To determine whether intracapsular tonsillectomy, using plasma ablation, results in differences in postoperative patient outcomes to total tonsillectomy.A systematic review of two databases (Embase and PubMed) was conducted in March 2022 to identify published English‐language randomized controlled trials and observational studies which provided a comparison between intracapsular tonsillectomy, using plasma ablation, and total tonsillectomy.Qualitative synthesis and meta‐analysis were used to compare outcomes between techniques.p < .0001), 4.1 , 3.5  and 2.8  days, respectively. Risk of posttonsillectomy hemorrhage was significantly lower following intracapsular tonsillectomy ; risk of posttonsillectomy hemorrhage requiring surgical management was lower but failed to reach significance .Seventeen studies were identified for inclusion. Across these, 1996 and 4565 patients underwent intracapsular and total tonsillectomy, respectively. Studies included 8 randomized controlled trials, 1 prospective cohort study, and 8 retrospective cohort studies. Time to pain free, time on analgesia, time to normal diet, and time to normal activity were significantly shorter with intracapsular tonsillectomy by on average 4.2 (95% confidence interval [CI] 1.5‐5.9; Intracapsular tonsillectomy using plasma ablation has similar efficacy in managing indications for tonsil surgery to total tonsillectomy while significantly reducing the postoperative morbidity and likelihood of posttonsillectomy hemorrhage experienced by patients, allowing them to return to their normal life faster. Tonsillectomy is commonly performed in both adult and pediatric populations primarily for obstructive sleep apnea and recurrent tonsillitis.The innervation of tonsil tissue with pain fibers is very much less than that of the pharyngeal musculature, and the diameter of blood vessels within the tonsil is less than those within the muscle. It, therefore, seems reasonable to contend that an avoidance of muscle exposure should reduce both postoperative pain, expediting the return to normal lifestyles, and the risk of PTH associated with total tonsillectomy. Consequently, in recent years attention has focused on the use of “partial” tonsillectomy procedures which avoid pharyngeal muscle exposure. Partial tonsillectomy techniques include a range of different surgical techniques that encompass a spectrum from tonsillotomy, which preserves some tonsil tissue , to intracapsular tonsillectomy, which preserves just the fibrous capsule .Previous systematic literature reviews have explored the evidence comparing total tonsillectomy to all partial tonsillectomy techniques combined, and not intracapsular tonsillectomy specifically.This review was performed and written in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.A systematic literature review was performed using PubMed and Embase databases in March 2022 to identify articles of potential relevance evaluating intracapsular tonsillectomy using plasma ablation. The search strategy incorporated the search string of “(Coblation OR Bipolar OR Radiofrequency) AND (Tonsil*)” without any limitations or restrictions. No limits on publication year were implemented. Reference lists of included studies were also reviewed to identify articles for inclusion.Articles identified during the execution of the search strategy were screened for suitability by 2 independent reviewers, first based on the title and abstract and second based on the full text. Inclusion criteria consisted of a full‐text publication in the English language of primary clinical evidence in the form of a comparative clinical trial. The comparison was required to include 1 study group undergoing intracapsular tonsillectomy using plasma ablation  and the remaining study group(s) undergoing total tonsillectomy for obstructive and/or infective indications, with each study group containing over 5 patients, and reporting on the identified primary or secondary outcomes.Intracapsular tonsillectomy was defined according to Windfuhr and WernerData associated with the study, patient and surgical procedure characteristics, along with outcome data were extracted into a predefined data extraction table by 1 reviewer and checked for accuracy by a second reviewer.Study characteristics included author name, year of publication, study design, and sample size. Patient characteristics included age at time of surgery and indication for surgery. Surgical characteristics included type of device used in the total tonsillectomy group.https://automeris.io/WebPlotDigitizer), a method described and validated by others.Postoperative outcomes of interest were: efficacy; absolute pain; time to pain free; time on analgesia; time to return to normal diet; time to return to normal activity; PTH rates ; and other complications. The incidence of events for binomial outcome variables and measure of central tendency and spread for continuous outcome variables were extracted. In cases where data was only available in the form of figures, this was extracted through electronic digitization , the Centre for Reviews and Dissemination's guidance for the assessment of risk of bias in RCTs was followed.g correction  was reported with a 95% CI as the summary statistic. Absolute pain scores were analysed at the 3 most frequent time domains of 1 day, 1 week (5‐8 days), and 2 weeks. Heterogeneity of included studies was assessed using the I2 statistic, the fixed effect model was utilized when I2 < 50% and the random effects model when I2 ≥ 50%. Forest plots support each meta‐analysis to visually display individual studies and heterogeneity within each synthesis. Sensitivity analysis was carried out by comparison of fixed effect and random effects outcomes, through leave‐one‐out analysis and substitution of equivalent data provided by patient or parent/guardian/caregiver. Additional qualitative synthesis was provided for studies which reported on a related outcome or when insufficient data were available preventing the use of meta‐analysis.Meta‐analysis was performed in R  using the “meta” package, for comparison of outcomes between the experimental procedure (CIT) and the control procedure. For binomial outcomes, a relative risk (RR) with a 95% confidence interval (CI) was reported as the summary statistic and for continuous variables a mean difference (MD)  or standardized mean difference (SMD) using Hedges Where data were missing within papers (mean or standard deviation), techniques used by others to obtain missing data were followed. When a median was presented with no spread of data, the median was considered equivalent to the mean when sample size was >25.p < .05 and continuous data are presented as mean (standard deviation) and dichotomous data as events (% of study group) throughout unless otherwise stated.Analyses were considered statistically significant at the level of The search strategy identified 1287 articles for consideration. After applying the inclusion and exclusion criteria, 17 articles were left as being relevant to the research question . Seven studies reported on absolute pain at 1 week (5‐8 days)p < .0001). Two studies reported on pain at 2 weeksp = .14).Eleven studies reported on absolute pain scores, and all observed statistically significantly lower pain score at earlier time‐points with CIT.p < .0001). These same studies reported on the time on analgesia and meta‐analysis identified statistically significantly less time on analgesia following CIT by a mean of 4.1 days .Three studies reported on time to pain free, all observing statistically significantly faster time to pain free following CIT compared to total tonsillectomy.p < .05) and if a patient did require analgesia they were also less likely to need multiple doses with CIT. This was also observed by Mukerji et al .p < .0005); however, Chang et alIn addition to the studies and data amenable to meta‐analysis, Braverman et alp < .0001). Five studies reported on time taken to return to normal dietp = .0002).Three studies reported on time taken to return to normal activity and all observed statistically significantly faster times following CIT than total tonsillectomy.In addition to studies amenable to meta‐analysis, 3 studies reported on the proportion of patients returning to normal activity,Three studies reported on the efficacy of CIT in comparison to total tonsillectomy. Braverman et alp = .0131); however, no statistical differences were identified when considering PTH requiring surgical management .Thirteen studies reported on PTHEleven studies reported on complications other than PTH .Sensitivity analyses were performed to determine the robustness of the conclusions reached from each analysis presented. Consideration of the alternative meta‐analysis model, leave‐one‐out analysis, and substitution of equivalent data provided by parent/guardian/caregiver over patient did not alter the observed statistical significance or overall conclusions for any of the outcomes assessed. Consideration of only pediatric data did not alter the observed statistical significance or overall conclusions for any of the outcomes assessed except for pain at 1 day postoperative  faster than following total tonsillectomy. In addition, absolute pain was reported to be significantly lower both a day and a week following CIT compared to total tonsillectomy, with the greatest difference occurring a week postoperatively. No significant differences were identified between CIT and total tonsillectomy two weeks postoperatively; this is perhaps not unexpected as most patients across all studies had become pain free prior to 2 weeks. Total tonsillectomy results in the removal of the tonsil capsule and consequently the exposure of the underlying muscle tissue, blood vessels, and nerves within the tonsillar fossae leading to the severe and prolonged pain and morbidity observed. CIT leaves the tonsil capsule in place, which has been proposed to act as a “biologic dressing” protecting the pharyngeal muscles, blood vessels and nerves, minimizing the postoperative pain and morbidity.p = .0131); however, PTH events requiring surgical management between CIT were not statistically different between techniques . This is likely to be an artifact of the relatively low sample size inherent to the comparative studies included in this systematic literature review combined with relatively low events resulting in a type II statistical error. Recent large case‐series of patients undergoing CIT have reported very low PTH rates of 0.5%One of the main complications associated with total tonsillectomy is PTH, with a systematic review reporting a mean total PTH rate of 3.4%, readmission rate associated with PTH of 1.8% and reoperation associated with PTH of 1.6%.The effectiveness of CIT in resolving the original indication for surgery was shown to be similar to total tonsillectomy in the 3 studies reporting such an outcome in this systematic literature review.Perhaps the largest objection to uptake of CIT, and intracapsular procedures in general, is the risk of needing a second surgery, due to regrowth of the tonsils and return of obstructive symptoms or remnant tonsil tissue being susceptible to further infection. In the present systematic literature review, the majority of studies did not include a sufficient follow‐up period to capture regrowth and revision surgery; however, Lu et alThe included studies in this systematic literature review tended to be of a smaller comparative design but no study was identified to be at high risk of bias. The most common threat to bias in RCTs was a lack of clarity on the method of randomization and concealment combined with lack of an intention‐to‐treat analysis. An intention‐to‐treat analysis is unlikely to contribute towards bias in these studies due to high patient follow‐up combined with no known deviation from the surgical procedure. The largest threat to bias in observational studies were lack of blinding to outcome assessors, particularly for subjective outcomes such as pain and return to normal, due to the assessor  being informed of the benefit and risk of the surgical procedure. Meta‐analysis for these subjective outcomes included studies from both RCTs and observational studies; observation of individual studies on forest plots showed similar outcomes across the two study designs. A second common threat to bias was the allocation of surgical techniques based on indications, with CIT typically performed on patients with obstructive indications only.The higher tendency to use CIT on patients with obstructive indications could be related to a view that the efficacy of resolving infective symptoms, and the potential resulting need for revision, is not favorable due to leaving remnant tonsil tissue.The clinical implications of these findings are multifaceted. The observed rise in tonsillar surgery for obstructive indications has meant that children undergoing this type of surgery are younger than has traditionally been the case. This has led to concerns with regard to the risks associated with bleeding in smaller children. The existence of an effective surgical technique with a decreased risk profile is a highly promising prospect when considering interventions in younger children. Decreased pain, compared with traditional, total tonsillectomy techniques is likely to allow earlier discharge from hospital resulting in more efficient delivery of services and has the potential to reduce reliance on opiate analgesia in the initial post‐operative period. The avoidance or minimization of the use of drugs with known respiratory suppressant effects is likely to have significant benefits when managing children with sleep‐disordered breathing. Reduction in pain in the days following surgery and a faster return to normal function has significant implications for patients and parents. The ability to return to daycare or school after surgery means that parents and caregivers are able to return to work more quickly with benefits not only to them but to society at large.This systematic literature review demonstrates that CIT has similar efficacy in managing indications for tonsil surgery to total tonsillectomy while significantly reducing the post‐operative morbidity experienced by patients, allowing them to return to their normal life faster. In addition, the evidence suggests that CIT did not result in additional complications compared to total tonsillectomy and, in most cases, CIT tended to provide a lower rate of complications including a significantly reduced risk of PTH. These findings would be further strengthened with additional large RCTs with increased inclusion of patients with infective indications and longer follow‐up to fully establish the short‐ and long‐term safety and effectiveness of the procedures.Matthew J. Sedgwick, conception/design of work; data acquisition, analysis and data interpretation; drafting the work; read and approved final manuscript; Christopher Saunders, Conception/design of work; data interpretation; critical review of manuscript; read and approved final manuscript; Neil Bateman, Data interpretation; critical review of manuscript; read and approved final manuscript.Neil Bateman receives consulting fees from Smith+Nephew. Matthew J. Sedgwick and Christopher Saunders are both employees of Smith+Nephew.None.None.Supplementary information.Click here for additional data file.


The aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulas may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT‐IS) to eradicate these deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistula treated with SIFT‐IS.A retrospective study was performed over a 2‐year period. Patients with transsphincteric anal fistula who underwent SIFT‐IS were enrolled. The primary endpoint was the anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications and clinical continence status.One hundred and fifty one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3–96) weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow‐up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed.Subcutaneous incision of the fistula tract and internal sphincterotomy is a promising surgical option for transsphincteric anal fistulas, with a satisfactory healing rate. The markedly deep crypts in the primary opening of an anal fistula may be one of the causes of the disease. Subcutaneous incision of the fistula tract and internal sphincterotomy is a procedure to eradicate the deep crypts and has a satisfactory healing rate for transsphincteric anal fistulas.The aetiology of anal fistulas is thought to be cryptoglandular infection . Faecal The aetiology of anal fistulas is still not completely clarified. Perianal abscesses and fistulas are considered two sequential phases of the same anorectal infectious process. Perianal abscesses arise from cryptoglandular infections and represent the acute phase, while anal fistulas represent the chronic phase; however, perianal abscesses do not always progress to anal fistulas; the frequency ranges from 16% to 41% , 12, 13.The primary openings of anal fistulas comprise wide and thick pockets referred to as deep crypts Figure . The shaClinical observations suggest that deep crypts are likely to be formed as the anorectal infection progresses from cryptoglandular infection to anal fistula. Contraction of the fibrous tissue attached behind the primary openings accentuates and opens the crypts to form deep crypts Figure . PatholoThe aim of SIFT is to flatten deep crypts by dissecting fistula tracts and fibrous subepithelial tissue connecting the deep crypt, which prevents faecal contents from entering the internal openings. The role of IS is to restore the compliance and distensibility of the fibrotic internal sphincter, which complements the effects of SIFT.The purpose of the current study was to assess the feasibility of SIFT‐IS for treating transsphincteric anal fistulas.This retrospective study was conducted at the Coloproctology Center, Tokyo Yamate Medical Center, Japan, from January 2016 to December 2017. RS and KM worked there until March 2020. The patients provided written informed consent for the procedure, and the study was approved by the hospital's institutional review board.Patients with transsphincteric fistula were included in this study. In accordance with the Parks classification , transspThe primary endpoint was the healing rate at 16 weeks postoperatively. Fistulas were considered healed when the surgical wound achieved complete epithelialization. Treatment failure was defined as a remnant fistula or recurrence. The presence of an unhealed wound at 16 weeks postoperatively was regarded as a remnant fistula. Recurrence was defined as the reappearance of local sepsis or fistula after primary wound healing had been observed. The secondary endpoints were healing time, postoperative complications and clinical continence status. Continence status was assessed based on interviews performed at each pre‐ and postoperative follow‐up medical examination.All patients were administered a laxative suppository  preoperatively. Surgery was performed with the patient in the prone jackknife position under spinal anaesthesia. The buttocks were stretched laterally using adhesive tape. After identification of the secondary opening, an encircling incision was made around the secondary opening and diathermy dissection was performed along the fistula to the lateral surface of the external sphincter where the fistula penetrated Figure . A 3 cm All patients were administered oral cefcapene pivoxil (300 mg/day for 3 days) postoperatively and were discharged within 3 days postoperatively. Follow‐up examinations were performed every 2–4 weeks until complete wound healing was achieved. Patients with follow‐up of less than 16 weeks and without confirmed wound healing were treated as drop‐outs. The assessed variables included healing time, recurrence, clinical continence status and any other associated morbidities.There were 1720 patients with anal fistula during the study period. Six hundred and ninety one patients were assigned to RS. Among these, 279 patients were diagnosed as having a transsphincteric fistula. SIFT‐IS was performed in 159 of 181 recruited patients. Other procedures were performed in 22 patients who had a very short fistula tracts or immature fistula. Eventually, 151 patients were included in this study. The flow diagram of screened patients is shown in Figure No patients received seton placement prior to SIFT‐IS because we only perform seton placement for patients with a complicated fistula or Crohn's disease.Primary healing was achieved in 129 patients (85%). The median duration of follow‐up was 10 (3–131) weeks. There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence.Among the patients with a remnant fistula, the wound healed spontaneously without any surgical intervention within 24 weeks in six patients and at 96 weeks in one patient. Thus, 136 patients (90%) were healed by SIFT‐IS without other procedures. The median healing time for SIFT‐IS including the patients who were healed after 16 weeks postoperatively without further surgical intervention was 6 (3–96) weeks. Seven patients required surgical intervention for a remnant fistula. Three patients are still being followed up.Five patients developed recurrence at 20–47 weeks after the primary surgery. Four patients required surgical intervention, while one healed spontaneously. A flow chart of the patients with treatment failure is shown in Figure Three of the total of 11 patients who needed further surgical intervention had a transsphincteric fistula that converted into a subepithelial fistula; these were treated via fistulotomy under local anaesthesia without readmission. The remaining eight patients had a residual transsphincteric fistula tract; of these, three patients underwent fistulotomy, one underwent repeat SIFT‐IS and four had a tight seton inserted. All patients with treatment failure who received surgical intervention were successfully cured. The median healing time after the surgical interventions was 11 (5–111) weeks. Complete healing of the fistula was finally accomplished in 148 patients (98%). The outcomes are summarized in Table Four patients had postoperative bleeding from the drainage wound that required haemostasis with bipolar forceps; none of these patients experienced changes in vital signs or required infusion or blood transfusion. There were no postoperative complications related to the surgical wound, such as abscess formation, severe pain or dermatitis. No patient experienced changes in their clinical continence.SIFT‐IS is a novel surgical procedure for anal fistula. The essential feature of SIFT‐IS is to eliminate the structural abnormalities of primary openings that cause persistent infection of the anal fistula. Our study showed that SIFT‐IS achieved primary healing in 85% of patients.The Parks classification categorizes anal fistulas as intersphincteric, transsphincteric, suprasphincteric or extrasphincteric . We focuThe primary healing rate with SIFT‐IS was 85% at 16 weeks, reaching 89% at 24 weeks without further surgical intervention. These results are comparable to the SSPs adopted by many surgeons. Previous studies have reported healing rates of 66%–83% after the endoanal advancement flap procedure , 21, 22 Our study may provide new insights into the aetiology of anal fistula. Cryptoglandular infection is considered the first step in the development of a perianal abscess, which is the preliminary stage of anal fistula formation. However, the cryptoglandular infection theory is not sufficient to explain the mechanism by which a perianal abscess transforms into an anal fistula because the majority of perianal abscesses will not develop into anal fistulas , 12, 13.Comparing existing procedures, we believe that SIFT‐IS has beneficial clinical characteristics owing to the dissection in the subepithelial layer. Fistulotomy is the most prevalent procedure for transsphincteric fistulas, but there are risks associated with impaired anal continence owing to the division of the internal sphincter , 18, 19 LIFT is a recent and widely performed SSP in which the anal fistula is divided and ligated in the dissected intersphincteric layer . LIFT isContraction of the longitudinal muscle plays a role in shortening and widening of the anal canal during the process of defaecation , and LIFIn the present study, no patient had faecal incontinence. SIFT‐IS involves cutting the internal sphincter, but IS seems to have only a minor effect on internal sphincter function because the cutting length of the IS is less than 1 cm and the depth is very shallow. Furthermore, IS restores the compliance and distensibility of the fibrotic internal sphincter, which may even be beneficial to anal function. However, the incidence of faecal incontinence based on the medical records may have been underestimated. Validated continence scoring systems and anal manometry are required to accurately evaluate anal competence after SIFT‐IS.Another beneficial characteristic of SIFT‐IS is that treatment failure comprised downstaging from a transsphincteric to a superficial fistula. Three of 11 (27%) patients with treatment failure who needed surgical intervention had a subepithelial fistula after SIFT‐IS. In contrast, patients with treatment failure after LIFT reportedly have downstaging of a transsphincteric fistula into an intersphincteric fistula , 31, proIn the present study, prophylactic antibiotics were administrated postoperatively based on traditional practice. We currently only administer prophylactic antibiotics preoperatively in accordance with the Japanese guidelines for antimicrobial prophylaxis published in 2016 .This is the first study of SIFT‐IS, which was conducted in patients with a simple transsphincteric fistula. We are now investigating the efficacy of SIFT‐IS in patients with complicated fistulas, namely multiple, horseshoe and recurrent fistulas. Currently, we are aware that the indications for recurrent fistulas with severe fibrosis around the primary opening should be carefully considered because subcutaneous dissection could involve technical difficulties leading to mucosal injury