Recent literature indicates that the long‐term success of dental implants is, in part, attributed to how dental crowns are attached to their associated implants. The commonly utilized method for crown attachment – cementation, has been criticized because of recent links between residual cement and peri‐implant disease. Residual cement extrusion from crown‐abutment margins post‐crown seating is a growing concern. This study aimed at (1) identifying key abutment features, which would improve dental cement flow characteristics, and (2) understanding how these features would impact the mechanical stability of the abutment under functional loads. Computational fluid dynamic modeling was used to evaluate cement flow in novel abutment geometries. These models were then evaluated using 3D‐printed surrogate models. Finite element analysis also provided an understanding of how the mechanical stability of these abutments was altered after key features were incorporated into the geometry. The findings demonstrated that the key features involved in improved venting of the abutment during crown seating were (1) addition of vents, (2) diameter of the vents, (3) location of the vents, (4) addition of a plastic screw insert, and (5) thickness of the abutment wall. This study culminated in a novel design for a vented abutment consisting of 8 vents located radially around the abutment neck‐margin plus a plastic insert to guide the cement during seating and provide retrievability to the abutment system.Venting of the dental abutment has been shown to decrease the risk of undetected residual dental cement post‐cement‐retained crown seating. This article will utilize a finite element analysis approach toward optimizing dental abutment designs for improved dental cement venting. Features investigated include (1) addition of vents, (2) diameter of vents, (3) location of vents, (4) addition of plastic screw insert, and (5) thickness of abutment wall. Dental implants have been used to improve the quality of life of millions of patients over the past 40 years or so  identify key abutment features, which would improve dental cement flow characteristics, and (2) understand how these features would impact the mechanical stability of the abutment under functional loads. To this end, several implant abutment designs have been developed, dedicated to (1) provide flow channels for dental cement within the crown‐abutment system to provide laminar flow, (2) increase volume within the abutment to decrease the risk of residual cement extrusion (decrease risk of overfilling crown), (3) increase surface area in contact with cement, thereby increasing retentive strength of the crown, and (4) add a screw insert to guide cement flow and protect the screw head. This information has the potential to direct future abutment design in an effort to improve flow of dental cements and potentially reduce the risk of residual cement extrusion by allowing for a standardization of cement loading volumes prior to seating.The methodology used for this study consisted of virtual modeling using specialized computer software capable of determining fluid dynamic flow. Evaluation was further performed by using surrogate models of dental abutments. Finite element analysis (FEA) was undertaken to determine the number, location, and diameter of vents that could be placed within the abutment without substantive structural yield/failure under load.Traditionally, implant abutment designs have been based on tooth form preparations resembling a frustum (truncated cone) . The cenAbutments in this study were designed to fit two major criteria: (1) provide increased cement flow throughout the entire geometry, and (2) increase the cement capacity (volume) within the crown‐abutment system.o wall taper, 30o wing taper) abutment (opening Ø 4 mm × 6.25 mm) with a connection depth of 3.5 mm and a cement channel of 8.65 mm   software  was used to determine the most optimal fluid dynamics with regard to minimizing dead space (unfilled space) within the abutment. Dead space was the primary parameter of interest here because of the assumption that reducing dead space in the abutment would reduce the ability for cement (during seating) to create air pockets. These systems are not designed to assume air pocket or void formation. These voids (areas without cement) will result in a discrepancy between the amount of cement loaded into the intaglio of the crown and the amount of cement, which the abutment can accommodate. Models were initially built in solidworks (computer aided design (CAD) software; Dassault Systemes, Waltham, MA) and transferred to the CFD software as stereolithography (.stl) files. Abutments were meshed using a polyhedral mesh with proximity refinement (minimum cell size of 0.05 mm and a maximum cell size of 2.5 mm).By utilizing a plastic insert into the screw head within the abutment screw channel prior to cementation, the screw head remains protected from the cement and can still be retrieved. Parameters of interest to this phase of the study included the height and taper of the insert to optimize the flow characteristics of fluid in the geometry Figs. ; Table 1‐4 evidencing the simulation was complete. Results were represented using fluid velocity to determine the rate of fluid flow within the abutment system during seating (mm/s).For the computations, the coronal portion of the screw access channel of the abutment was defined as a fluid inlet with fluid flow of 5 mm/s. The abutment was further modified with up to 16 vents located within the margin of the abutment (defined as fluid outlets). The cement simulations were run using viscosity properties acquired using dynamic rheometry  (250 Pa/s), which closely resembles that of freshly mixed TempoCem – a zinc oxide/eugenol cement . A steady state solver (time independent) was used and was run until residuals converged below 1 en = 3) with insert dimensions  were fabricated by 3D‐printing after scaling 5× (3D‐printed test models were five times the size of abutment design) using a Connex350 . Printed models  were transferred using standard ACIS text files into abaqus fe (Dassault Systemes) to generate meshes and perform the numerical simulation. All components were meshed with tetrahedral elements of type C3D10 type elements readily available in abaqus element library. Meshes were generated varying element size parameters to verify mesh independence for each geometry. All results had less than 2.6% variation between mesh sizes.The three‐dimensional CAD geometry models designed in X‐, Y‐, and Z‐directions.In this study, we assumed the abutments were homogeneous, linear elastic, and had isotropic mechanical properties. Material properties for abutment components  were collected from reliable resource and published data . Subsequently, a concentrated force  was loaded 30o offset from the abutment surface to investigate the impact of non‐normal loading in abutments with various abutment wall thicknesses (0.15 mm vs. 0.65 mm).A distributed force of 250 N (average maximum human bite force) was applied onto the top surface of the abutment in the form of pressure  was used to analyze model data and perform the stress analysis in the abutments subject to loading.In this study, we selected nine novel implant models to investigate the stress distribution in the abutment systems. Parameters of interest included channel depth, wall thickness, vent number, vent diameter, and vent location. For a direct and systematic comparison, the same load conditions, boundary conditions and constraints were applied in all three models. o taper, and Figure o taper. The color scale is representative of the fluid velocity in these locations, which gives an idea of areas of low fluid flow, which can result in air in the system (blue). The 5.21 mm × 75o taper demonstrated the most aerodynamic characteristics of the inserts examined and was selected to be utilized in the subsequent 3D‐printed evaluation experiment.Results from the CFD modeling are illustrated in Figure Figure Figure Further investigation of the key parameters  was conducted on each of the abutments outlined in Figure o offset.The investigation of the impact of increasing abutment wall thickness to match that amended for the plastic insert study  of the vents in the abutment geometry because of the normal loading of the implant Fig. .The aim of this study was to understand how abutment features designed to allow for venting within the crown‐abutment system would impact the mechanical stability of the abutment. This understanding could then be utilized in the redesign of the abutment to allow for venting and thus improve the flow of dental cements within the system. Once predictable cement flow is achieved, the precise volume of cement preloaded into the crown for the abutment‐crown seating procedure can be standardized. This standardization of cement volume in the abutment‐crown seating should reduce the risk of unwanted, excess dental luting cement leakage. The overall goal of this study was to utilize finite element analysis tools to preliminarily investigate new abutment designs as a means of yielding evidence for future in vitro bench top models and clinical investigations.This study was conducted in two primary phases: (1) design of novel abutment geometries to improve cement flow through the crown‐abutment system, and (2) test these abutment geometries to evaluate mechanical stability using finite element analysis tools. CAD tools have made the rapid redesign of implantable devices much more accessible and cost effective. FEA has been the most influential tool available in the simulation of dental restorations under various loading scenarios . The optimal way to allow for such venting was to utilize the interior portion of the abutment body. Thus, the cement channel was developed to allow cement to flow into and through the entire abutment body. The concern with allowing cement to flow through the abutment body in existing abutment geometries stemmed from the need to have the abutment system being retrievable. The clinician must be able to gain access to the screw retaining the abutment to the implant in order to remove the abutment if necessary. To allow for the continued retrievability of the abutment system, the screw insert Figs. , 4, 5, 63 of dental cement would fill the system before extrusion would occur. However, the crown, grossly filled, could typically hold over 100 mm3. The vented geometries designed in this study . Fluid dynamic modeling enabled the systematic evaluation of the different insert heights and taper angles Fig. . These CP > 0.05)  in the finite element analysis. Because the flow analysis confirmed that the thick cement wall resulted in less “dead space” in the abutment system and the FEA results demonstrated a reduction in maximum stress with these abutments, this novel vent design will now be further characterized using in‐depth flow analysis and laboratory benchtop mechanical modeling in future follow‐on studies  would have on the mechanical stability of the abutment. From a mechanical standpoint, the perforation of the abutment neck with vent channels could have led to a decrease the geometry's mechanical stability by increasing stress risers in an already at‐risk location of the abutment. However, from a design perspective, it was hypothesized that vent channels could be incorporated to improve cement flow and then the abutment design could be amended to compensate for such mechanical risks. Mastication is a highly dynamic mechanical process. According to Takaki et al. , the avees Figs. , and 11.Finite element analysis is certainly not without its limitations. One limitation to these computational models is they are based on the assumptions input by the user of the software. These studies require validation. Future studies will validate these results by investigating the novel abutment geometry in a mechanical bench top model to determine static, fatigue, and retentive stresses on the abutment in 3D‐printed laser sintered titanium. Additional studies will also investigate how dental cement rheological properties impact flow within the abutment system as well. The flow behavior of commercially available dental cements needs to be better investigated, as cements will exhibit particular rheological behavior depending on their chemical composition and abutment placement technique. This flow behavior discrepancy (pseudoplasticity) implies that the flow of a particular cement brand may be more susceptible to changes in pressure (shear‐thinning) during crown placement, which may increase its risk of extrusion and accumulation in peri‐implant tissues.In conclusion, venting dental abutments can be accomplished to allow for improved dental cement flow within the system. However, the abutment geometry must be carefully designed to ensure mechanical stability. This improved, completely laminar dental cement flow is reliable and reproducible. Knowing how cement will behave in a crown‐abutment system will allow for predictable cementation procedures, which will enable the standardization of cementation techniques for clinicians.None declared.


