnother unavoidable limitation is that the risk of deferral is a proportion of baseline risk. We chose to base our calculations on a treated 1‐year survival rate of 90%, which is close to that seen in contemporary RCTsFinally, our participants were a convenience sample of clinicians encountered in meetings, educational sessions and conferences. We did not attempt to stratify or target particular groups of clinicians. However, heart failure is increasingly commonany of the classes of medical therapy for a year, even in a patient with low‐risk heart failure, carries a far greater risk for death. Deferral of all three classes of treatment, even in a patient with low‐risk heart failure, carries an absolute mortality risk of around 1% per month.There is startling disparity in clinician behaviour in the context of discussing risk arising from procedural interventions compared with the deferral of life‐prolonging therapy in a chronic disease. For procedures with a risk for death of one in 100 or lower, the majority of clinicians report recording the discussion of this in writing. Yet the decision to defer This asymmetry is not because clinicians fail to appreciate the risk of deferring treatment, which, if anything, they may overestimate. However, more formal consideration of deferral as an active choice with implications worthy of written consent may help to focus patients and their clinicians on the importance of maximal early application of life‐saving therapy.MJS‐S (grant no. FS/14/27/30752), DPF (grant no. FS/010/038) and GDC (grant no. FS/12/12/29294) are funded by the British Heart Foundation.Conflict of interest: none declared.Appendix S1. References for randomized controlled trials included in the meta‐analyses.Table S1. Absolute increase in mortality (extra deaths per 100 patients) arising from deferral of heart failure therapy in patients who would achieve 1‐year survival of 95%, 90%, 85% and 80% with full treatment.Table S2. Randomized controlled trials of angiotensin‐converting enzyme inhibitors included in the meta‐analysis according to intervention, concurrent medication in the control group, mortality in the control and treatment arms, and follow‐up period.Table S3. Randomized controlled trials of beta‐blockers included in the meta‐analysis according to intervention, concurrent medication in the control group, mortality in the control and treatment arms, and follow‐up period.Table S4. Randomized controlled trials of aldosterone antagonists included in the meta‐analysis according to intervention, concurrent medication in the control group, mortality in the control and treatment arms, and follow‐up period.Click here for additional data file.


Protein‐based biomaterials are widely utilized as scaffolds for tissue engineering applications given their advantages related to biocompatibility and controllable degradation via enzymes. However, issues related to synthesis and manufacturing have limited their clinical use. In this issue of Bioengineering & Translational Medicine, engineers from Harvard and Northeastern Universities detail a method to synthesize kertain‐PEG hydrogels that form when exposed to visible light. Keratin is an essential structural protein and is the predominant component in tissues such as our hair, nails, and skin and thus represents a key protein of interest. The authors show that by utilizing the cysteine rich residues naturally present in keratin, click‐chemistry between the thiol‐norbene groups can be used to form the gels in under one minute. The gels can be tuned to exhibit a variety of mechanical (∼2 kPa to ∼45 kPa compressive modulus) and chemical (complete degradation as fast as 3 hours up to > 5 hours) properties. The scaffolds exhibited the ability to facilitate attachment, spreading, and growth of fibroblast cells in both 2D cell culture and 3D cell encapsulating substrates. Importantly, this click chemistry approach was amenable to widely utilized microfabrication approaches such as micropatterning and wet spinning. This study highlights a novel approach to prepare human protein‐based hydrogels that is well‐suited for scale‐up and could potentially be used as scaffolds for a variety of keratin‐rich tissues.10.1002/btm2.10077DOI: Low volume and portable testing of patient blood samples could address unmet needs in both the developed and developing world, such as rapid benchside diagnostics and blood‐testing for patients who do not have access to large clinical labs. One of the main challenges with the existing portable devices is the lack of detection of analytes via multiple analytical methods  at low blood volumes. This limits the use of these devices thereby promoting continued reliance on large clinical labs. Described in this issue of Bioengineering & Translational Medicine, a team from Theranos details the design and implementation of a clinical laboratory system (miniLab) that is portable, minimally designed (3 component system), and capable of detecting analytes in blood via a variety of detection methods ranging from molecular diagnostics to immunoassays. Specifically, the miniLab showed capability to analyze blood samples for both: (i) detection of Zika virus via molecular diagnostics and HSV‐2 via immunoassay, and for (ii) descriptive clinical panels for lipids and lymphocytes. This work