and failure to eradicate the deep crypts. We consider that deroofing procedures from the primary opening might be more appropriate than SIFT‐IS. Recent deroofing procedures from the primary opening to the intersphincteric layer without division of the external sphincter, such as TROPIS   and BastThe present study has several limitations. First, structural abnormalities of the primary opening, which may be attributed to fibrosis caused by cryptoglandular infection, were assessed through our clinical and surgical observations. Histopathological examination is necessary to confirm these findings. Second, patient selection was non‐consecutive and the outcomes were evaluated by the attending surgeons. Thus, this study might include selection and information bias. Third, in this study the follow‐up examinations were complete when operative wound healing was confirmed. This contributed to the short median follow‐up period (10 weeks) and might have caused underestimation of the recurrence rate. For the future we plan to assess an accurate recurrence rate with an adequate follow‐up period and identify the risk factors for remnant fistula and recurrence.SIFT‐IS is a novel and promising procedure for treating anal fistula. We hope that our research will contribute to providing new insights into the incompletely understood aetiology of anal fistula.RS developed the surgical procedure, collected the data and contributed to the design of this study. MK analysed the data and wrote the manuscript. KM collected and interpreted the data and prepared the figures and tables. IK contributed to the interpretation of the results and critical revision of the manuscript. All authors discussed the results and approved the final version of the manuscript.This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.The authors have no conflicts of interest relevant to the content of this manuscript.The patients provided written informed consent for the procedure, and the study was approved by the Institutional Review Board of Tokyo Yamate Medical Center.Informed consent was obtained from all individual participants included in the study.None.Video S1Click here for additional data file.


Dactylis glomerata and Plantago lanceolata to a large gradient of drought intensity and quantified the resistance and recovery of multiple measures of plant productivity, including gross‐primary productivity, vegetative height, Normalized Difference Vegetation Index, and aboveground biomass production. Drought intensity had nonlinear and contrasting effects on plant productivity during drought and recovery, which differed between the two species. Increasing drought intensity decreased the resistance of plant productivity and caused rapid compensatory growth during postdrought recovery, the degree of which was highly dependent on drought intensity. Across multiple response parameters two thresholds of drought intensity emerged, upon which we observed abrupt changes in plant resistance and recovery, as well as their relationship. We conclude that across gradients of drought intensity resistance and recovery are tightly coupled and that both the magnitude and the direction of drought effects on resistance and recovery can change abruptly upon specific thresholds of stress intensity. These findings highlight the urgent need to account for nonlinear responses of resistance and recovery to drought intensity as critical drivers of productivity in a changing climate.The ecological consequences of future droughts are difficult to predict due to a limited understanding of the nonlinear responses of plants to increasing drought intensity, which can change abruptly when critical thresholds of drought intensity are crossed. Drought responses are composed of resistance and postdrought recovery. Although it is well established that higher drought intensity increases the impact and, thus, reduces plant resistance, less is known about how drought intensity affects recovery and how resistance and recovery are related. In this study, we tested the hypothesis that resistance, recovery, and their relationship change abruptly upon crossing critical thresholds of drought intensity. We exposed mesocosms of two monospecific stands of the common grassland species  Drought is considered the most widespread climate extreme affecting ecosystem productivity and the terrestrial carbon cycle  a decline in the resistance of plant productivity would accelerate when a threshold of drought intensity was reached Figure , (ii) plD. glomerata (var. Tandem) and P. lanceolata grown in monocultures in a common‐garden experiment located at the Botanical Garden in Innsbruck . D. glomerata (grass) and P. lanceolata (forb) are perennial C3 species common in European grasslands. Seeds of both plant species were sourced from the Climgrass Project at HBLFA Raumberg‐Gumpenstein, Austria , soil dry mass (msoil), and water content at field capacity The drought treatment imposed a gradient of drought intensity following a gradient design  to 95% of field capacity Appendix . MesocosThroughout the period of the experiment, we repeatedly assessed gross primary productivity (GPP), Normalized Difference Vegetation Index (NDVI), and vegetative height as nondestructive measures of plant productivity.2 uptake rate of the plant canopy, has been shown to be a suitable measurement to compare the drought responses of grassland communities  were measured pairwise with closed dynamic chambers, as described by Ingrisch et al.  and a water vapor sensor , and a fan was placed airtight on the mesocosms. CO2 concentration in the chamber was measured for 1 min in 5‐s intervals. Then Reco was measured using a dark chamber. Measurements were done in the late morning on days with a mostly clear sky, and photosynthetic active radiation (PAR) was recorded with each measurement . Fluxes were calculated from the slope of a linear regression between time and chamber concentration and quality controlled based on visual inspection of data and the quality of the linear fit , and rehydrated following protocol , samples were dried at 80°C for 72 h prior to measurement of the dry weight (mdry). rLWC was calculated as rLWC (%) = (mfresh − mdry)/(msat − mdry) × 100. Microclimatic parameters  were measured continuously  inside the rain‐out shelter at 1.5 m above ground  of the different response parameters for specific measurement days. Where repeated measurements were available  we selected measurement days that showed the strongest effect of SWD on the respective parameter, since drought effects generally diminished toward the end of the growing season.Thresholds of SWD for drought resistance and recovery were identified using threshold regression models . In this model, the coefficient β0 is the intercept, and β1 reflects the effect of plant species Plantago . The functions f1,…,f3 of covariates Doy and SWD have possible nonlinear effects and are modeled nonparametrically using regression splines. The model term f3 accounts for possible interactions of Doy and SWD on the response of variable Y. Similarly, functions f4,…,f6 represent possible nonlinear deviations for the species Plantago  over SWD and time using GAM , generally declined with increasing drought intensity Figure  and S3. Appendix .We identified threshold responses in the resistance of several response parameters in both plant species Figures  and 4. APlantago, where the survival rate was 80% and 20% for SWD of 90% and 95%, respectively. Repeated nondestructive measurements of the different productivity measures showed an immediate onset of regrowth, and within 20–30 days after rewetting NDVI, GPP, and vegetative height reached their maximum , the relationship between impact and recovery was positive for Plantago and negative for Dactylis.We mapped the response curves of resistance and recovery to SWD derived for the different productivity parameters into a bivariate framework of resistance and recovery Figure . The anaThe primary aim of this study was to investigate how drought intensity affected the resistance and recovery of plant productivity and whether critical thresholds affected their relationship. We found nonlinear relationships between plant resistance and recovery across the imposed gradient of stress intensity Figure . These rPlantago than for Dactylis. Enhanced regrowth of drought‐stressed plants could result from rapid use of carbohydrates stored below ground, including osmoprotective compounds accumulated during drought  beyond individual species and (ii) at higher ecological scales.First, given the pronounced interspecific differences, plant drought responses should be assessed across a broader range of species, which would make it possible to generalize the results beyond the species‐specific results presented here. It remains to be explored whether and to what degree traits and trait syndromes can serve to predict species' responses to drought across gradients of drought intensity. For example, resistance and recovery have been shown to be related to the fast–slow economic spectrum of plants (de Boeck et al., Second, the pronounced effects of drought intensity on plant response trajectories raise questions about how these effects scale up to resistance and recovery responses at higher ecological scales. The differential drought sensitivity of species within communities presents an important mechanistic pathway buffering community‐ or ecosystem‐level responses by enhancing the asynchrony and reordering of species abundances (Craven et al., We conclude that plant drought resistance and recovery are tightly coupled but that thresholds in drought responses can alter both the degree and the direction of drought effects, especially as concerns the postdrought compensatory growth dynamics in both the same and the following year. Furthermore, the responses differed considerably between the two studied species in particular with regard to their ability to recover after a drought. Thus, the resistance–recovery relationship is critically dependent on drought intensity and the considered timescale of recovery and species identity. Our study highlights the importance of drought intensity and the critical role of functional thresholds for plant responses to drought and emphasizes the need to understand nonlinear threshold responses across a broad range of species and ecological scales in order to predict the consequences of a more extreme future climate.Johannes Ingrisch designed the experiment with input from Michael Bahn. Johannes Ingrisch conducted the experiment and analysis with the help of Nikolaus Umlauf and Michael Bahn. Johannes Ingrisch drafted the manuscript with the assistance of Michael Bahn. All authors contributed to the final draft.The authors declare no conflict of interest.Appendix S1.Click here for additional data file.