Alcohol misuse and harm are more prevalent amongst sports people than non‐sports people. Few studies have trialled interventions to address alcohol misuse for this group. The study aimed to test the effectiveness of an intervention to reduce alcohol misuse and related harms amongst amateur sports people in Ireland.A controlled trial was conducted in two counties in Ireland. A random selection of sports clubs in one county received a 4 month multi‐faceted intervention. All sports clubs in a non‐adjacent county acted as control sites. Consumption of more than 21 units of alcohol per week and six or more standard drinks on a single occasion at least once per week was the primary study outcome. Alcohol Use Disorders Identification Test scores and number of alcohol‐related harms were also reported. Outcomes were assessed for cross‐sectional samples of players at pre‐intervention and post‐intervention and paired samples of players who completed surveys at both times. Generalised linear mixed model analysis was used.P = 0.005].There was no evidence of effect for the primary outcomes or Alcohol Use Disorders Identification Test scores. There was a statistically significant difference in the median number of alcohol‐related harms reported by intervention group players compared with control group players at post‐intervention for the paired samples Intervention in community sports clubs may be effective in reducing the number of alcohol‐related harms. Low levels of intervention participation and inadequate intervention dose are possible reasons for lack of a broader intervention effect. [O'Farrell A, Kingsland M, Kenny S, Eldin N, Wiggers J, Wolfenden L, Allwright S. A multi‐faceted intervention to reduce alcohol misuse and harm amongst sports people in Ireland: A controlled trial.  Ireland has a history of excessive alcohol consumption, with average annual consumption peaking in 2001 at 14.4 l of pure alcohol per adult aged 15 years and over The link between alcohol misuse, risk of alcohol‐related harms and sport is well established, with people who participate in sport being more likely to engage in alcohol misuse than non‐sports people In Ireland, amateur Gaelic football and hurling players report high levels of alcohol consumption, heavy episodic drinking and alcohol‐related harms. For instance, 54% of players have reported regular heavy episodic drinkers (six or more drinks at least once a week) compared with 40% of males nationally Community‐level interventions have been shown to be effective in reducing alcohol‐related harm including drinking and driving, alcohol‐related traffic fatalities and assault injuries P = 0.05] and risk of alcohol‐related harm overall  Although the sport setting has potential for inclusion in such community‐level interventions, a Cochrane systematic review on interventions implemented through sporting organisations to improve alcohol misuse and harms found no controlled trials This study aimed to assess the effectiveness of a multi‐faceted intervention in reducing alcohol consumption and risk of alcohol‐related harms amongst Gaelic Athletic Association (GAA) club players.Ethical approval was obtained from the Research Ethics Committee of the Faculty of Public Health Medicine of Ireland and the Royal College of Physicians in Ireland.A cluster controlled trial was undertaken involving GAA clubs in two counties  in the Republic of Ireland. To avoid contamination, two counties with non‐contiguous boundaries from two different provinces in Ireland were selected. Of these, the county nearer to the study team was selected for intervention for pragmatic reasons. The GAA is the largest amateur sporting and community organisation in Ireland (>2000 clubs/800 000 members) with clubs competing in Gaelic football and/or hurling leagues and championships from January to September n = 29) in the control county and a random sample of 14 (20%) of the 70 GAA clubs in the intervention county were invited to participate. Random sampling of intervention clubs was undertaken as resource constraints meant that only 14 clubs could receive the intervention. However, to increase study power, all clubs within the control county were invited to participate. The random sequence for selecting intervention clubs was generated using a random number generator in Microsoft Excel. Consent for clubs to participate in the study was obtained from GAA County Boards.All GAA clubs  alcohol education for players; (ii) alcohol education for coaches; (iii) alcohol policy training for club managers and coaches; and (iv) an awareness campaign. The intervention was based on successful, multi‐faceted community‐based interventions for the reduction of alcohol‐related harm Players from both control and intervention group clubs received an education session on sports nutrition that did not include any alcohol‐related content.A self‐administered pen and paper questionnaire was used to collect baseline data (April 2006 to February 2008) and post‐intervention data (May and October 2008). The survey items were developed based on established and previously used measures of alcohol consumption Primary study outcomes were the proportions of players consuming more than 21 units of alcohol per week and six or more standard drinks on a single occasion at least once per week. A modified version of the Quantity–Frequency Scale Alcohol Use Disorders Identification Test (AUDIT) total and subscale scores Players were asked their age, highest level of education, sports that they played at the club  and age when they had their first full alcoholic drink. Club managers were asked the number of players at the club. Clubs were classified as rural  or urban based on geographic location.Project records were used to collect data on implementation of the intervention components and on the number of players, managers and coaches that attended intervention sessions. Club managers reported on the development and implementation of a club alcohol policy.Sample size was based on detecting a 10% reduction in the prevalence of the consumption of six or more drinks on a single occasion once a week for the repeat cross‐sectional samples. The baseline prevalence of this outcome was estimated to be 48% The primary analysis of all trial outcomes was undertaken using data from the repeat cross‐sectional samples of players at pre‐intervention and post‐intervention for those clubs that had both pre‐intervention and post‐intervention data (‘complete’ data). For all outcomes, secondary analysis was undertaken on paired data available for players who completed both pre‐intervention and post‐intervention surveys.For all outcome measures, generalised linear mixed models were developed utilising logistic regression analyses for categorical outcomes, linear regression for continuous outcomes and negative binomial regression for count outcomes. Time and group variables were included in each model, and adjustments made for clustering at the club level through a random club‐specific intercept term. Each model controlled for age, level of education and age of onset of alcohol consumption  as baseline data showed these variables to be associated with alcohol use outcomes. A significance threshold of 0.05 was used for analysis of primary outcomes and 0.01 for secondary outcomes. Such analysis was undertaken for the repeat cross‐sectional samples of players and paired participant data, with an additional random subject‐specific intercept to account for repeated measurements on the same subject for the paired data.For the cross‐sectional samples, additional sensitivity analysis was undertaken for all outcomes to assess the impact of missing data. Using multiple imputations, missing data were assigned using the chained equation method to generate a number of complete data sets All statistical analyses were conducted using SAS v9.4 .n = 628, 70.2% consent rate; intervention: n = 332, 77.2% consent rate). Two control clubs were lost to follow‐up for which data were imputed. Players from 25 control clubs (n = 441) and all 12 intervention clubs (n = 218) participated in post‐intervention data collection.Club and player participation in the trial is described in Figure One‐hundred and eighty‐two players from 23 control group clubs and 106 players from 12 intervention group clubs provided both pre‐intervention and post‐intervention data.Pre‐intervention, control and intervention clubs were similar in size, but differed on geographic region, with 84% of control clubs classified as rural compared with 58% of intervention clubs. Most players from both control and intervention group clubs were football players (95 and 89% respectively) with 43 and 30% respectively, playing both hurling and football. The mean age of players was 24.0 years (SD: 5.2), and the mean age at first alcoholic drink was 15.3 years (SD: 2.4). Both were similar across control and intervention groups. Refer to Table Summary statistics for each primary and secondary outcome for the repeat cross‐sectional sample analysis are shown in Table The proportion of players that reported a total AUDIT score above 8 was similar across both groups pre‐intervention  and post‐intervention . Based on the AUDIT subscales, at pre‐intervention, almost all players  were assessed as drinking at hazardous levels, three‐quarters at levels that placed them in harmful situations  and 60% at risk of alcohol dependence . For all AUDIT subscale measures, post‐intervention proportions remained similar to pre‐intervention proportions.P = 0.029]   Table .n = 115, 52.7%) from intervention group clubs that were surveyed post‐intervention reported that they attended the alcohol training session, and 14.2% (n = 31) reported being aware of the awareness campaign.Player and manager/coach participation in the various components of the intervention was low. Just over half of the players (n = 8) of the 12 intervention club managers attended the alcohol training session, and half (n = 6) attended the alcohol policy session. None of the clubs had a written alcohol policy prior to the intervention, and one‐third (n = 4) had one in place after the intervention. All 12 of the managers were aware of the intervention being conducted at their club. Thirteen coaches from a quarter of the clubs (n = 3) attended the alcohol education session for coaches.Two‐thirds  data, a statistically significant difference, post‐intervention, in the median number of alcohol‐related harms reported by players of intervention clubs compared with players of control group clubs [IRR 0.56 ; et al. with community football clubs in Australia. Compared with the findings of this trial, the intervention reported by Kingsland et al. was found to be effective in reducing risky alcohol consumption by community football club members at the club as well as risk of alcohol‐related harm overall et al. trial were a mixture of players (53%), fans/supporters (16%) and club management/coaches/other (30%). While