describes a single, tunable, device that is capable of providing a means to test for multiple clinically‐relevant diseases and provide descriptive analysis for essential blood panels.10.1111/btm2.10084DOI: Research from the Ashutosh Chilkoti lab from the Department of Biomedical Engineering at Duke University describes how a nanoparticle‐based approach to treat tumors can facilitate additional anti‐tumor benefits by modulating the tumor microenvironment towards improved antitumor immune response. This work focused on utilizing a previously described nanoparticle system that leverages chimeric polypeptides to self‐assemble into nanoparticles in the presence of doxorubicin. The authors show that an injection of their nanoparticle chimeric polypetide doxorubicin formulation induces a significant (nearly 2‐fold more) increase in the number of tumor‐infiltrating leukocytes, as compared to free doxorubicin. Specifically, the nanoparticle formulation stimulated CD8+ T cells and increased the ratio of Th1 to Th2 cytokines in the tumor, which are both antitumor immunomodulatory effects. The authors postulate that the cause for this is likely due to increased drug accumulation at the tumor, to the point where the immunomodulatory effects of the drugs can be achieved. It is possible that nanoparticle delivery systems can benefit from these findings, so that they are better designed and poised for clinical treatment.Mastria et al., Journal of Controlled Release. 2017; doi: 10.1016/j.jconrel.2017.11.021


The emergence of Zika virus has challenged outbreak surveillance systems in many at-risk, low-resource countries. As the virus has been linked with Guillain–Barré syndrome, routine data on the incidence of acute flaccid paralysis (AFP) may provide a useful early warning system for the emergence of Zika virus.We documented all Zika virus outbreaks and cases in 21 Pacific Islands and territories for the years 2007 to 2015. We extracted data from the Global Polio Eradication Initiative database on the reported and expected annual incidence of AFP in children younger than 15 years. Using a Poisson probability test, we tested the significance of unexpected increases in AFP in years correlating with Zika virus emergence. Data were analysed separately for each Pacific Island country and territory.In most Pacific Island countries, early warning surveillance for acute public health threats such as Zika virus is hampered by poor health infrastructure, insufficient human resources and geographical isolation.Only one example was found (Solomon Islands in 2015) of a significant increase in reported AFP cases correlating with Zika virus emergence. We found no conclusive evidence that routinely reported AFP incidence data in children were useful for detecting emergence of Zika virus in this setting. More evidence may be needed from adult populations, who are more likely to be affected by Guillain–Barré syndrome. Reporting of AFP may be deficient in regions certified as polio-free. Zika virus surveillance strategies need to be convenient, timely and cost-effective, ideally using routinely collected information. Data on the incidence of acute flaccid paralysis (AFP) in children younger than 15 years are routinely collected for polio surveillance by 177 of the 194 WHO Member States as part of the Global Polio Eradication Initiative. The most common cause of AFP is Guillain–Barré syndrome.The Pacific Islands, which fall within WHO’s Western Pacific Region, are home to several of the world’s smallest, least developed and most isolated populations. The collective population of these islands  is approximately 11.4 million people, of whom 8.2 million reside in Papua New Guinea and the rest are dispersed over the thousands of islands and atolls that make up the other 20 Pacific Island countries and territories. Most islands’ health authorities rely on simple syndromic surveillance and ad hoc event reporting by clinicians for disease outbreak detection. Their ability to enhance early warning surveillance in response to acute public health threats such as Zika virus is hampered by limited coverage and sensitivity of existing early warning surveillance; limited capacity to investigate outbreaks; geographic isolation and widely dispersed populations; poor communication infrastructure; and inadequately resourced health systems.We documented all Zika virus outbreaks and cases in the Pacific Islands for the years 2007–2015 and tested the significance of unexpected increases in AFP in years that correlated with Zika virus emergence.We obtained data on Zika virus outbreaks in the 21 Pacific Island countries and territories from published and unpublished information. For published information, we performed a literature search using the search terms “Zika” and “Zika virus” in the PubMed database; the identified papers were reviewed for relevance to the Pacific Islands. Unpublished event-relevant information was extracted from WHO’s weekly Pacific Surveillance Syndromic ReportsAFP surveillance for polio eradication purposes requires health workers to promptly report and investigate identified cases of AFP, including the results of testing for wild polio virus. We extracted data on the expected and reported annual incidence of AFP in children younger than 15 years for Pacific Island countries