Condom use among young people in South Africa has declined in recent years and adolescent girls and young women continue to bear the highest incidence of HIV in the country. Young women who have dropped out of school may be more at risk because of traditional gender norms that create substantial power imbalances and a lack of power to negotiate condom use with their male partners, especially when using alcohol and other drugs.This study presents an analysis of baseline data provided by 500 adolescent girls and young women (AGYW) from Cape Town communities between November 2016 and November 2018 who were reached for a cluster-randomised trial conducted to assess the efficacy of an evidence-based, young woman-focused intervention seeking to reduce HIV risk and substance use behaviours. The analysis focuses on associations between binge drinking, condom use, and sexual negotiation, including impaired sex (any substance use at last sex).p < 0.05). AGYW who reported frequent binge drinking in the past month (n = 177) had significantly reduced odds of condom use at last sex, irrespective of whether the sex was impaired  or not impaired .AGYW who reported frequent condom negotiation with their partners were 8.92 times  as likely to use a condom when alcohol or other drugs were not used at last sex and 5.50 times  as likely when alcohol or other drugs were used at last sex . 29/11/2016. For decades, South African youth have benefitted from robust government-supported condom distribution and educational programs that promote understanding of the importance of consistent condom use for preventing HIV, other sexually transmitted infections (STIs), and unintended pregnancy –3. DespiNonetheless condom use within heterosexual partnerships is a dyadic behaviour influenced by multiple sociocultural factors. For example, multiple studies have shown that young people who talk about condom use with their partners are significantly more likely to have used a condom during their last sexual experience , 5, 9. FHowever, AGYW’s likelihood to feel comfortable communicating about their needs with their male partners, including their desire to use condoms, is inherently dependent on sociocultural norms, many of which perpetuate gendered power imbalances, affect their sense of self-efficacy, and influence other behaviours that could put them at risk for HIV , 11, 12.Many AGYW, facing societal pressures, expectations, and gender inequality, such as gender violence, may turn to binge drinking as a coping mechanism –16. SociThe relationships between perceived agency, financial support between partners in heterosexual relationships, binge drinking, and adolescents’ and young peoples’ sexual behaviours, including condom negotiation, remain under researched –24. As SThis study analyses baseline data from the Cape Town Young Women’s Health CoOp Study (YWHC), a cluster-randomised trial that assessed the efficacy of a young-woman–focused intervention relative to treatment as usual for addressing substance use, victimisation, and sexual risk for HIV among AGYW in Cape Town. The specific methods are described in detail elsewhere .Participants were recruited from 24 target communities (clusters), 12 of which primarily comprised populations self-identifying as Coloured or of mixed racial or ethnic background and 12 of which primarily comprised populations identifying as Black African . These rn = 500) had to (1) be between 16 and 19 years old at the time of study enrollment, (2) self-identify as female, (3) report consuming 2 to 3 alcoholic drinks at least once in the past month (30 days) or report using illicit drugs at least once per week in the past 30 days, (4) be currently dropped out of school, (5) have been out of school for at least 6 months, (6) have not completed high school or a high school equivalent, (7) report condomless sex with a male partner in the past 3 months, (8) reside in one of the 24 target communities for at least 6 months, and plan to live in the target community for at least the next year, and (9) provide verbal and written consent.To be eligible for trial participation, participants ((1) Not at all to (4) All the time. Responses of (3) Many times or (4) All the time to several questions assessing condom negotiation were dichotomously coded as frequent negotiation (1) and all other responses were coded as infrequent negotiation (0). In this analysis, condom use refers to both male and female condom use, as only 3 participants reported asking their partners to use female condoms most or all of the time.Items from the adapted sexual communication scale were used to assess frequency of male and female condom negotiation over the past 6 months. Participants responded to these items on a four-point Likert scale with responses ranging from (3) Many times or (4) All the time to several questions assessing use of condoms during impaired sex were dichotomously coded as frequent use of condoms during impaired sex (1); all other responses were coded as infrequent use of condoms during impaired sex (0). Responses of (3) Many times or (4) All the time to these items were coded as frequent use of condoms during impaired sex (1) and responses of (1) Not at all or (2) Response options were coded as infrequent use of condoms during impaired sex (0).During impaired sex, condom use was assessed using the following items from the same four-point Likert scale: ‘In the past 6 months how often did you use a condom even if you were high or drunk?’ and ‘In the past 6 months how often did you use a condom even if your boyfriend was high or drunk?’ Responses of A single item assessed if participants reported condom use at last sex. Responses for each item were coded as 0 = No and 1 = Yes.This study defined binge drinking as drinking four or more alcoholic drinks on at least one day in the past month. This aligns with the Substance Abuse and Mental Health Services Administration (SAMHSA) definition of binge-drinking .Level of education was assessed by asking the question, ‘What is the highest standard/grade that you passed at school?’ Because over half of school dropout occurs after Grade 8 (first year of high school), responses were dichotomised into completed Grade 8 or less (0) and completed Grade 9 to 11 (1).(2) Somewhat helpful or (3) A great deal helpful were dichotomously coded as financially supported by boyfriend (1); all other responses were coded as not financially supported by boyfriend (0).Financial support from partners was assessed through a single item, ‘When you need money and other things, how helpful is your boyfriend?’ Responses of (1) Strongly agree to (5) Strongly disagree. Scenarios to which participants were asked to respond included a) Sometimes you have sex with your boyfriend even when you do not want to because it is expected of you; b) Sometimes you have sex with your boyfriend even when you do not want to because you are afraid to say NO; c) If you refuse to have sex with your boyfriend, he will refuse to give you money or pay the bills; d) If you refuse to have sex with your boyfriend he will stop giving you his love; and e) If you refuse to have sex with your boyfriend he will become angry or shout at you. Participants’ responses for each item were averaged. Higher average scores reflected more agency and power with their boyfriend. These total scores were recoded into a dichotomous variable: scores ≤ 3 were coded as Low Agency and Power and scores ≥ 3 were coded as High Agency and Power.Power and agency in one’s sexual relationships with their boyfriend was assessed by asking five questions around their perceptions of what would happen if they refused sex with their boyfriend, to which participants responded on a five-point scale ranging from A single item assessed how long participants had been dating their boyfriend or person with whom they have regular sex. Participants were asked to provide the duration in days, months, and/or years. Participants were coded as 0 = 6 months or less, 1 = 6 months to 1 year, 2 = 1–2 years, and 3 = More than 2 years.A single item assessed whether last sexual encounter was impaired by AOD use. For each question, participants were coded as 0 = No and 1 = Yes. Condom use at last sex was used as a proxy for condom negotiation in this analysis.Stata/SE version 16.1 was used for all analyses. Descriptive analyses were performed and the associations among the outcomes of interest  and conceptually meaningful covariates  were explored first. Next, separate logistic regression models were conducted to explore the association between any binge drinking in the past 30 days and other variables mentioned above and the frequency of condom negotiation and frequency of condom use during impaired sex. Lastly, separate logistic regression models were conducted to examine the association between the covariates and condom use at last penetrative sex among participants who did and did not report impairment at their last penetrative sex. All analyses accounted for clustering at the neighborhood level using a robust cluster estimator, as neighborhoods are very homogenous with respect to population groups. Thus, we consider that the confounds of population group inequity have been accounted for in the analysis.The sociodemographic characteristics of the participants are shown in Table As shown in Table n = 177) had significantly reduced odds of condom use at last sex irrespective of whether the sex was impaired  or not impaired .The odds of using a condom at last sex for participants who reported frequent condom negotiation with their partners in the past 6 months were 8.92 times  the odds of participants who did not report frequent condom negotiation when AODs were not used at last sex, and 5.50 times  the odds when AODs were used at last sex (p < 0.05) The study findings suggest that binge drinking behaviours among AGYW are associated with a lower likelihood of condom negotiation with their boyfriends. Consistent with the previous literature, AGYW in more established relationships, including relationships where they are financially dependent on their partner, were less likely than AGYW in newer relationships to consistently negotiate condom use and to use condoms when AOD use is involved , 34. ImpIn South Africa, the co-occurring public health issues of alcohol use disorders and HIV have a significant population-level impact. Specifically, high rates of HIV prevalence are seen among AGYW who may lack the power to negotiate condom use within their relationships , 35. AltThe data for this study came from questions assessed at baseline prior to AGYW’s participation in the Cape Town Young Women’s CoOp, a larger trial examining the efficacy of a young-woman − focused HIV prevention intervention. In the baseline instrument, the assessment period of condom negotiation behaviours was the past 6 months, whereas binge drinking behaviours were measured in the past 30 days. Because this is an analysis of baseline data, it did not take into account life changes or other factors that may contribute to increased binge drinking in the past month, which could have indicated a longer pattern of binge drinking contributing to an unequal power dynamic among AGYW and their boyfriends. Because of the difference in assessment periods of each outcome, direct causality cannot be inferred. Additionally, it is likely that participants who reported binge drinking were also using other drugs or substances that may impact the likelihood of them negotiating condom use.Further, this analysis was limited only to participants who reported having a boyfriend or someone with whom they regularly have sex. Because of the exclusion of AGYW who report casual sex with multiple partners, this analysis does not investigate the nuances of power, empowerment, and ability to negotiate condom use within AGYW’s casual sexual encounters, which may be more frequent and make them at even great risk of HIV. Consequently, it may be important for future research to investigate the impact of binge drinking behaviours on AGYW’s ability to negotiate condom use during casual sex. In addition, most participants reported receiving financial support from their boyfriends when they needed it, and a similar proportion reported high levels of agency and personal power. However, despite our understanding that equitable, supportive relationships may increase young women’s power and agency, AGYW who received financial support still had reduced odds of both frequent condom negotiation and frequent use of condoms during impaired sex. Further research should focus on the nuances of this financial support in a greater sociocultural context. Additionally, this study created a combined variable estimating condom negotiation behaviours for use of both male and female condoms, as very few participants reported female condom negotiation and subsequent use. Previous studies have found that AGYW may feel more empowered to negotiate female condom use as compared with male condom