the Kingsland et al. trial did not report effectiveness for these participant groups individually, there is the potential that alcohol management interventions implemented at the club bar may have been more effective for groups other than players The findings of this trial differ, in part, from those of the trial conducted by Kingsland et al. trial was supported by a suite of practice change support strategies that were not included in the current study, such as observational audit and feedback, accreditation, cost recovery and support from sporting associations Second, the implementation of the intervention in the Kingsland et al. was implemented over 2.5 years compared with the 4 month period in this study. The longer period of the Kingsland et al. intervention may have resulted in greater club member exposure to the intervention and hence greater impact on levels of alcohol consumption and related harms. Both time and dose have been found to be associated with intervention effectiveness and may account for some of the differential effect between the two studies Third, the intervention in the trial conducted by Kingsland Low levels of intervention participation and acceptability may have also contributed to the ineffectiveness of the intervention. Only 52.7% of the players in the intervention group attended the alcohol training session, and only 14.2% reported knowledge of the awareness campaign. Attendance at the coach training session was also low with only 13 coaches (from three clubs) attending the training session. As the coaches found the alcohol training session useful, higher uptake amongst the clubs may have had more impact on alcohol outcome measures. Furthermore, although a majority of the managers (83.3%) reported that they found the intervention useful, only 4 of the 12 clubs had implemented a written alcohol policy at the end of the intervention, an important environmental strategy to support the other education‐based intervention strategies. Future alcohol harm reduction trials in the sports setting should seek to increase the implementation of socio‐environmental strategies, which theory and evidence suggest are important in modifying alcohol use behaviour per se. This finding, together with unpublished evidence of GAA clubs independently implementing harm reduction measures and limiting alcohol industry sponsorship, suggests that re‐designed alcohol harm reduction program trials are warranted and feasible.Despite these factors, the positive intervention effect for the alcohol‐related harm outcome suggests the intervention was of sufficient intensity and duration to impact on this measure. Possible explanations for the differential findings by outcome measure may be the greater statistical power obtained from a repeated measures analytical approach for the paired count data or the greater appeal of the intervention content focussing on the avoidance of harms rather than on alcohol consumption While the controlled study design and the randomisation of intervention county clubs were strengths of the study, a number of limitations need to be noted. Counties were not randomly assigned to control and intervention groups, and this may have resulted in the outcomes being confounded by factors that were not controlled for in the analysis. The study only included male players, and as such, the findings cannot be generalised to female players, and the study was not powered to assess any differential intervention effects by level of player professionalism or rural/urban location. Differences in the length of pre‐intervention (May 2006 to April 2008) and post‐intervention (May to October 2008) data collection periods should also be noted. While it is unknown how these differences may have affected the trial outcomes, periods of similar length and seasonality might have elicited a different result. Finally, the study may have been underpowered to detect effects of the intervention given that the final participant numbers were substantially lower than the predicted required sample size.et al., a longer implementation period and strategies focused on modifying the drinking environment as well as providing training to players and clubs.Given the limited number of controlled trials of interventions to reduce alcohol misuse and alcohol‐related harm in the sports setting, and the different findings of the two that have been conducted, further high‐quality trials are required to determine if such interventions are feasible and effective. These trials should include greater focus on strategies to support implementation, such as those employed by Kingsland None to declare.Table S1: Intervention content and formatClick here for additional data file.Table S2: Comparison of club and player characteristics at baselineClick here for additional data file.Box S1: Measurement of primary outcomesClick here for additional data file.Box S2: Measurement of player experience of alcohol‐related harmsClick here for additional data file.


While developmental surveillance programs promote early identification of child developmental problems, evidence has indicated suboptimal uptake. This study aimed to identify predictors of developmental surveillance completion at 6 months postpartum.Parents' Evaluation of Developmental Status (PEDS) at 6 months postpartum were modelled separately using multivariable logistic regression.Questionnaires were administered to the parents of 510 infants who were born in south western Sydney, Australia over a 22‐month period. Attendance for developmental screening and completion of the Developmental surveillance attendance was predicted by higher levels of maternal education, annual income and being informed about checks. PEDS completion at 6 months of age was predicted by higher income and being informed, as well as being married, employed, speaking English at home, full‐term birth and the professional status of the practitioner completing the check.Barriers to developmental surveillance included low socioeconomic status, linguistic diversity and possible gaps in parental knowledge and professional education. Developmental surveillance rates may be increased by the addition of targeted parental and professional support within current universal frameworks. Between 1 and 4 years of age, attendance decreased to 33%, with similar rates observed internationally . As part of this interview, the 6‐month PEDS was completed with the parent if answers had not been recorded previously in the PHR.Sociodemographic and health service use information was obtained using a baseline questionnaire at birth and a follow‐up telephone interview at 7 to 12 months postpartum. Both questionnaires were developed in collaboration with local healthcare providers, and incorporated questions from other Australian birth cohort studies .All analyses were conducted in SPSS version 22. Group differences were examined using the chi‐square and non‐parametric Mann–Whitney p < .25 in a single predictor logistic regression model was included in a multivariable logistic regression model. The final model was determined using the backward selection method, and discriminatory power was measured by the coefficient of discrimination statistic , families with an annual income over $25 000  and parents who were informed about DS . The estimated coefficient of discrimination was D = .08  or unemployed , English spoken at home , annual income over $25 000 , being informed of DS , full‐term birth  and Child and Family Health Nurse completing DS . Within the Anderson Behavioural Model, these predictors represented three predisposing characteristics, one enabling resource and one need factor  was more promising than the 65% reported by the Centre for Epidemiology and Research ; howeveret al.et al.et al.et al.Predictors of increased DS attendance and PEDS completion included multiple factors previously identified as providing protection from child developmental problems  was conducted by GPs. PEDS completion may therefore be increased by improving parental awareness of the Child and Family Health Nurse's role, and increasing access to standardised training in DS administration by all primary health professionals. This is supported by the work of Woolfenden et al.  who founet al.et al.The increased PEDS completion in English‐speaking households adds to the body of research suggesting cultural and linguistic barriers to universal healthcare uptake . Retention at 6 months was 75%, and it is possible that DS was higher in this sample because of factors associated with continued research engagement. Strengths of this research included sample diversity and the inclusion of low SES families who were broadly representative of the population of south western Sydney.et al.Child developmental problems present a significant health and economic concern.Developmental surveillance programs aim to identify children at risk of developmental problems and lead to early and accurate diagnosis.Socioeconomic disadvantage, linguistic barriers and gaps in parental knowledge and professional education contribute to suboptimal uptake of developmental surveillance.A policy focus on the provision of targeted support within a universal framework may facilitate timely identification of children who could benefit from early intervention.Recent advances have highlighted the benefit of programs aimed at early identification of children at developmental risk (Oberklaid