and territories from the Global Polio Eradication Initiative’s surveillance database.P ≤ 0.05) of unexpected increases in the incidence of AFP in children in the years when Zika virus emerged in each Pacific Island country or territory:We used the following Poisson probability formula to test the significance ; and λ is the expected number of events in the specified time period. Where ,,The first human outbreak of Zika virus was documented in the Pacific Islands in Yap State, Federated States of Micronesia in April 2007.,In 2016  three other Pacific Island countries and territories and Kosrae State, in the Federated States of Micronesia (on which Zika had previously not been detected) reported autochthonous transmission: Tonga , American Samoa , Marshall Islands  and Kosrae State . In November 2016, Palau reported a single confirmed Zika case.In addition, in March 2016 Papua New Guinea reported that six cases of Zika virus infection had been confirmed through retrospective testing of samples collected in May 2015 (one case), December 2015 (two cases) and February 2016 (three cases), indicating low levels of Zika virus transmission within the country.Based on Global Polio Eradication Initiative predictions, the total expected annual number of AFP cases for the year 2015 was 36 (26 for Papua New Guinea and 10 for the other 20 Pacific Island countries and territories). The aggregated number of AFP cases among children reported in each year were 38 (2007), 35 (2008), 30 (2009), 37 (2010), 26 (2011), 14 (2012), 18 (2013), 27 (2014) and 41 2015; .P ≤ 0.001). From February to May 2015, there were five confirmed cases of Zika virus infection out of 324 suspected cases in a population of about 651 700 people. In that year, nine cases of AFP were reported compared with the expected number of two. None of the seven other countries and territories reporting Zika virus cases from 2007 to 2015  showed significant rises in reported cases of AFP associated with emergence of Zika virus.Analysis of individual Pacific Island countries and territories found only one example – the Solomon Islands in 2015 – where a statistically significant increase in reported AFP cases correlated with the emergence of Zika virus  incidence in children were insufficient for the identification of Zika virus emergence in Pacific Island countries and territories.Data from adults, who are more affected by Guillain-Barré syndrome, may confirm whether AFP incidence is a suitable early warning surveillance strategy for emergence of Zika virus in low-resource settings.More evidence is needed that AFP reporting requirements are being met in remote areas and in regions certified as polio free.Populations in Pacific Island countries are small and it is likely that the capacity to conduct and ensure compliance with AFP reporting requirements varies. This may be influenced by a lack of awareness of polio surveillance and associated AFP reporting, given that the last indigenous case of polio virus in the Western Pacific Region was reported in Cambodia in 1997, and the Region has been certified as polio free since 2000.It should be noted that the Global Polio Eradication Initiative’s AFP surveillance targets paediatric populations, who are less likely than adults to be affected by Guillain–Barré syndrome.


UPE) under the variable temperature, relative humidity and oxygen conditions they could experience in the soil seed bank. Using a custom‐built luminometer we measured UPE intensity and spectra (300–700 nm) from Phaseolus vulgaris seeds, seed coats and cotyledons. UPE was greatest from the internal surface of the seed coat. Seed coat UPE increased concomitantly with both increasing temperature and decreasing relative humidity. Emission was oxygen dependent and it was abolished by treatment with dinitrophenylhydrazine, demonstrating the key role of seed coat carbonyls in the phenomenon. We hypothesize that beneath the soil surface the attenuation of light  enables seeds to exploit UPE for transducing key environmental variables in the soil  to inform them of seasonal and local temperature patterns. Overall, seed coats were found to have potential as effective transducers of key fluctuating environmental variables in the soil.Seeds beneath the soil sense the changing environment to time germination and seedling emergence with the optimum time of year for survival. Environmental signals first impact with the seed at the seed coat. To investigate whether seed coats have a role in environmental sensing we investigated their ultraweak photon emission ( The wavelength indicates the electronically excited species responsible for their emission. UPE in the near UVA‐green region (350–550 nm) is associated with the relaxation of triplet excited carbonyls (3(C=O)). Triplet excited carbonyls are formed by the oxidative action of ROS on biomolecules, resulting in the decomposition of the high‐energy intermediates dioxetane and tetroxide 1O2) (dimol form), which emit in the green‐red region (550–750 nm) and red region (634 and 703 nm), respectively 2˙−) radicals and between excited pigments and molecular oxygen Ultraweak photon emission covers a broad spectrum of wavelengths 350–1300 nm), with emission intensity ranging from 10300 nm, wgion 550–50 nm andvia glass or quartz barriers were possible. The