use, which, coupled with men’s comparative willingness to use a female condom instead of a male condom, could be imperative for improving condom use behaviours . HoweverThe Women’s Health CoOp and subsequent adaptations of the intervention have been implemented over the course of almost 20 years in South Africa, with each adaptation seeking to provide the education and skills necessary for women to effectively reduce their alcohol use and improve their overall physical and mental health . These aIn recent years, key global health collaborators have joined forces to take significant steps to address the unique HIV risks faced by AGYW in South Africa. In 2014, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) launched the Determined, Resilient, Empow-ered, AIDS-free, Mentored and Safe (DREAMS) Public/Private Partnership. One of the primary goals of the DREAMS partnership is to empower AGYW by promoting safer sex behaviours, including condom provision and promotion and, notably, by promoting PrEP for young women through a layered intervention approach , 42. BecGiven this consideration, an adapted version of this YWHC implemented in Pretoria, South Africa, has added educational elements of PrEP and sexual and reproductive health for both AGYW and clinic staff who play a critical role in ensuring initiation and adherence to both family planning and HIV prevention methods . The YWHUnderstanding the relationship between binge drinking and AGYW’s likelihood to negotiate condom use with their partners is critical to understanding the necessity of interventions, such as the Cape Town YWHC, for empowering this population both economically and socially and to promote condom negotiation and use , 36, 44.The findings highlight how patterns of binge drinking can disempower women in relationships, leading to a lower likelihood of negotiating condom use, consequently putting AGYW at higher risk for transmission of HIV and other STIs and unintended pregnancy. Woman-focused interventions, such as the Cape Town YWHC, must strive to incorporate conversations about the impact of binge drinking on AGYW’s potential empowerment within their sexual relationships, including how to engage in conversations about HIV and pregnancy protection through condom use and other methods, with their male partners. Key program decision-makers need to consider the ways in which alcohol use interacts with other potentially disempowering factors, such as AGYW’s financial dependence on their partners and the length of their relationships. Addressing the intersectionality of the identities that empower or disempower AGYW in their relationships is crucial to understanding and mitigating their unique HIV risk.Not applicable.


Obesity is a major risk factor in the development of endometrial cancer (EC) in young patients of reproductive age. Fertility sparing treatment is a viable option for a select group of patients with early EC, and involves systemic and intra‐uterine hormonal therapy. Weight loss has been associated with improved outcomes in this group. Bariatric surgery (BS) has been shown to be the most efficient and durable method of weight loss in obese patients. However, there is a paucity of data studying the benefit of BS as part of fertility sparing treatment.We present a retrospective case series of five patients who are undergoing fertility sparing treatment for early EC, who also underwent BS for treatment of obesity and related comorbidities. We aim to show early regression of EC for all the patients and also report on the other health benefits of BS.All five patients in the series achieved regression of EC within 6 months of undergoing BS. They also achieved significant weight loss consistent with previous studies, and three patients who had comorbidities related to obesity had remission of these conditions. One of the patients with EC regression also managed to conceive with IVF (In‐vitro Fertilisation).Patients on fertility sparing treatment for early EC who underwent BS was associated with early regression within 6 months, significant weight loss and resolution of comorbidities. BS could be a promising component of fertility sparing treatment. Long term, prospective studies are required to confirm the benefits reported in this case series. The worldwide epidemic of obesity is likely to be a key factor in the increasing incidence of EC.There is a paucity of studies that includes BS as a component of fertility sparing treatment of EC. The aim of this study is to provide a case series of patients on fertility sparing treatment who underwent BS for the treatment of morbid obesity. We aim to provide an observational analysis on the early regression of EC (within 6 months) with successful weight loss after and to report outcomes from BS including weight loss and improvement in related medical co‐morbidities.22, (2) BMI above 32.5 kg/m2, with co‐morbidities related to obesity and (3) patients of reproductive age who wish to preserve fertility. Exclusion criteria included (1) patients who did not undergo BS, (2) patients who underwent THBSO for treatment of EC and (3) patients on fertility sparing treatment, whose EC had regressed before BS. The study was approved by the Institutional Review Board (CIRB no: 2022/2195).This is a single‐centre, retrospective case series. The patients included in this case series underwent BS for treatment of morbid obesity. In addition, they also had EC and were on fertility sparing treatment. Other inclusion criteria included (1) BMI (Body Mass Index) above 37.5 kg/mStarting from January 2021 to December 2022, from the hospital database, we identified five patients who fulfilled the inclusion criteria. After written consent was obtained from the patients, we collected data from electronic medical records (EMR). The data consisted of baseline patient characteristics, EC disease characteristics, fertility sparing treatment details, BS details and treatment outcome  after BS. The descriptive analysis of the data is show in the section below.32. Table Five patients with confirmed EC were included in this case series. All of them were females at reproductive age who opted for fertility sparing treatment. Their age ranged between 27 and 37; the median patient age was 32. Three patients (60%) had co‐morbidities, which were related to obesity. The mean pre‐op weight was 109.54 kg and the mean pre‐op BMI was 40.73 kg/mNotably, there were two cases (Patients 4 and 5), where the endometrial cancer had previously regressed with hormonal treatment but subsequently recurred. In addition, Patient 1 had been treated with hormonal therapy for 12 months without regression. Patients 2 and 3 were diagnosed with endometrial cancer and started on hormonal treatment, but the tumour did not regress before they underwent BS, therefore they were included in the study. Four patients (80%) were diagnosed with hysteroscopy, dilatation and endometrial curettage (HDC), and one (20%) was diagnosed on endometrial sampling with the Explora Device. All patients had stage 1A, grade 1 (FIGO G1),Before fertility sparing treatment was offered to all the patients, the cases were discussed in a multidisciplinary tumour board meeting, with concurrence from all treating specialists. All patients underwent hormonal therapy with oral Megestrol, gonadotropin‐releasing hormone agonists (Triptorelin and Leuprolide) as well as levonorgestrel‐releasing intra‐uterine device (Mirena), in accordance to the standard treatment pathway. After starting on treatment, patients underwent HDC on three monthly interval for surveillance. Table were instructed about contraception and to avoid conceiving for at least 12 months after BS. Two patients 1 and 3 underwent IVF (In‐vitro Fertilisation) 12 months after BS, with patient 1 successfully conceiving. There were no maternal or foetal complications during the gestation period up to the end of the follow‐up period.All the patients were referred to undergo BS as their BMI fulfilled criteria based on national healthcare guidelines. Pre‐operative preparation was done for all patients based on a standard pathway, including review by members of a multidisciplinary team, blood tests, upper gastro‐intestinal endoscopy and 2 weeks of meal replacement with a very low‐calorie diet (VLCD). All patients underwent laparoscopic sleeve gastrectomy (LSG) and there were no complications from BS. After BS, all patients had EC regression within 6 months based on histology on HDC Table . After BAfter BS, all patients were followed‐up at three monthly intervals for the first 12 months, with regular blood tests to check for resolution of obesity‐related comorbidities and nutritional deficiency. All the patients were placed on vitamin, calcium and iron supplement as part of the standard treatment pathway. The weight loss and comorbidity resolution outcome are reported in Table 4p = .02). In this study, BS was offered as a treatment for obese patients and resulted in a greater and more sustainable weight loss compared to nonsurgical treatment. No other studies have explored using BS as part of fertility sparing treatment of EC.This study describes BS as a promising component in the fertility sparing treatment for patients who have early EC. There is a paucity of data for using BS as part of the fertility sparing treatment and this study adds to the body of knowledge regarding this subject. The only other study that discusses this subject is a prospective nonrandomized study conducted by Barr et. alMorbid obesity is the underlying biological factor that drives the development of endometroid EC in young patients in the reproductive age group.Fertility sparing treatment itself may exacerbate the problem of obesity. The most commonly reported side effects from hormonal therapy are appetite stimulation and weight gain. BS can help limit this by appetite suppression from reduced gastric volume and gut hormone alteration.BS has been shown to be the most durable and effective treatment for obesityIn addition, weight loss induced by BS improves the chances of fertility,The limitations of this study include the retrospective nature of the study design, the lack of a control group, the short follow‐up time and the small number of patients in the study group. The retrospective nature of the study design makes it prone to selection and measurement bias. The patients included in this study are only those that are treated in the centres in which the authors are based. In addition, the early cancer regression in this group of patient who chose to undergo BS may be due to other factors like higher compliance to the fertility sparing treatment or increased health seeking behaviour. Measurement bias can also result from incomplete or heterogeneous data from a lack of standard study protocol. This is partially mitigated by the fact that all the treatment received by the patient (both fertility sparing treatment for EC and BS) were according to a standard pathway, and all data collected were from the same comprehensive EMR system used in both public healthcare institutions. The outcomes measured were also objective in nature for example, histology proving that EC has regressed and weight loss measured in the outpatient clinic during follow‐up appointments. The lack of a control group prevents us from inferring a causal relationship between EC regression and BS. We are also unable to draw any conclusions about the longevity of the cancer regression due to the short follow‐up period.5In this retrospective case series, patients on fertility sparing treatment for early EC who underwent BS were associated with early cancer regression within 6 months. In addition, patients had significant weight loss and resolution of comorbidities. BS could be a promising component of fertility sparing treatment for early EC. The overall and metabolic health benefits from weight loss induced by BS in this study are consistent with current literature. Larger scale, prospective case controlled studies with longer follow‐up period is required to confirm the oncological benefit of BS for this purpose. This study could add to the body of evidence and raise awareness for this promising treatment strategy, while forming the background data for future prospective studies.Jinlin Lin: Conceptualization ; data curation ; formal analysis ; investigation ; methodology ; writing – original draft ; writing – review and editing . Weng Yan Ho: Conceptualization ; methodology ; writing – review and editing . Qi Xuan Lim: Writing – original draft ; writing – review and editing . Hui Xian Felicia Chin: Conceptualization ; methodology ; writing – review and editing .The authors report no conflict of interests in connection with this article.The study above has been approved by the Singhealth Institutional Review Board (CIRB no: 2022/2195), in accordance with the Human Biomedical Research Act 2015 of the Republic of Singapore. Explicit written consent was obtained from all subjects before inclusion in this study.