Equus caballus) to experimentally test whether semen characteristics are adjusted to the oestrous cycle of the mare a stallion is exposed to during few moments before ejaculation. We analysed 122 weekly semen samples collected from 16 stallions during exposure to either an oestrous or a dioestrous mare. Semen volume and the rate of motile sperm were higher when stallions were exposed to an oestrous than to a diestrous mare, while total sperm counts and sperm velocity remained unchanged. Sperm collected after exposure to an oestrous mare also showed reduced oxidative degeneration of cell membranes over a period of 48 hours. We conclude that stallions invest more into their seminal fluids when the chance of fertilization is elevated, and that this adjustment of ejaculate quality can happen very quickly.The theory of ejaculate economics was mainly built around different sperm competition scenarios but also predicts that investments into ejaculates depend on female fecundity. Previous tests of this prediction focused on invertebrates and lower vertebrate, and on species with high female reproductive potential. It remains unclear whether the prediction also holds for polygynous mammals with low female reproductive potential . We used horses ( The theory of ejaculate economics235671Regardless of whether an ejaculate is adjusted to the number of rivals or the fecundity of a female, an important question in ejaculate economics is always whether each sperm has the same chance of fertilizing an eggSeminal fluids often make up a larger part of an ejaculate. They may contain specific proteins, hormones, antimicrobials, immunity suppressors, fats, sugars, salts, and different types of cells, including immunity cells121420Equus caballus) to test experimentally whether blood testosterone concentration, behavioural indicators of sexual arousal, and ejaculate characteristics vary with oestrous cycle of a stimulus mare that a stallion is exposed to shortly before and during ejaculation. We used a within-subject experimental design to control for possible variance among stallions. Semen quality was determined immediately after ejaculation and over a period of 48 hours thereafter.We chose the polygamous horse . All methods were performed in accordance with the relevant guidelines and regulations (Vaud canton and Swiss Confederation).Sixteen clinically healthy and sexually experienced stallions  and mares A and B  were used for the experiments . They were kept in individual boxes bedded with straw, with other horses of only the same sex in the same stable each, i.e. the sexes were separated in different stables and there was no contact between the sexes other than during experimental exposure. All horses were regularly exercised and had daily access to a paddock. The study was approved by the th week, each stallion had been exposed to each mare once in oestrus and 2 or 3 times in dioestrus. The stallions were always handled by the same person who was not informed about the study design and its objectives.The experiments lasted over a period of 7 weeks and took place every Tuesday in a building that was separated from the housing stables. One of the two mares was led to this building and tethered close to a dummy. Stallions were then individually led to this building where they were first exposed to this mare’s faeces for 15 seconds (presented on a plastic plate on the ground). The stallion was then held in front of the mare’s head at a distance of about 2 meters and for about 30 seconds, then led to a dummy that the stallion could mount and that was used to collect the semen in an artificial vagina (type “Avenches”). A second faeces sample of the stimulus mare was hung in a perforated bag above the dummy. The stallion was then returned to its box, the hind part of the dummy was wrapped with a new plastic film (routine sanitary procedure), and the procedure was repeated with the next stallion. After 8 stallions, the mare was replaced by the other one, and the experiments continued with the remaining 8 stallions and with new faeces samples from this other mare. In order to ensure a crossover study design, the order of presentation changed over the first 6 weeks so that by the end of the 7®, Intervet, Boxmeer, Netherlands) intravenously on the Monday evening before the experimental exposures on the following Tuesday in order to induce ovulation.The cycles of the two mares were regularly assessed by rectal ultrasonography of ovaries and uterus. The mares were in dioestrus on two or three consecutive Tuesdays and in oestrus the following Tuesday. Oestrus was defined as existence of a follicle >35 mm, uterus oedema at stage >223® SP-100TM system . Semen was then diluted with INRA 96TM  to a concentration of 30 × 106 spermatozoa/ml. Diluted semen was placed in a pre-warmed 20 μm standard count analysis chamber  and assessed for motility parameters in 10 fields using a computer-assisted sperm analyser  and standardized settings for stallion semenTM  and sent to the Clinic of Reproductive Medicine, University of Zurich/Switzerland, for analysis of sperm motility, viability and membrane lipid peroxidation after 24 and 48 hours of cold (4 °C) storage. Evaluation of the plasma membrane and acrosome integrity as well as of the lipid peroxidation of spermatozoa was performed using a Cell Lab Quanta SC MPL flow cytometer operated by the Cell Lab Quanta SC Software for instrument Control Data Acquisition . The system was equipped with a solid state LASER exciting at 488 nm and emission filters detecting green, orange and red fluorescence at 525, 590, 670 nm, respectively. Flow rate was set to 500 cells/s and for each sample 10000 events were analysed after incubation of stained sperm for 15 min at 38 °C. Membrane integrity and acrosomal status of spermatozoa were evaluated after double staining with propidium iodide (PI) and peanut agglutinin conjugated with fluorescein isothiocyanate (FITC-PNA)296 spermatozoa/ml were stained by adding 1.5 μl of 2,99-mM PI  and 5 μl FITC-PNA (100 μg/ml) . The percentage of membrane and acrosome intact spermatozoa was defined as viability. For determination of lipid peroxidation in spermatozoa a combined staining with the BODIPY581/591-C11 probe31581/591-C11  and 1.5 μl of 2,99-mM PI  were added to 5 μl of semen and mixed with 241 μl Tyrode’s medium to a final concentration of 0.6 × 106 spermatozoa/ml. Mean BODIPY581/591-C11 fluorescence intensity of live (PI negative) sperm cells was considered for further analysis.The behaviour of both the mare and the stallion was filmed (two cameras from different angles) to record time until erection, first mount on the dummy, and ejaculation confirmed by rhythmic tail flagging25® 11.2. Effects of stallion and mare identity (ID) on potential measures of sexual arousal and on characteristics of fresh semen were analysed in least square multiple regressions, with oestrous stage nested in mare ID. Repeated measures on consecutive testosterone measurements and on semen characteristics taken 24 h and 48 h after ejaculation were analysed in MANOVAs. Some semen and some blood samples could not be measured due to technical problems. It turned out, however, that no experimental cell of the factorial within-subject design was lost because all missed samples had been taken during exposure to dioestrous mares for which we always had several replicates per combination of stallion and mare. Therefore, using average values per stallion, time point of measurement, mare, and oestrous stage (n = 16 × 2 × 2 × 2 = 128) ensured a balanced data set for all analyses. We used directed testing (pdir) when there was a strong a priori expectancy about the direction of an effect and to avoid inflation of the alpha valueStatistical analyses were done in JMPThe stallions differed in mean time to erection, time to first mount the dummy, and time to ejaculation . All theThe stallions differed in average sperm number, concentration, volume, velocity, and motility as determined immediately after semen collection , in blooBlood plasma testosterone increased from before to immediately after ejaculation  and was The stallions differed significantly in all measurements we took, from indicators of sexual arousal and testosterone blood plasma concentration to all characteristics of fresh and aging ejaculates. It therefore turned out to be important to use a within-subject experimental design that controls for this variance. The origins of such strong male effects are unclear. It has been suggested that reproductive parameters may reveal variance in health and vigour, but this hypothesis is little supported in humansIn contrast to the significant stallion effects, the ID of the two mares seemed to play no role here . What mattered instead was whether a mare was in oestrus or not. Stallions showed behaviour that indicated higher sexual arousal when exposed to an oestrous mare and/or her faeces than when exposed to the same mares in dioestrus. The mares’ oestrous cycle also affected semen characteristics. When exposed to an oestrous mare, the stallions ejaculated more seminal fluids. Total sperm number and sperm velocity per ejaculate did not seem to increase, but sperm motility in fresh ejaculates was elevated, and sperm suffered less from oxidative stress over the following 48 hours. We conclude that the seminal fluids supported sperm motility and longevity better when the stallions were stimulated by a mare in oestrus than in dioestrus. It remains to be tested whether these effects are only due to the increased amounts of seminal fluids or also due to changes in their compositions.It remains unclear whether testosterone played a role in inducing the effects of the mares’ oestrous cycle on semen characteristics. While blood plasma testosterone levels showed a marked increase from before to immediately after the ejaculation, we found no significant effect of the mares’ oestrous cycle on testosterone levels, neither in our between-subject not in the within-subject analyses. This suggests either that testosterone plasma levels do not react strongly to the mares’ oestrous cycle during only a short-term exposure and that the semen quality was regulated differently , or that the temporal dynamics of testosterone release requires a higher time resolution in measurements, e.g. one measurement per minuteGallus gallus), roosters allocate larger ejaculates to more attractive hens, and seminal fluids allocated to more attractive hens support increased sperm velocity40et al.39et al.39In fowls  or in bachelor bands together with other stallions. Harem stallions interact continuously with their harem mares and show signs of sexual interest (including mounting attempts) for both oestrous and dioestrous mares, even if dioestrous mares will typically try to avoid copulationFemale pheromones have been found in other mammals to stimulate immediate reactionsIn horses, a typical oestrous cycle takes approximately 3 weeks during the reproductive seasonIn stud farms, cooled sperm that are subject to oxidative stress are routinely used, and the per-cycle conception is typically more variable and on average clearly lower than in many other life stockWe conclude that sperm differ in their probability of fertilizing an ovum not only because of the female’s state (oestrus or dioestrus) but also because of the male’s reaction to the female’s state . Our observations support predictions derived from ejaculate economics if the variation in female state that we studied here sufficiently represents variation in female fecundity as modelled by this theory1How to cite this article: Jeannerat, E. et al. Quality of seminal fluids varies with type of stimulus at ejaculation. Sci. Rep.7, 44339; doi: 10.1038/srep44339 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