effect was lost when these barriers were blinded by metal films Ultraweak photon emission is implicated in cell‐to‐cell signaling; for example, neutrophils stimulated to undergo respiratory burst showed increased UPE and induced activation of a neighboring population chemically separated, but optically coupled In rice and wheat seeds, UPE showed an initial spike on the addition of liquid water that declined as hydration proceeded; emission also increased with temperature and wounding The detection of UPE from seeds and seedlings was used diagnostically to look at stress responses during aging and germination via dormancy cycling spreads seedling emergence over several years, making dormancy a major component of plant fitness When seeds are shed from the mother plant some enter the soil forming the soil seed bank. This persistent seed reserve buffers the population against adverse conditions and e.g. cryptochrome and phytochrome) that perceive light quality and intensity enabling them to detect and respond to the light environment In the soil seeds are effectively in virtual darkness. Light penetration of soil is rapidly attenuated by covering vegetation and soil depth as a result of soil color, particle size, and moisture content especially at lower wavelengths (<700 nm). Little light of physiological significance is thought to penetrate below 5 mm In seeds, photo‐activated phytochrome does not decay back to the inactive form at low moisture contents via the formation of triplet excited species were responsible for UPE from the inner layer of the seed coat next to the embryo. This emission was highly responsive to temperature, humidity and oxygen in the range seeds experience beneath the soil surface. This indicates the seed coat has the potential to act as a transducer of temperature, humidity and oxygen signals into UPE. These are key fluctuating environmental variables used as signals by seeds in the soil to time germination and seedling emergence in tune with seasonal and prevailing weather patterns In this study we investigated UPE from intact seeds, isolated cotyledons and seed coats. We found that seed coat carbonyls likely Phaseolus vulgaris, 8% moisture content) were purchased from a local grocery and used as such. Seeds of this type were chosen as the experimental model due to their size and ease of manipulation. UPE was recorded from intact seeds, isolated seed coats or cotyledons. To isolate the seed coat, a dry seed was longitudinally cut in half with a razor blade and the coat gently detached from the underlying embryo (embryonic axis and cotyledons). Only seed coats structurally undamaged as assessed by visual inspection were used. Finally, the poles of the seed coat were excised to avoid curling of the coat after isolation. Seed coats were then weighed and the two half seed coats were put side by side into the sample holder and transferred into the luminometer .Dry white Haricot (Cannellini‐Lingot) bean seeds  in the measuring chamber . All the luminometer functions were operated by a series of electronically integrated modules  controlled by a dedicated LabVIEW  software module.−1 in the range 20–40°C). Changes in RH and gaseous composition inside the sample chamber had no effect on the dark count.Ultraweak photon emission was detected by a photon‐counting device consisting of a low noise 1″ diameter head‐on photomultiplier tube (PMT), high‐voltage power supply circuit and photon‐counting circuit . The PMT had a 300–700 nm detection range with maximal quantum efficiency at 400 nm of approximately 25%. The PMT operated at room temperature with a low dark count rate that increased slightly with increasing chamber temperature within the sample holder  were used to measure the spectrum of UPE. The spectral behavior of each filter was verified by recording the light transmission curve in a Beckman DU‐65 spectrophotometer. UPE in the different regions of the spectrum  was derived by difference and normalized on the relative PMT quantum efficiency in each region .−1). Readings from experiments with isolated coats were then normalized on the sample weight and expressed as counts s−1 g−1 (samples weights are given in figure legends). Preliminary experiments showed that weight and surface area of isolated coats were linearly related, and a conversion coefficient equal to 55 was calculated. To obtain counts s−1 cm−2 from counts s−1 g−1, simply divide the latter by that coefficient. Emission data were analyzed and plotted using Microsoft Excel®. Best fits to data were elaborated using Sigmaplot 12 ® (Systat Software Inc). UPE was consistent between seed coats and each trace is representative of at least three experiments. All the experiments were carried out at the Biofluorimetry and Nanoscopy Laboratory of the Department of Experimental Medicine at Sapienza University of Rome, Italy.Typically, UPE recording was started after 20 min from sample transfer into the reading chamber. Preliminary experiments showed that delayed luminescence resulting from seed manipulation in the light decayed to a minimum in 15 min and did not change for up to 5 h. Basal UPE signals were collected for 5–10 min at the selected reading integration time before starting the treatments. In each experiment, dark counts were subtracted from UPE readings , a