Opening up regional ontologies for climate action is a necessary and underexplored dimension of climate change policymaking. This commentary explores how a regional lens might be integrated into the complex mosaic of climate governance, particularly in the context of resilient regions. I argue regional ontologies for climate policymaking could have greater analytical power if integrated into a theoretical framing of action that goes beyond the nation‐state, beyond formal policy processes and beyond a strict binary between science and policy. Applying this lens to resilient regions, I argue there are particular opportunities at the regional scale for highlighting diverse perspectives or adaptation issues obscured through a national ontology, using existing transnational data infrastructure and community‐led data systems to support the regional ontology and reframing the scale of collective future visions for a climate‐adapted world. In the UN climate negotiations at the end of 2022, national government representatives sat in deadlock in the beach resort of Sharm el‐Sheikh seeking to negotiate what a global target should be for adapting to climate change, known within the negotiations as the global goal on adaptation. Some Parties wanted the goal to contain targets and a framework of important dimensions. Others wanted to keep the negotiating text broad and spend more time developing the details. Many of the differences come down to differing national incentives for the goal and disagreements between countries over the role of climate finance in the process (Beauchamp & Motaroki The geographical ontology challenge in attending to anthropogenic climate change: regional geography revisited (This tension in the ongoing negotiations highlights the impact of the ontological gap Taylor outlines in his article—evisited —the lackIn this commentary, I take Taylor's useful proposition and extend the argument in two directions. Firstly, I explore how a regional ontology might be integrated into a broader understanding of the mosaic of climate action, and secondly, I develop these ideas in more detail through the proposition of resilient regions.et al. There are already some networks and new coalitions of actors shaping climate action outside the political ontology of nation‐states. For example, cities have formed peer‐to‐peer networks that are taking independent action on mitigating and adapting to climate change beyond their national policy commitments Fisher . Some coet al. Regional ontological interventions sit within a complex policy landscape where non‐state and sub‐national actors play significant roles in shaping outcomes within the UN regime through mechanisms such as advocacy, finance and technical support (Nasiritousi et al. et al. et al. et al. et al. Non‐state and sub‐national actors also play a role in directly governing climate action outside of nation‐state policies and multilateral agreements through for example action to reduce greenhouse gas emissions within city networks, supply chain risk management by corporations and investments made by the finance sector in high‐risk locations. These mechanisms can also be indirect and include shifting norms and values, changing incentives and framing solutions and relevant knowledge Merry . InternaIt is also useful when considering ontological interventions to conceptualise the relationship between the scientific institution of the IPCC and the political one of the UNFCCC as a negotiated and contested line between science and policy (Mahony & Hulme In this first section, I have argued that we can take the proposition of regional ontologies for climate policymaking further by integrating these interventions into the complex mosaic of climate action that goes beyond the nation‐state, beyond formal policy processes and beyond a strict binary between science and policy. The regional lens is underexplored in these contexts and has much to add. Situating it within this mosaic allows a nuanced analysis of how regional ontologies would operate within this polycentric picture, the relationship they could have to the non‐state and sub‐national actors as well as the role they might play in changing norms, values, scientific cultures and shaping the science–policy interface.et al. The second area where I wish to extend Taylor's arguments is around what new geographical ontologies for resilient regions might look like. Starting from Scott's argument  that theBuilding on Taylor's ‘relatively modest’ regional governance proposals for areas of risk, I argue there are other roles that could enhance the function of resilient regions. Firstly, there are issues of climate impacts that are hidden at the national scale but may not become fully visible if a regional focus does not explicitly move beyond an aggregated understanding of national risks. National ontologies may underplay the role of transboundary risks and global policy issues such as international migration and trade that require action at a different scale. A regional ontology could also make visible risks that are not prioritised by any powerful nation‐state, but when aggregated across regional contexts have a global impact such as sub‐national islands. Some risks may only become relevant when multiple shocks are experienced simultaneously that may not be fully considered in any one national plan, or a regional lens may show negative effects of a national project in neighbouring countries through the redistribution of risk.et al. A second dimension to consider in a resilient region that was more than a collection of nation‐states would be data architecture, and how the region would ‘come to be known’ when many data systems rely on national structures which underpin and reinforce a national ontology. Here, I suggest the transnational data systems of international organisations have a role to play. Tools such as the multi‐dimensional poverty index can be broken down to understand risks among different groups and offer comparable methodologies combined with some data infrastructure through the international system. The World Bank and UN statistical offices support a range of surveys that are increasing standardisation across national contexts and could also speak to a regional ontology. Another space for data framed with a regional ontology could be locally generated data, for example, the data collection by residents from informal settlements using settlement profiles, house‐by‐house surveys and mapping supported by Slum and Shack Dwellers International (Patel Thirdly, a regional ontology could shape how and at what scale visions of the future are built and sustained for living with climate impacts. Adaptation policies and programmes embed an implicit or explicit framing of the type of future a country is seeking to move towards. In the current dominant ontology of adaptation that visioning process remains at the level of the national government, although there are varying levels of engagement at local scales. These ideas can become embedded as collectively held visions or socio‐technical imaginaries Sismondo . These iet al. To conclude, I argue that situating the resilient regions within the mosaic of climate action discussed above, offers new points for a regional ontological intervention to shape action in new ways. The values and norms shared within the transnational community of international organisations and multilateral banks, for example, may shape national action through lending practices, understandings of credibility and expertise and technical assistance that supports a particular framing of adaptation (Singh


The WHO Unity Studies initiative engaged low‐ and middle‐income countries in the implementation of standardised SARS‐CoV‐2 sero‐epidemiological investigation protocols and timely sharing of comparable results for evidence‐based action. To gain a deeper understanding of the methodological challenges faced when conducting seroprevalence studies in the African region, we conducted unstructured interviews with key study teams in five countries. We discuss the challenges identified: participant recruitment and retention, sampling, sample and data management, data analysis and presentation. Potential solutions to aid future implementation include preparedness actions such as the development of new tools, robust planning and practice. We present four key reoccurring methodological challenges identified during these interviews and potential solutions to aid future implementation.1.1(Ghana)‘People were reluctant to participate because of fear and stigma.’ (Burkina Faso)‘When initially enrolling participants into the study, we informed them that we would provide them with their test results as soon as they were available. However, there were delays with the delivery of the test kits provided by WHO, as such, we were unable to get the results to participants before the next round of follow‐up visits. People didn't want to continue with the study and give a new sample before they received their results.’ Seroprevalence studies require the inclusion of a predetermined minimum number of participants to estimate the population prevalence with good precision.These examples add weight to the well documented importance of risk communication and community engagement (RCCE) in surveillance and operational research.‘We were able to build a young, dynamic, multidisciplinary team capable of implementing future studies, with involvement of stakeholders at all levels including policy makers, community leaders, epidemiologists, immunologists, biologists, data mangers, sociologists and anthropologists.’ The Malian team reported that one of the main successes of their study was that:Engagement with and continual support of teams such as these is an important way to ensure timely community‐based investigations during future pandemics.1.2(Burkina Faso)‘We were obliged to conduct a mini census before we could sample. The last population census was conducted in 2006 and the data needed to be updated. After randomly sampling the enumeration areas , we visited the households in these areas and gathered information on the sociodemographic characteristics and sizes of the households. In this way we did a small census to find out about our sample to better establish our sampling frame.’ In an idealised setting, a perfect sampling frame (study population from which the sample is selected in order to adequately address study objectives and extrapolate conclusions appropriately to the broader target population) would be a list where each person with known characteristics  is listed once.This process was time and resource intensive and delayed the start of the study.(South Sudan)‘We used satellite imagery to randomly select shelters for inclusion in the study, some of the sampled households could not be located in the community due to poor internet access in some remote locations which affected the use of GPS to locate the shelters, some households were also empty when study teams arrived, hence the need for supplementary sampling.’ Sampling issues also affected the South Sudan team:Before implementation, partners need to check if an ad hoc census is required and feasible based on available resources and sampling techniques need to be adapted for the constraints of each particular setting, such as limited connectivity.1.3Sample and data management was noted as a key area that could be improved for future studies.Teams mentioned that using easy‐to‐collect samples like dried blood spots (DBS) significantly decreases the complexity around sample management. However, prior validation of serological tests using an appropriate panel of paired samples and a sufficient number of samples, to study test accuracy when using DBS samples is required. Validation of both serological tests and using DBS samples was challenging at the start of the SARS‐CoV‐2 pandemic, which meant that the robustness of non‐validated study results was unknown. As such, it is recommended to use well validated serological tests and sample types where possible and that results are adjusted for test performance (see below).Manual capturing of participant identifiers on collection forms and samples posed a challenge for teams and led to errors, which further resulted in delays while these discrepancies were resolved. A possible solution suggested by several teams was the development of sample collection standard operating procedures (SOPs) including how samples will be linked through unique identifiers to epidemiological data collected such as through the use of barcodes.(South Africa)‘We used web‐based data collection forms on a platform the team was familiar with as we didn't have time to learn a new software. We had several challenges with connectivity due to limited cell phone network connections in our sampling areas. A better tool would have been a reliable, user‐friendly application that you can capture data with offline.’ Respondents noted that having access to and training on offline electronic data collection tools is necessary.To overcome connectivity issues, some teams used offline mobile data collection tools. They suggested that trainings on how to set up and use these tools should be done in the preparation phase, so that when studies need to be implemented, the tools are familiar to study teams and ready for deployment.1.4Teams reported needing assistance with data analysis. The WHO Unity team collaborated with SeroTrackerOne of the main aims of the Unity Studies is to provide robust evidence for rapid policy decision‐making.1.5Tools ; investigation ; writing—original draft ; writing—review and editing . Joseph Okeibunor: Funding acquisition ; writing—review and editing . Thierno Balde: writing—review and editing . Irene Owusu Donkor: Investigation ; writing—review and editing . Jackie Kleynhans: Investigation ; writing—review and editing . Joseph Francis Wamala: Investigation ; writing—review and editing . Nongodo Firmin Kaboré: Investigation ; writing—review and editing . Saidou Balam: Investigation ; writing—review and editing . Dick Chamla: Writing—review and editing . Fiona Braka: Writing—review and editing . Lorenzo Subissi: Investigation ; writing—review and editing . Belinda Herring: Writing—review and editing . Mairead Whelan: Investigation ; writing—review and editing . Isabel Bergeri: Funding acquisition ; writing—review and editing . Hannah C. Lewis: Conceptualization ; supervision (lead); investigation ; writing—original draft ; writing—review and editing .The authors declare no conflict of interest.https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/irv.13170.The peer review history for this article is available at This short communication was exempt from ethical approval.