SNNS) in patients with early gastric cancer. Further, development of an intraoperative imaging system and an indocyanine green fluorescence imaging approach has been attracting attention as a novel tool for detection of the sentinel node (SN). The greatest advantage of an in vivo imaging system is that it visualizes SN and afferent lymphatic vessels from the primary tumor site more clearly than the conventional dye approach. Besides visualization of the SN, it is also essential to accurately assess the presence or absence of lymph node metastasis in the intraoperative management of SNNS. However, the clinical significance of lymph node micrometastasis (LNM) in patients with gastric cancer remains controversial. Reverse transcription‐polymerase chain reaction (RT‐PCR) is one of the representative assays used to identify LNM. A rapid RT‐PCR assay that completes the detection of LNM within approximately 40 minutes has recently been produced and applied in the clinical management of SNNS. From the viewpoint of surgical methods, modified laparoscopic and endoscopic cooperative surgery with non‐exposed approaches has recently been highlighted as a promising technique to prevent tumor dissemination caused by surgical procedures, and is likely to be clinically applied to SNNS in the future. When carrying out SNNS as a minimally invasive surgery, it is important to consider the balance between post‐surgical quality of life and curability. Future prospective studies on SNNS will greatly contribute to furthering its establishment as a beneficial procedure for patients with early gastric cancer.Recent prospective multicenter trials have demonstrated the clinical safety and efficacy of sentinel node navigation surgery ( However, conventional surgical treatments are associated with the development of post‐gastrectomy syndrome in some patients. Therefore, it is important to consider the balance between post‐surgical quality of life (QOL) and curability when selecting surgical procedures for the clinical management of patients with early gastric cancer. A large number of surgeons have recently focused on function‐preserving gastrectomy as a promising procedure that considers QOL. For example, pylorus‐preserving gastrectomy, segmental gastrectomy, and local resection are representative examples of function‐preserving gastrectomy. According to the Japanese Gastric Cancer Treatment Guidelines 2014 (ver. 4), these procedures are defined based on the stomach volume to be resected.The sentinel node (SN) concept was initially proposed by Morton et al.2Many researchers have reported retrospective findings on SNNS for patients with gastric cancer.Table The Japan Clinical Oncology Group (JCOG) conducted a multicenter trial (JCOG0302) to assess the accuracy of SN biopsy in patients with cT1 gastric cancer measuring <4.0 cm at the maximum diameter.A Korean group conducted a prospective multicenter feasibility study as prerequisite quality control for the surgical standardization of laparoscopic sentinel node basin dissection (SBD) before starting a phase III trial .The clinical validity of the SN concept in patients with cT1 and cN0 gastric cancer has, thus, been adequately confirmed by clinical studies on SNNS, including retrospective analyses. As patients with early gastric cancer have a better prognosis after standard treatments, SNNS based on individualized lymphadenectomy should be safely carried out to prevent lymph node recurrence. Further standardization of clinical procedures will contribute greatly to the development of SNNS for patients with early gastric cancer.3The performance of intraoperative imaging systems for SN detection has been markedly improved by recent advances in medical instruments. The ICG fluorescence imaging approach has been attracting attention in this field. The greatest advantage of the ICG fluorescence imaging system is that it allows visualization of SN and afferent lymphatic vessels from primary tumor sites more clearly than a conventional dye approach based on visual recognition without special tools. To date, several investigators have demonstrated the clinical benefit of the ICG fluorescence imaging approach for SN detection in patients with several malignancies, including gastric cancer.From June 2012, we introduced a laparoscopic ICG fluorescence imaging system when carrying out SNNS. The PINPOINT Endoscopic Fluorescence Imaging System  is currently used for SN detection in our institution. This system allows visualization of high‐definition images under conventional white light and near‐infrared fluorescence using ICG.4Lymph node metastasis is one of the most significant prognostic indicators in patients with gastric cancer.Reverse transcription‐polymerase chain reaction (RT‐PCR) is a representative tool to identify LNM. RT‐PCR assays are used for the intraoperative diagnosis of LNM in SNNS because of their ability to provide a rapid analysis. Recent advances in technology have led to the development of several RT‐PCR systems to fulfill this key requirement. One‐step nucleic acid amplification and SmartCycler  both complete the detection of LNM within approximately 40 minutes.5Laparoscopic and endoscopic cooperative surgery (LECS) has been developed as a novel surgical technique for patients with gastric submucosal tumors, such as gastrointestinal stromal tumors.99mtechnetium‐tin colloid and ICG is basically adopted for the detection of SN. We then carry out SBD, including resection of SN identified by the laparoscopic ICG fluorescence imaging system. After confirming a pathologically negative status in SN by HE staining and RT‐PCR, CLEAN‐NET is subsequently conducted to remove primary tumors. For this, serosal markings are placed approximately 20 mm outside the lesion using a monopolar electrocautery knife under laparoscopy. In order to prevent a gap between the mucosa and muscularis propria during serosal traction, full‐thickness fixing of the gastric wall is done using 3‐0 absorbable sutures at four sites around the tumor. These stay sutures are also used for counter‐traction. The seromuscular layer is then dissected along the outside of the four stay sutures using a spatula‐shaped electrocautery knife under laparoscopy (Figure In recent years, we have carried out CLEAN‐NET with SBD for selected patients with cT1 and cN0 gastric cancer measuring <4.0 cm in diameter. According to our criteria regarding the indications for CLEAN‐NET with SBD, tumors located in the pylorus are judged as non‐indicative lesions as a result of postoperative stenosis of the gastric lumen as part of local resection. Moreover, a dual‐tracer method using In future, the indications for modified LECS with a non‐exposed approach, such as NEWS and CLEAN‐NET, will be progressively extended to patients with early gastric cancer meeting the indications for SNNS. If this method will be further stylized from the standpoint of surgical procedures, it may come to be regarded as a standard surgical tool in SNNS.6A prospective multicenter phase II trial of personalized surgery based on a diagnosis of metastasis to SN is ongoing in Japan. This clinical study will advance medical care and, hence, we await its findings expectantly. If SNNS is clinically developed as a safe surgical approach based on the findings obtained, the clinical application of SNNS will be extensively extended among patients with early gastric cancer. Furthermore, advances have been made in endoscopic treatments for patients with early malignancies, including gastric cancer.In conclusion, we need to assess the patients’ post‐surgical QOL in order to confirm the clinical benefits of function‐preserving gastrectomy for patients undergoing SNNS. If the benefits of SNNS on QOL are substantiated by prospective multicenter trials, minimally invasive surgery with individualized lymphadenectomy may become the recommended procedure for early gastric cancer in consideration of the balance between QOL and curability. Moreover, future studies on the surgical techniques used will greatly facilitate the establishment of SNNS for patients with early gastric cancer.Conflict of Interest: Authors declare no conflicts of interest for this article.


Significant health inequities exist around maternal and infant health for Māori, the indigenous people of Aotearoa New Zealand – and in particular around a premature (preterm) delivery. Māori babies are more likely to be born preterm  and they are more likely to have a preterm death. An essential part of redressing these disparities is to examine the clinical care pathway and outcomes associated with preterm deliveries. This paper describes a protocol utilising national and local health collections to enable such a study.This is a retrospective cohort study comprising 5 years data pertaining to preterm deliveries from 2010 to 2014. These data are generated from linked national administrative and local health information collections to explore a range of neonatal outcomes and infant mortality in relation to the antenatal care pathway and known risk factors for preterm delivery. This study is being conducted within a Kaupapa Māori paradigm that dismisses victim blaming and seeks to intervene at structural levels to improve the health and wellbeing of Māori whānau (family).Our data-linkage methodology optimises the utility of New Zealand health collections to address a significant health issue. Our findings will fill the information gaps around the burden of preterm delivery by quantifying the incidence of preterm delivery and adverse neonatal and infant outcomes in Aotearoa New Zealand. It will explore access to evidenced based care including use of steroids before birth, and appropriate place of delivery. The results from this study will inform maternity care services to improve management of preterm deliveries – both locally and internationally. This in turn will improve the preterm sequela by reducing the long-term health burden and health inequities. Premature deliveries (preterm) represent a global health burden  for whicThis paper describes the protocol for a retrospective cohort study that links local hospital, community laboratories and national health information datasets to explore the preterm delivery clinical care pathway, delivery and neonatal outcomes and infant mortality (≤ 1 yr. of age) of Māori and Pākehā  women and their babies. Building on an approach we have previously described, , 9 we ha40 including cerebral palsy, cognitive, visual and learning impairments [A premature delivery (preterm) can potentially result in adverse outcomes such as death, brain haemorrhage, infection, chronic lung disease and long-term growth impairment and harmairments –14. Māorairments , Craig [airments  and the This is a retrospective cohort study comprising 5 years data pertaining to preterm deliveries from 2010 to 2014. These data are generated from linked national administrative and local health information collections to explore a range of neonatal outcomes and infant mortality in relation to the antenatal care pathway and known risk factors for preterm delivery such as the lack of antenatal corticosteroids prior to delivery or delivery at the appropriate care centre , 17.This study is being conducted within a Kaupapa Māori paradigm that dismisses victim blaming and seeks to intervene at structural levels to improve the health and wellbeing of Māori whānau. It seeks to identify where resources may be best allocated to improve Māori health and wellbeing. Kaupapa Māori Research is about ensuring good health outcomes for Māori and frames our approach –20.To compare for Māori and Pākehā the proportion