chemical used to qualitatively detect carbonyl functionality in aldehydes and ketones both in solution and on solid supports m DNPH (Sigma‐Aldrich) stock solution was prepared just before use by dissolving DNPH in dimethylsulfoxide (DMSO). A 10 mm DNPH working solution was then prepared by stepwise addition of the DNPH stock solution to water with vigorous stirring.A 100 mm DNPH working solution. After incubation, both control and DNPH‐treated coats were thoroughly washed in distilled water, wrapped in filter paper and allowed to dry overnight under gentle pressure. On visual inspection of dried samples, only DNPH‐treated coats looked pale orange, indicating the reaction between DNPH and carbonyl groups had occurred.Isolated bean coats were incubated overnight at room temperature (24°C) in 1 mL of either a 10% (v/v) DMSO solution (control) or 10 mFor ultrastructural analysis, isolated, unfixed seed coat fragments were imaged with a field emission scanning electron microscope  at the Research Centre on Nanotechnology Applied to Engineering of Sapienza .Initial experiments evaluated induced UPE from intact seeds, naked cotyledons and isolated seed coats. At 25°C, UPE from seed coats increased as RH decreased from 75% to 10% .P < 0.01; Student's t‐test, n ≥ 3) from the internal surface  to determine whether UPE was the same from each face. At 30°C and 11% RH, UPE was statistically higher  . This indicates the same mechanism is responsible for the UPE. At constant temperatures (25°C and 35°C) UPE exponentially declined with increasing RH  compared with higher humidity conditions (>60% RH) Fig. a. Arrhen25°C and 5°C UPE e% RH compn = 5), whereas the change in UPE when %RH increases (i.e. during water vapor adsorption) is described by a double exponential model with time constants of 1.7 ± 0.4 and 10.9 ± 1.5 min for the fast and slow phases, respectively (n = 5). These data indicate that different photon emitters are involved in the two processes.Analysis of the dynamic changes seen in Figs. Under dry conditions, when air was replaced with nitrogen, UPE declined two‐fold, and then increased more than eight‐fold when exposed to dry oxygen Fig. . This deLong‐pass filters were used to analyze the photon wavelengths. Under low humidity conditions (10% RH) emissions at 25°C and 35°C were compared. Two temperature‐sensitive emission peaks were observed, one centered on the blue region (450 nm) of the spectrum and another larger one centered on the yellow region (590 nm), encompassing the green to red spectral regions (500–650 nm) Fig. . These pUltraweak photon emission from the inner surface of DNPH‐treated and untreated seed coats was measured at 35°C through a cycle from 60% > 10% > 60% RH. Untreated seed coats exhibited the typical increase and spike in emission when RH was cycled. In contrast UPE stayed at background levels in DNPH‐treated seed coats Fig. . This inThe majority of UPE reports are from hydrated multicellular organisms or cells; here we report emission from the dead tissues of the seed coat, formed during seed development from differentiated cell layers (integuments). Seed coats are highly resistant to environmental degradation in the soil and have a role in the control of dormancy, germination and longevity P. vulgaris seed coats emits photons in response to both increasing temperature and decreasing relative humidity. At maturity the seed coat is composed of dead tissue as confirmed in Phaseolus lunatus by viability staining Phaseolus vulgaris seed coats are 78% polysaccharide with a lipid component measured as fatty acid of less than 0.2% Phaseolus seed coats suggests the UPEs in this study are derived from oxidation of seed coat polysaccharides.In the present study we show that in the presence of oxygen, the internal layer of Ea) values for seed coats (47–48 kJ mol−1) similar to that for cellulose (55 kJ mol−1) at temperatures below 100°C Seed coat UPE in response to temperature, oxygen and RH is consistent with that seen in the oxidative degradation of cellulose, with the energy of activation (1O2) (dimol form) or excited pigments, which then emit at longer wavelengths (550–750 nm) Thus, we hypothesize that the direct interaction of oxygen with electron acceptor moieties in the cellulose structure provides the energy to excite carbonyl groups, which in turn emit light (350–550 nm wavelength range) as they return to the ground state via carbonyls. The rapid phase of UPE decrease would then reflect the decay of this phenomenon whereas the subsequent slower phase (as well as the single phase of UPE increase during water vapor desorption) would instead reflect the effects of water adsorption/desorption onto the coat matrix. Seed coat moisture may modulate UPE intensity in different ways: on the one hand, water vapor adsorption increases polymer chain mobility leading to excited species relaxation via nonradiative energy transfer The kinetics of UPE from seed coats under decreasing and increasing relative humidity indicates different mechanisms contribute to photon emission during water vapor adsorption and desorption. The transient, abrupt increase in UPE during seed coat rehydration may result from water‐induced production of singlet oxygen radicals from superoxide anions that accumulate during the dry phase All the above suggests that