Non‐human animals are natural hosts for the virus causing COVID‐19 (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2]) and a diversity of species appear susceptible to infection. Cats are of particular concern because of their close affiliation with humans and susceptibility to infection. Cats also harbour feline enteric coronavirus (FECV). Our objectives were to document the prevalence of SARS‐CoV‐2 and FECV in feline populations with high turnover and movement among households in the Central Valley of California, USA.A cross‐sectional study of 128 shelter and foster cats and kittens in the Central Valley of California was performed from July to December 2020. PCR was performed on rectal and oropharyngeal samples to detect SARS‐CoV‐2 RNA and on rectal samples to detect FECV RNA.Among 163 rectal and oropharyngeal fluid samples gathered from sheltered and fostered cats and kittens in central California, SARS‐CoV‐2 nucleic acids were not detected from any cat or kitten. In contrast, FECV nucleic acids were detected in 18% of shelter‐housed cats; 83% of these positive samples were collected from cats housed in adjacent cages.These data may be helpful when considering the allocation of resources to minimise the harm of FECV and SARS‐CoV‐2 in household pets and shelter environments. The COVID‐19 pandemic is considered the most devastating health crisis of the 21st century,Throughout the COVID‐19 pandemic, animal shelters continued to serve important roles in society, working to find suitable and permanent homes for unowned animals. However, relinquished, sheltered and fostered cats and kittens may be at high risk for infection with numerous pathogens, including SARS‐CoV‐2 and FECV due to the high turnover rates, proximity to other cats, overcrowding, influx of animals with complicated medical conditions, stress or limited shelter resources. These factors increase cat‐to‐cat, cat‐to‐human and human‐to‐cat contact, possibly exacerbating epidemiological cycles of disease.The extent to which SARS‐CoV‐2 replicates in vulnerable cat populations, especially in those with high turnover rates and high rates of movement among households or institutions, has yet to be determined. Although cats seem to play a limited role in the spread of SARS‐CoV‐2 and the risk of cats spreading this virus to humans is considered to be low,Samples were collected from cats and kittens at two locations: the City of Stockton Animal Services Center (SAS) and kittens seen at the William R. Pritchard Veterinary Medical Teaching Hospital at the University of California, Davis (UCD). The SAS is an organised animal care facility (‘shelter’) with an annual intake of approximately 11,000 animals. The facility conforms to local animal safety guidelines and rabies quarantine. It provides veterinary care and other pertinent services to the residents of Stockton and San Joaquin County. The cat population was segregated based on their health status and age group. Within each unit, cats were housed separately in stainless steel cages, while kittens were often left in small family groups. Every day, dishes and litter boxes were removed and cleaned in an industrial dishwasher and the cage was wiped down with hot water. On every cat's exit, the cage contents were cleaned in the dishwasher and the cage was sterilised with a 4.25% hydrogen peroxide‐based cleaner. Cats and kittens of all ages were examined by the authors on various days post‐intake (as they were made available for study enrolment). Staff collected rectal and oropharyngeal swab samples for PCR, and they collected data on sex, neutering status, breed, vaccination and health status, cage location within the shelter and age group—as defined by the American Association of Feline Practitioners/American Animal Hospital Association Feline Life Stage Guidelines .At UCD, oropharyngeal samples were collected from kittens diagnosed with ocular disease associated with upper respiratory tract infection at the time of enrollment in another study (protocol 20962). All kittens sampled at UCD were less than 12 weeks of age and less than 3.0 lb bodyweight. They were owned by local 501c3 animal or government‐run animal shelters within 25 miles of UCD. All kittens owned by 501c3 had originally been taken in from government‐run shelters and distributed to the foster families. Because of the diversity of original sources and foster housing in this group, details of management varied and were not available to the authors.Sixty‐eight samples from SAS and 93 from UCD were collected at the respective facilities or by foster caregivers at home (two samples). They comprised 35 rectal swabs and 126 oropharyngeal swabs. When samples were obtained by caregivers, a package of sampling equipment was posted to the participant along with instructions. Rectal and faecal samples suitable for FECV testing were not collected from UCD kittens. Samples from UCD kittens were collected upon intake at UCD.For sample collection, operators wore latex gloves wetted with RNase AWAY surface decontaminant . A sterile polyester swab  was then used to collect samples from the oropharynx. The tip of the swab was then broken off and placed in an RNase‐free Eppendorf tube taking care to avoid contacting the inside or lid of the Eppendorf tube. At SAS, a second sample was collected from the rectum of each cat or kitten. Samples were transported on ice to the laboratory and then subjected to RNA extraction and PCR.RNA was extracted from faeces and oropharyngeal swabs using a commercial kit . Total RNA was transcribed to cDNA using 5× all‐in‐one RT MasterMix . RNA extraction and transcription were performed in class II biosafety cabinets and all pipetting was done with plugged tips. All runs included positive (sequence‐confirmed coronavirus‐infected samples) and negative (water) controls.N) using published primers,Real‐time PCR for SARS‐CoV‐2 was performed on rectal and oropharyngeal swabs by amplifying two conserved fragments of two target genes, including open reading frame 1ab (ORF1ab) and nucleocapsid protein , with a cutoff of p‐value less than 0.05 used to infer statistical significance. Fisher's exact test was used to compare sex ratios between the UCD and SAS populations; logistic regression was used to compare age distribution between sites. For cats at SAS, logistic regression models with binomial distribution were also constructed to evaluate the association of the presence/absence of FECV infection (response variable) with sex, age, breed, neuter status and whether or not the cat was immunised against herpesvirus, calicivirus and panleukopenia virus as explanatory variables. A Wilcoxon rank sum test with continuity correction was performed to analyse whether cats that were, or were not, FECV PCR‐positive were likely to be in proximity to other FECV PCR‐positive cats.The study was structured as a cross‐sectional survey of prevalence of SARS‐CoV‐2. Statistical analysis was performed in R 4.0.3  from those for kittens at UCD (0.96:1). Considering age, 82.8% were kittens, 13.3% were juniors, 1.6% were adults and 2.3% were mature. While the UCD group sampled kittens only, the SAS group included cats of multiple age classes, with significantly (p = 0.87 × 10−6) more junior cats at SAS than at UCD. In total, 42.2% of cats were neutered . There was documentation of vaccination for 40.6% of the cats or kittens  were not significantly different  housed at SAS. Using univariate logistic regression models, none of the predictors  was significantly associated with the detection of FECV RNA , the median proximity index (MPI), as described in Figure Cats in the Stockton shelter were housed in one of two banks of cages. As shown in Figure This study aimed to provide insight into the risk of SARS‐CoV‐2 infection among cats and kittens in high‐turnover environments in the Central Valley of California during 2020 using rectal and oropharyngeal samples, as well as to perform an updated prevalence survey for an endemic FECV using rectal samples from cats in a Californian animal shelter. Although SARS‐CoV‐2 RNA was not detected in any cats or kittens sampled, there was a considerable presence of FECV in cats within the shelter.The fact that SARS‐CoV‐2 RNA was not found in samples from foster or shelter cats may alleviate some reservations potential adopters may have regarding taking cats into their household and, thereby, lessen the burdens of shelters. However, there have been several cases of SARS‐CoV‐2 infection in pet animals, including an infected dog and two cats in New York, a cat in Belgium, a cat in Seoul and two dogs in Hong Kong.A prevalence survey of FECV in a shelter was performed, in part as a proof of concept that we could detect other circulating coronaviruses (SARS‐CoV‐2) in the target populations. Due to early permitting concerns, faecal samples suitable for FECV testing could not be collected from foster cats. Wild‐type FECV causes few or no clinical signs but often proves to be fatal when the virus mutates to the FIP virus,The two populations in our study had important distinctions. Although most kittens in the UCD population originated in animal shelters, they were younger than the SAS population and were distributed in a network of homes; they all initially presented with respiratory tract and ocular infections because they were concurrently enrolled in another study. In contrast, at SAS, cats of all ages were housed in individual cages within a single large facility.There were some important limitations to our study. These included the differences in the populations, the lack of background data available on the cats and the variability in management of the cats prior to the time of sampling. Moreover, the two populations tested may not be representative of all shelter cat populations, where there may, for example, be differences in exposure and housing density. Cats in the surveyed shelter were sampled as available. They were of various ages and had been in the shelter for differing durations and information about