for infants born preterm having at least one of the following outcomes:Death, up to 1 year post birthBrain injury )Chronic lung disease of infancy (Bronchopulmonary BPD subtype)Oxygen and/or tube feeding on dischargeLength of stay (LOS) (until first discharge home) at hospital > 4 months2.To compare for Māori and Pākehā the national rate of infants born preterm with at least one of the following outcomes: death, small for gestational age and chronic lung disease of infancy.Women delivering preterm who receive full-course antenatal corticosteroid administrationThe percentage of infants born pretermPreterm infants not born at an appropriate level hospital .Preterm infants with retinopathy of prematurity and or deafnessWomen who have a preterm delivery who receive appropriate antenatal screeningTo compare for Māori and Pākehā women the proportion of:The study population includes pregnant women and their preterm babies born between 2010 and 2014 in Aotearoa New Zealand. For Primary Outcome 1, the study population includes pregnant women and their preterm infants born in 5 different district health board (DHBs) regions.0 and 366 completed week’s gestation between January 1st 2010 and 31st December 2014.All infants born to women between 24Women not domiciled in the respective DHBs at the time of delivery (Primary Outcome 1 only). Infants less than 24 and greater than 36 weeks gestation will be excluded.The data for our study is sourced from routine health information collections at both national and local levels Table . In Aoteborn at less than 32 weeks gestation, orweighed less than 1500 g at birth, orreceived assisted ventilation  including intermittent positive pressure ventilation (IPPV) or continuous positive airways pressure (CPAP) or high flow nasal cannulae for four or more consecutive hours, or died while receiving mechanical ventilation prior to 4 hours of age, orreceived major surgery (surgery that involved opening a body cavity), orreceived therapeutic hypothermiaIn addition, there is an Australia New Zealand Neonatal Network (ANZNN) collection which is a collaboration of every neonatal intensive care unit in the two countries, established in 1994 . The incClinical information that is not reported to the Ministry of Health  is held locally within independent information systems maintained within each DHB: for example the Perinatal Information Management System (PIMS), which collects information on perinatal events Table .In Aotearoa community laboratories offer a range of services; taken as indicator/proxy of receiving appropriate antenatal care  and relevant to this study include antenatal blood tests such as blood count and gestational diabetes screening.The variables retrieved from each collection (as described in the associated data dictionaries) were discussed in consultation with the research team and were informed by the Client Insights and Analytics group who were able to provide information pertaining to the quality of data (e.g. missing data). Risk factor variables  for preterm delivery were also discussed in-line with available data and where possible were collected  or constructed (e.g. inter-timing pregnancy and previous preterm delivery).For Primary Outcome 2, two datasets, pregnancy information and fetal-neonatal outcome information, are joined using the unique pregnancy identifier as outlined in Fig. Based on domicile status from the combined pregnancy-fetal-neonatal dataset we have identified relevant pregnancies for Primary Outcome 1  have been or will be extracted from any of the data sources.In Aotearoa New Zealand there are approximately 60,000 live births per annum which for 5 years data would equate to 300, 000 delivery events. Based on a national average of preterm deliveries of 7.5%  our estiSample size estimates are presented for Primary Outcome 1. To estimate the number of Māori and Pākehā babies born preterm per year between 2010 and 2014 we used annual maternity data on births for each of the 5 DHBs, and based the proportion of births that were preterm for Māori and Pākehā on a tertiary level DHB . Using these assumptions, there are approximately 654 Maori preterm births and 1236 Pākehā preterm births per year across the 5 DHBs. Working from a baseline assumption that the preterm infants of Pākehā women will have an 8% rate of poor outcomes   with 1 yFor Primary Outcome 1 multivariable Poisson regression models will compare the rates of poor outcomes between preterm infants of Māori and Pākehā mothers, after adjusting for potential personal and care-related confounders –27 e.g. This is a multi-disciplinary collaborative study that aims to bring about positive changes in antenatal care for women at risk of having preterm delivery, and consequently for their infants.Our data-linkage methodology optimises the utility of New Zealand health collections to address a significant health issue , 28, 29.The described study utilises both local and national level data collections and through a process of linking by unique identifiers is able to quantitatively explore and analyse the preterm care pathway and its outcomes. We are informed both by clinical expertise in the area of obstetrics and neonatalogy – both from the research team and local investigators. We are also informed by our kaumātua (Māori elders). The analysis for this study is still underway. It is expected that this in-depth investigation from a mother to infant perspective will provide a greater understanding of the clinical care pathway in preterm deliveries, which will inform local national health care policy and procedures around such maternities. As such maternity care providers will be able to identify high risk patients, intervene earlier and provide more appropriate management. This will in turn reduce the health burden of being “born too soon”  and also


HIV‐free survival at 12–24 months in breastfed children by maternal ART (6 months or lifelong) to inform WHO HIV and Infant Feeding guidelines.To provide estimates of HIV‐free survival by maternal ART regimen in a random effects model. We also grouped studies by feeding modality. Study quality was assessed using a modified Newcastle–Ottawa Scale (NOS) and GRADE.Eighteen studies published 2005–2015 were included in a systematic literature review ; papers were analysed by narrative synthesis and meta‐analysis of HIV‐free survival were 89.8%  for infants of mothers on ART for 6 months post‐natally (six studies) and 91.4%  for infants of mothers on lifelong ART (three studies). Eighteen‐month HIV‐free survival estimates were 89.0%  with 6 months ART (five studies) and 96.1%  with lifelong ART (three studies). Twenty‐four‐month HIV‐free survival for infants whose mothers were on ART to 6 months post‐natally (two studies) was 89.2% . Heterogeneity was considerable throughout. In four studies, HIV‐free survival in breastfed infants ranged from 87%  to 96%  and in formula‐fed infants from 67%  to 97.6% .The pooled estimates for 12‐month ART in reducing the risk of mother‐to‐child HIV transmission and support the WHO recommendation to initiate ART for life immediately after HIV diagnosis.Our results highlight the importance of breastfeeding for infant survival and of  The 2010 WHO infant feeding guidelines in the context of HIV infection recommended exclusive breastfeeding (EBF) for 6 months followed by complementary feeding and continued breastfeeding (CBF) for up to 1 year, under the cover of antiretroviral treatment (ART) to either the mother or the infant In late 2015, WHO revised HIV ART guidelines to include treatment for all immediately upon diagnosis of HIV infection Our systematic review considered both experimental and observational studies and included HIV‐positive mothers receiving ART and their breastfed children. Infants may also have received prophylactic ART as per WHO 2010 guidelines. Exposure was defined as HIV ART (and duration) and breastfeeding (and duration), and outcome measures were HIV‐free survival and overall and post‐partum HIV transmission between birth and 24 months of age.SB, LB and MLN searched English literature from multiple electronic databases including PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and CINAHL for articles published between 2005 and 2015. The search words in PubMed are shown in a footnote to Figure Reference lists from relevant studies, grey literature and online abstracts from the International IAS AIDS Conference in Melbourne 2014 and the 2013–2015 Conferences on Retroviruses and Opportunistic Infections were also searched. Reference lists of articles identified from the search of databases and conference abstracts were scrutinised, and in cases where relevant information was not available in the publication, authors were contacted for specific additional information regarding infant feeding modality.The quality of studies included in the analysis was assessed using a modified Newcastle–Ottawa Scale (NOS) The information obtained from the NOS was used to comment on the quality of the included studies in GRADE with respect to study limitations/risk of bias We undertook a narrative synthesis and obtained pooled estimates of HIV‐free survival with a heterogeneity score based on a random effects meta‐analysis in STATA 13 . We also summarised the information in graphs depicting HIV‐free survival rates by duration of maternal ART where possible and additionally presented HIV transmission rates for studies that provided transmission rates at 6 months and at the end of follow‐up. If no confidence interval for HIV‐free survival estimated was provided, it was calculated based on the number of events and those at risk using the formula described by Eayres The search process identified 1295 citations, of which 1139 were excluded on the basis of being a duplicate, review, qualitative study or not evaluating transmission, mortality or HIV‐free survival  of HIV and infant deaths et al. et al. et al. et al. et al. et al. et al. et al. et al. Table S4 presents findings of the assessment of the quality of the studies based on the modified Newcastle–Ottawa Scale. The study by Ngoma et al. Most studies did not provide details on type of feeding and assumed  that most mothers exclusively breastfed up to 5 or 6 months as recommended. Estimates of HIV‐free survival by type of feeding could only be obtained from four studies Eleven studies provided HIV‐free survival or rates of transmission and mortality from birth I2 = 83.1%).Estimates of 12‐month HIV‐free survival, with confidence intervals, for breastfed infants by duration of maternal ART were obtained from 10 studies .In three studies, 12‐month HIV‐free survival was estimated amongst infants whose mothers were on lifelong ART .Eight studies provided estimates for 18‐month HIV‐free survival Figure , by duraI2 = 78.5%).In studies where women were on lifelong ART .Twenty‐four‐month HV‐free survival estimates from three studies are shown in Figure et al. In the study by Giuliano