ROS play a crucial role in seed coat UPE. Cellulose is degraded by the oxidative action of ROS The conditions used in this study are within the physiological range of the environmental signals seeds experience in seasonally variable soil environments via the hilum and micropyle. These structures are in close proximity to the embryonic axis/radicle tip where growth leading to germination completion is initiated. In P. vulgaris, changes in moisture content first occur in the hilum region and associated testa before the underlying radicle and cotyledons The seed coat is the first seed layer to experience changes in the soil environment. The outer integuments of the seed coat are water and oxygen impermeable to varying degrees with exchange of air and water occurring Ultraweak photon emissions from intact seeds are low and relatively unvarying in response to variable temperature and RH levels in comparison with the detached seed coat. It could be argued that coats in intact seeds, as compared to isolated coats, equilibrate at a lower rate which contributes to this difference. Furthermore, in intact seeds UPE from the inner layers of the seed coat may be absorbed either by the lignified outer seed coat layers or by the enclosed seed also contributing to the above difference. Notably, the seed contains many air spaces typically in the crushed parenchyma layer of the seed coat and between the seed coat and the underlying seed in the vicinity of the hilum In endospermic species the endosperm  layers that surround the embryo in particular the micropylar endosperm cap that covers the radicle tip, exist immediately below the seed coat. The behavior of this cap is consistent with it being the principal receptor for environmental signals that control of germination As seed dormancy cycles in the dark of the soil seed bank, slow seasonal change  driven by temperature alters the depth of dormancy. When dormancy is lowest, seed germination potential increases with the seed becoming increasingly sensitive to environmental signals  that inform the seed of its depth in the soil  and the presence of competing plants  2O g−1 dry weight), active phytochrome formed by red light (660 nm) survives further desiccation and on hydration induces germination 2O g−1 dry weight dormancy loss is associated with nonenzymatic generation of ROS Seeds contain both cryptochrome and phytochrome that can detect the blue and yellow parts of the spectrum we show for peaks of UPE from the seed coat. Of the phytochromes, we propose PHYA is a candidate sensor for UPE. In seeds, PHYA is the most abundant phytochrome, accumulates to high levels in the dark d light 6 nm survie.g. to a depth of 45 cm in clay soil), and is highest in dry soils  decreasing rapidly as the pore structure becomes water filled or reduced as field capacity is approached  or as soil is compacted. The oxygen content of soil air is also relatively constant at 19–20% to a depth of 15 cm Beneath the soil seeds are effectively in perpetual darkness at a depth of ~5 mm depending on soil type and vegetation cover Datura ferox seeds responding to <0.01% active phytochrome −2 s−1. In the same study a 50% germination threshold was crossed by fluence rates from 0.1 to 10 μmol m−2 s−1 at wavelengths from 300 to 560 nm When light sensitivity increases in the spatial sensing phase dormancy can be broken by millisecond flashes of low‐fluence sun light. This is PHYA mediated and saturated by <1% of active phytochrome −2 s−1 was measured −2 s−1) were not tested and the instrument used was unable to measure fluence values less that few dozen pmol m−2 s−1.In the case of UPE the proximity between the emitter (inner seed coat) and receiver (radicle tip/micropylar endosperm cap) may provide the required intimacy to overcome fluence rate response thresholds. In etiolated seedlings a response threshold of 10 pmoles mFinally the potential involvement of heterotrimeric G proteins in PHYA‐mediated signaling and germination Seeds have evolved to be highly specialized environmental sensors in order to adjust dormancy status and germination potential to their immediate and long‐term environments. In the results presented here we demonstrate that the biophysical properties of seed coats have the potential to function as transducers of temperature, relative humidity and oxygen signals over the range seeds experience in the soil seed bank. This presents a sensory mechanism potentially operating in parallel with other sensing mechanisms controlling the seeds’ response to the environment. If environmentally sensitive regions such as the micropylar endosperm and radicle tip can detect UPE from the seed coat during cycles of wetting and drying within the soil seed bank it means they are far more intimately in tune with the environment than previously envisaged.Figure S1. Picture of the sample holder unit with two half‐seed coats put side by side for UPE recording.Figure S2. Schematic representation of luminometer and related equipment.Figure S3. PMT sensitivity curve as modified by the long‐pass filters used for UPE spectral analysis.Figure S4. Effect of seed coat damage on photon emission from intact seeds.Figure S5. Arrhenius plots showing the activation energy (Ea) of photon emission from isolated seed coats.Click here for additional data file.