whether they were healthy or had some concurrent illness, was not available to study staff. Because of the nature of the kitten rescue organisations, kittens may have been co‐housed with littermates or other similarly aged kittens, with or without the queen, and possibly from a shelter and through one or several foster homes. Furthermore, the fact that cats in the foster network were all kittens and presented with ocular and respiratory diseases could also impact our results and the probability of being exposed to SARS‐CoV‐2 or other viral pathogens. However, a previous report of SARS‐CoV‐2 showed no difference in prevalence between cats with and without clinical evidence of respiratory disease,Another shortcoming was that rectal swabs and faecal samples suitable for FECV testing were not collected from UCD kittens. Due to the small sample size for FECV and sampling limitations, caution should be exercised when extrapolating this information to the overall population of adoptable cats. With a larger sample size, knowing that so few cats and kittens in the community and available for adoption were infected with SARS‐CoV‐2 should reduce concern about cat adoption contributing to this serious public health risk. Despite the study limitations, this study provides no evidence that SARS‐CoV‐2 was present in cats and kittens housed in shelter or foster homes. Knowing the prevalence of FECV is important for development of shelter protocols such as quarantine, housing and cleaning, as well as guiding adopter and staff expectations of cats developing FIP.All authors contributed to the study design. Sample collection was done by Karen Vernau, David Maggs, Andrés M. López‐Pérez and Daniel Chen. Material preparation and analysis were performed by Daniel Chen and Andrés M. López‐Pérez. The first draft of the manuscript was written by Daniel Chen and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Janet Foley managed the laboratory, permitting and funding.The authors declare they have no conflicts of interest.This project was conducted with informed consent and approval by the UC Davis Institutional Animal Care and Use Committee under protocol number 21301.


Invasive recording of His bundle signals (HBS) in electrophysiological study (EPS) is important in determining HV interval, the time taken to activate the ventricles from the His bundle. Noninvasive surface measurements of HBS are attempted by averaging typically 100–200 cardiac cycles of ECG time series in body surface potential mapping (BSPM) and in magnetocardiography (MCG) which records weak cardiac magnetic fields by highly sensitive detectors. However, noninvasive beat‐by‐beat extraction of HBS is challenged by ramp‐like atrial signals and noise in PR segment of the cardiac cycle.By making use of a signal‐averaged trace showing prominent HBS as a guide trace, we developed a method combining interval‐dependent wavelet thresholding (IDWT) and signal space projection (SSP) technique to eliminate artifacts from single beats. The method was applied on MCG recorded on 21 subjects with known HV intervals based on EPS and noninvasive signal‐averaging, including five subjects with BSPM recorded subsequently. The method was also applied on stress‐MCG of a subject featuring autonomic dynamics.HBS could be extracted from 19 out of 21 subjects by signal‐averaging whose timing differed from EPS between −8 and 11 ms as tested by 2 observers. HBS in single beats were seen as aligned patterns in inter‐beat contours and were appreciable in stress‐MCG and conspicuous than BSPM. The performance of the method was evaluated on simulated and measured MCG to be adequate if the signal‐to‐noise ratio was at least 20 dB.These results suggest the use of this method for noninvasive assessments on HBS. A novel method to unravel beat‐by‐beat surface recordings of His bundle signals is proposed. The method has been successfully demonstrated on 19 subjects for whom the invasive electrophysiological study had already been performed. This is inclusive of five subjects with BSPM measurements. The method has been qualitatively and quantitatively compared and these results persuade to use it for noninvasive assessments. Wavelet Toolbox of MATLAB software, version R2013a (The MathWorks Inc.) was used for IDWT. The averaged signal was decomposed to a set of approximation and detail coefficients by ‘coif 5’ wavelet in five levels of decomposition. The choice of this wavelet basis was based on a report which discussed its suitability for analyzing His bundle signal features Lee, . The mag2.2.3SSP aimed at separating HBS from the PR interval by creating an orthonormal basis function of the atrial components generated from the PR epochs. The wavelet thresholded epochs of the PR intervals were smoothed by applying Savitzky–Golay (SG) filter which acted as a local least square polynomial estimator  as represented by Equation . It is rbA(t) was characterized by magnetic field/electric potential waveforms of ‘m’ number of epochs of a chosen measurement channel, then a matrix Un with each column forming an orthonormal basis vector could be constituted by singular value decomposition . It was then possible to form a subspace Pper that was orthogonal to the atrial subspace and was devoid of atrial components as given by Equation (I is an identity matrix of the same size as Un.If Equation .(2)PpePper, the His bundle signals could be selectively retrieved from the PR interval epochs as given by Equation bHBDetailed descriptions of SSP technique and its use for removing common‐mode background artifacts are given elsewhere   ramps that commonly occur in the PR interval , and PTa with a magnitude exceeding one‐half of the magnitude of P wave in the positive direction (designated as Type 3) were used. Additive white Gaussian noise was added to each type of the simulated PR interval waveform with signal‐to‐noise ratio (SNR) ranging between 5–28 dB . Pearson's correlation coefficient was calculated between a reference HBS  and the retrieved HBS using the proposed method in each type of the simulated waveform.The proposed analysis method was assessed for its ability to extract HBS under varying levels of atrial influence and random noise using a synthetic signal representing a PR interval epoch containing a reference HBS at an interval of 60 ms before the QRS‐onset . Varying magnitudes and configurations of ramps mimicking atrial repolarization activity and fluctuations caused by random noise which corrupt the PR interval were simulated. This simulation involved generating three different types of atrial T wave  and signal‐to‐error ratio (SER)  which is widely used to assess inter‐observer variability in medical research  for HBS, but with significant dominance of atrial activity seen from SNR at P wave. This was drastically reduced by the proposed method even in a single cardiac beat. Similarly, the observations of higher values of SER at HBS frequency and low SER values at P wave and at noise frequencies further endorsed the fact the prominence of HBS alone was facilitated in the PR interval by the proposed IDWT‐SSP method.3.3Figure 3.4p value <.00065 for both the cases. Figure The Spearman's rank correlation coefficient (ρ) on the inter‐observer variability of HV intervals was computed using Equation  to be 0.4The present work reported the surface registration of the HBS using MCG in a beat‐by‐beat manner by logically approaching the problem of HBS tracking, utilizing the relative constancy of HV interval. In the absence of any clue on the signal features in the individual beats, traces of signal components that eventually contribute to the overall evolution of the averaged HBS components were visualized using the proposed method. Even though the number of cases shown in this work was only a few, the formulation of the proposed approach was more viable owing to their corroboration with invasive EPS for all the cases studied and as shown in Figure a was also within the expected range considering independent studies on the measurements of atrial repolarization  across these modalities indicated the reliability of the proposed method as shown for two subjects in Figures It should be admitted that the proposed method has some limitations primarily on its application to cases where significant beat‐by‐beat variations are expected in the HV duration. Second, the method could not be applied on measurement data where the noise floor far exceeds the magnitude of the His bundle signal. The latter situation is a common scenario in most of the experimental conditions irrespective of the fact these measurements are performed inside MSR. Nevertheless, the usefulness of the IDWT‐SSP method and the visualization of HBS in inter‐beat contour as shown in this work could still be acceptable for needy cases where continuous tracking of HBS is expected to be informative like for example, in studying the influence of pharmacological interventions  showed the superiority of MCG in unraveling HBS and were visualized in the inter‐beat contour maps. The utility of this method had also been shown on a healthy subject under moderate exertion. These demonstrations provide confidence in using the technique in various investigations where continuous non‐invasive monitoring of HBS is required.Sengottuvel was the originator of the idea and lead investigation on the research problem. Shenbaga Devi provided the conceptual design of the work and guidance. Sasikala reviewed the software codes. Santhosh Satheesh and Raja Selvaraj provided clinical interpretation of the results and critical review of the overall work. All the authors contributed to manuscript compilation. All the authors had read and approved the final manuscript.There is no conflict of interest for any of the author of this manuscript.The research reported in this work was approved by the Institutional Human ethics committee of JIPMER, Pondicherry, JIP/IEC/3/2012/7. All the subjects gave informed consent in participating in the experiment conducting MCG measurements.