et al. et al. et al. Three studies provided estimates of HIV‐free survival at 12, 18 and 24 months allowing a comparison of HIV‐free survival between 12 and 24 months et al. et al. In the Kesho Bora study et al. et al. et al. , there were eight infections overall, four before weaning at 6 months and four after weaning. In the study by Giuliano et al., two of the four mothers who transmitted HIV after weaning were still receiving ART. In the other five studies, there were fewer infections after 6 months of age than before Eight studies provided estimates of death and transmission overall and after 6 months of age, when the infant would have been weaned and mothers were no longer receiving ART. In Ngoma et al. et al. et al. et al. et al. [et al. [P = 0.007), and the same was shown comparing those who were weaned before 3 months of age and those aged 3 months or more at weaning . Cournil et al. The pattern of infant deaths before and after weaning varied across studies. Jamieson . et al. . and Mar [et al. . reporteAn evaluation of the overall quality of the combined studies for each outcome is provided in Table S5 using the GRADE approach This systematic review confirms substantially reduced rates of overall and post‐natal HIV transmission and mortality up to 24 months of age when pregnant and breastfeeding women receive ART. The difference in HIV‐free survival between infants of mothers receiving ART for PMTCT only or for life diverged beyond 6 months post‐delivery and became particularly evident at 18 months. At this time‐point, the estimated HIV‐free survival was about 89% when mothers ceased ART at 6 months, and 96% when mothers continued ART for life. The risk of transmission through breastfeeding continued beyond the recommended 6 months and after cessation of maternal ART Our results thus confirm the importance of breastfeeding for infant survival and the effectiveness of ART in reducing the risk of mother‐to‐child HIV transmission. In most studies 5 of 8), there were more infant deaths after weaning than before, but in only one of eight studies was the number of HIV transmissions after 6 months higher than before, which together would suggest that HIV‐free survival in the first year of life is substantially affected by increased mortality following early cessation of breastfeeding rather than by increased infections that may occur in infants of women who had stopped taking ART , there wOur review, although systematic in nature, had limitations. There was considerable statistical heterogeneity in all pooled estimates, and the overall assessment of quality of the evidence was very low. The low quality of evidence was mainly attributed to the fact that all studies included in the analysis were observational and the evidence was further downgraded due to indirectness, and lack of data on feeding history and adherence to ART. The absolute estimates of HIV‐free survival should thus be interpreted with caution and consider both the mean value and the confidence interval limits. Further, we were unable to formally allow for factors known to be associated with transmission and/or child survival, and heterogeneity between studies could be partially due to differences in other factors associated with child mortality. There was limited information on children born to women on lifelong ART where ART was initiated before advanced HIV progression, and most of the women on lifelong ART in the studies that reported such information would have been eligible as per the national and WHO guidelines at the time of the study Increased HIV‐free survival in the studied populations was linked to early initiation of maternal ART in pregnancy, continued post‐partum and breastfeeding. Increased infant/child mortality after 6 months of life may be attributed to early cessation of breastfeeding and could possibly contribute to reduced HIV‐free survival in non‐breastfed HIV‐exposed infants. Recent findings from a randomised trial, evaluating the use of two different infant antiviral drugs in the prevention of post‐natal HIV acquisition, showed HIV‐free survival similar to what we present here with maternal ART Table S1 Modified Newcastle – Ottawa Quality Assessment ScaleClick here for additional data file.Table S2 Excluded papers  with reason for exclusion, after full text screeningClick here for additional data file.Table S3 Included Studies: Descriptive information of studies providing information on breastfeeding and ARTClick here for additional data file.Table S4 Assessment of studies HIV‐free Survival in breastfed infants whose mothers were on ART based on the Modified Newcastle‐Ottawa ScaleClick here for additional data file.Table S5 Grade Evidence ProfilesClick here for additional data file.


The demand for therapeutic biologics has rapidly grown over recent decades, creating a dramatic shift in the pharmaceutical industry from small molecule drugs to biological macromolecular therapeutics. As a result of their large size and innate instability, the systemic, topical, and local delivery of biologic drugs remains a highly challenging task. Although there exist many types of delivery vehicles, peptides and peptide conjugates have received continuously increasing interest as molecular blocks to create a great diversity of supramolecular nanostructures and hydrogels for the effective delivery of biologics, due to their inherent biocompatibility, tunable biodegradability, and responsiveness to various biological stimuli. In this context, we discuss the design principles of supramolecular hydrogels using small molecule peptides and peptide conjugates as molecular building units, and review the recent effort in using these materials for protein delivery and gene delivery. In most cases, biologics refer to the biopharmaceuticals produced through recombinant DNA technology. The development and maturation of recombinant DNA technology during the past four decades has led to industrial production of biologics in a cost‐effective manner. In 1982, the first biopharmaceutical Humulin (human insulin) was approved by the U.S. Food and Drug Administration (FDA). Between 1982 and 2012, more than 300 new biological products have received FDA approval for clinical use.Therapeutic proteins, mainly consisting of mAbs, Fc fusion proteins, recombinant enzymes, and antibody fragments, are the most rapidly growing field in biopharmaceutical industry.Gene therapy is another promising biological therapy that has drawn considerate attention which focuses on diseases that include cystic fibrosis, hemophilia, cancer, AIDS, cardiovascular pathologies and others.The continued growth of the biopharmaceutical market necessitates the development of efficient delivery systems that can address the numerous challenges in delivering biologics. For both protein carriers and gene vectors, their introduced delivery systems play a vital role in their PK and drug release profiles, and thus should be at least non‐toxic and biocompatible.The delivery of therapeutics using hydrogels has been extensively explored over the past two decades, mainly focusing on synthetic polymer hydrogels. However, several limiting factors such as component and degradation product toxicity, pains caused by post‐gelation swelling, and short‐term release, remain to be overcome. Among the recently developed hydrogel platforms, self‐assembling peptide nanofibrous hydrogels are particularly fascinating because of their biocompatibility, biodegradability, and low toxicity.2When dissolved in solvents, amphiphiles such as surfactants, lipids, and amphiphilic block copolymers are able to self‐assemble into various nanostructures , with the solvophilic moieties facing towards the solvent and solvophobic moieties packed internally. The final morphology is determined by a balance of the hydrophobic attraction with hydrophilic or ionic repulsion, the system entropy, as well as some directional interactions such as hydrogen bonding or π–π stacking. Among nanostructures of diverse morphologies, one dimensional filaments show great tendency to form supramolecular networks through entanglement or inter filament interactions. Rapid responses to diverse external stimuli are easy to achieve because of the highly reversible property of non‐covalent interactions. Extensive research and reviews have discussed supramolecular hydrogels formed by urea derivatives,With their hierarchically organized structures and the diversity of amino acid function, peptide‐based materials are suitable as building blocks for forming bioresponsive hydrogels. Typical nanofibers formed by self‐assembling peptides have diameters between 5 nm and 15 nm and lengths on the micro‐meter scale, and are able to further entangle to form a 3D network. The inherent biocompatibility and biodegradability are the most fascinating properties for peptidic hydrogels, because the degradation products can be metabolized and reused by cells. Moreover, the well‐established solid‐phase peptide synthesis (SPPS) protocols further contribute to the efficient and easy synthesis of peptides by researchers who have not had rigorous chemistry trainings. The varying functionality of the constituent amino acid side chains within peptides provide a broad basis for non‐covalent interactions including hydrogen bonding (polar amino acids like glutamine), π–π stacking , hydrophobic collapse , and electrostatic interactions (acidic and basic amino acids like glutamic acid and lysine) 3‐CONH2 peptide hydrogels were shown to sustained release human antibodies for a period of over 3 months.A variety of native peptides are able to self‐assemble into filamentous networks.DPPTKVKVKVKV‐NH2) is composed of high β‐sheet propensity valine and charged lysine residues in an alternating manner.DPPT‐) was designed to adopt a type II′ turn structure that leads to β‐hairpin formation.nVDPPT(VK)n‐based peptide hydrogels can be engineered to be transparent, shear recoverable, injectable and pH or ionic strength responsive, all important properties for biomedical applications.DPPTKVEVKVKV‐NH2) was shown to self‐assemble and gelate at a much faster rate than MAX1 and form more rigid gels with smaller mesh sizes.Schneider, Pochan, and coworkers developed a series of β‐hairpin peptides that undergo fibril formation and triggered hydrogelation for various biomedical applications.4(Pro‐Hyp‐Gly)4(Asp‐Hyp‐Gly)4 to mimic the multi‐hierarchical self‐assembly of a collagen fiber from triple helix to nanofiber and hydrogel ‐b‐poly(l‐leucine) and poly(l‐lysine)‐b‐poly  containing charged and hydrophobic segments such as poly Figure f.53, 64,4N‐alkanoyl‐l‐alanine amphiphiles in an immiscible system.N‐C16H33‐chain‐appended L‐alanine amphiphile and a redox‐active viologen‐based partner.Amino acids or short peptides conjugated to alkyl chains or aromatic groups have been extensively investigated over the recent decades. Both alkyl chains and aromatic groups serve as the hydrophobic segment to promote the aggregation. Bhattacharya et al. reported the gelation of oil using The Xu Lab has made significant contributions to Fmoc protected amino acids such as Fmoc‐Lys and Fmoc‐phenylalanine.Xu and coworkers pioneered the design of β‐amino acid and D‐amino acid derivatives for creating supramolecular hydrogels.16‐V2A2E2‐NH2 PA hydrogels were used as a sonic hedgehog protein delivery system for the treatment of erectile dysfunction, suggesting the PA hydrogels have potentially broad applications as protein vehicles.16GSH was optimized to have greater utility for peripheral nerve repair compared with a commercially available collagen gel.Peptide amphiphiles (PAs) are peptide conjugates containing one or more linear alkyl chains that structurally resemble small molecule surfactants Figures i–l.54, 9The peptides or polypeptides conjugated to a polymer have been shown to be effective molecular gelators. Peptide–polymer conjugates combine the desired functionality of peptides and synthetic polymers.Although all of these above‐mentioned peptide‐based hydrogel systems have unique design principles and properties, what remains essentially the same is the spontaneous or triggered hydrogelation after self‐assembly driven by supramolecular interactions, which provides the foundation for delivery of biologics. Of particular note is that these peptide systems themselves can be used as bioactive agents by incorporating or directly using therapeutic or other functional peptide sequences into the hydrogel networks.5Challenges in the delivery of therapeutic proteins derive from their large size and complicated structures that lead to limited solubility, stability, and membrane permeability. Desirable properties for the ideal protein delivery vehicles include high protein loading and biocompatibility; the ability to shield the proteins from enzymatic degradation and rapid clearance; the function to provide sustained release in a desired and therapeutically effective way. Among many kinds of delivery systems, the self‐assembling peptide nanofibrous hydrogels are one of the most fascinating candidates for protein delivery applications. The high‐water content in peptide‐based supramolecular hydrogels provides the open space to store biologics. Either hydrophilic or hydrophobic molecules could be entrapped in the inter‐ or intrafiber areas, greatly increasing the solubility of biologics to be delivered. Generally, biologics can be directly encapsulated into the hydrogel during the self‐assembly and gelation process by simply mixing with hydrogelators under mild conditions. The peptide‐based supramolecular hydrogels are supposed to ideally mimic the extracellular matrix and expected to be more biocompatible than polymer hydrogels. This provides the foundation for protection and stabilization of biologics to avoid their inactivation before they reach the desired location. Based on their potential in presenting sustained release, self‐assembling peptide hydrogels are of high interest to be engineered to optimize the release profile of proteins in a desirable fashion. Although, the delivery of small molecule drugs using supramolecular hydrogels have been largely reported, peptidic hydrogel based delivery of macromolecules such as proteins and gene therapeutics is still in its infancy. Recent advances in protein delivery using self‐assembling peptide hydrogels and corresponding applications are summarized in Table C‐terminus of native bovine rhodopsin. A comparison of the association constant ak or dissociation constant dk, the binding affinity between the monoclonal IgG and rhodopsin (antigen) did not change significantly before and after being released through the peptide hydrogel for 48 h. This result suggested that the functionality of IgG is maintained during the release from the peptide hydrogel. In a subsequent study, Zhang and coworkers reported a 3‐month study on the release kinetics for human IgG through a two‐layered hydrogel structure with an Ac‐(RADA)4‐CONH2 core and Ac‐(KLDL)3‐CONH2 shell.The largest and fastest growing protein therapeutics in the United States are antibody‐related drugs for the treatment of many diseases such as cancer, chronic inflammatory disease, cardiovascular, and infectious diseases.6Growth factors are proteins that are able to stimulate cellular growth and differentiation and regulate a variety of cellular processes, making them useful in tissue engineering and regenerative medicine. For this reason, they are also one of the most commonly investigated protein classes delivered by self‐assembling peptide hydrogels, given the widespread use of hydrogels in this field.l‐lactic acid) (PLLA) matrices by adding a certain amount of aqueous HBPA, and a heparin/growth factor mixed solution, and were transplanted adjacent to islets. The experimental results showed that the HBPA scaffolds containing VEGF/FGF‐2 could significantly increase neovessel densities in the mouse omentum compared with control scaffolds without growth factors. Meanwhile, the cure percentage of the diabetic mice that treated with HBPA scaffolds containing VEGF/FGF‐2 (78%) was more than twice that of control animals treated with scaffolds alone (30%) or growth factors alone (20%). This indicated the effective delivery of growth factors through the HBPA scaffolds contributed to the enhanced engraftment. In a subsequent study, the infiltration of the same HBPA nanofibers into the dense islet interior was achieved by using a 100 times diluted HBPA solution, suggesting the amplified signaling of angiogenic factors leads to an increase in both islet survival and insulin secretion.The peptide amphiphile (PA) system developed in the Stupp lab serves as a natural and powerful platform for delivery of growth factors and related cells. The Zhang Lab designed the biotinylated RAD16‐II peptide to deliver the cardiomyocyte growth and differentiation factor IGF‐1 to the myocardium to improve cell therapy.The diffusion of mobile proteins in the hydrogel networks could be hindered both sterically and electrostatically. In the β‐hairpin peptide hydrogel system developed by Schneider and Pochan, a clear relationship between protein release kinetics and hydrogel mesh size as well as electrostatic interactions was demonstrated by studying the release profile of dextran and protein lactoferrin through MAX1 or MAX8 hydrogels.in vitro and in vivo tests using the polypeptide assembly system developed in the Deming Lab  are able to confer the readily tuned architecture of DCH that can optimize the effect of protein delivery. Results showed that DCH could be safely injected into the central nervous system without unwanted side effects and could deliver bioactive protein inside the blood brain barrier. The DCH scaffolds were proved to provide a temporary gradient of NGF over several millimeters and significantly longer delivery in comparison with injecting NGF solution alone, indicating the high promise of DCH to deliver therapeutic proteins in the CNS and other systems. The release of NGF from self‐assembled β‐hairpin hydrogels has also been reported by Langhans, Pochan, and Schneider.Nerve growth factor (NGF) is a neurotrophic factor that has been extensively explored in various applications including tissue engineering and gene therapy. Sofroniew, Deming, and coworkers have investigated the local delivery of lysozyme and nerve growth factor (NGF) for both b Figure .69 The w74‐CONH2 peptide hydrosol w/v) PM hydrosol formulations was found in hydrogel‐released insulin. Additionally, a PM concentration‐dependent increase of the release profile was unexpectedly observed and was later attributed to the increase in osmotic pressure and insulin concentration caused by the increase of PM concentration. The PM hydrosol containing insulin was also subcutaneously injected into rats and was speculated to transform into a gel in response to the increased ionic strength of phosphate or pH of the physiological environment. The difference in release profiles between PM‐delivered insulin and positive control Humulin R, as well as the PM concentration dependent release that resembled the phenomenon in an in vitro study, confirmed this speculation. The systemic circulation of insulin occurring after subcutaneous administration in rats and its pharmacokinetic profile were also investigated. This in vivo sol‐gel transition of PM hydrosol is favorable for systemic delivery of proteins from supramolecular peptide hydrogels, breaking through the restrictions of regular local delivery.Human insulin (Humulin®) is the first recombinant human protein therapeutic derived from recombinant DNA technology. Nishimura et al. investigated the in vitro release profile of insulin from hydrogels formed by the Ac‐(RADA)Yang and coworkers have reported that the differently charged peptides of NapGFFY(X)ssEE (X stands for Lys (K), Glu (E), or Ser (S)) could form supramolecular nanofibers upon glutathione (GSH) reduction.2 (gelation stimuli) within the corpora cavernosa; (b) preformed PA hydrogels placed on top of an exposed cavernous nerve. In both cases, the SHH released from PA displayed a translational impact on suppressing the abnormal increase of collagen.Recently, Podlasek and coworkers reported the use of self‐assembling peptide amphiphile nanofiber hydrogels for sonic hedgehog (SHH) protein delivery to prevent erectile dysfunction (ED) induced by cavernous nerve injury.In summary, many peptide‐based supramolecular hydrogel systems have been explored as the carrier of therapeutic or characteristic proteins including growth factors, antibodies and other protein drugs. There were also many systematic studies conducted to understand the influence of physicochemical properties for both proteins and nanofibers on release kinetics. Most reports have focused on the local delivery of proteins by placing preformed peptide hydrogels at the desired site. The benefits of the self‐assembling peptide hydrogels as protein carriers can be summarized as follows: (a) large amounts of proteins can be easily incorporated into the peptide hydrogel networks under mild conditions; (b) the hydrogel networks can provide prolonged release for the encapsulated proteins; (c) the hydrogels can effectively shield the protein therapeutics within their three dimensional networks, thus maintaining their bioactivity until release and minimizing their potential toxicity; (d) the release profile can be well tuned by consideration of the protein size, the hydrogel mesh size, and the charge properties of both proteins and hydrogels; (e) in some cases, the hydrogels were speculated to increase the membrane permeability or enhance the therapeutic effect of the encapsulated proteins; (f) the peptide hydrogels can be designed to be injectable and shear‐thinning recoverable, and thus enable injection without syringe‐clogging or changes in properties of hydrogels. With these attractive and easily achieved advantages, self‐assembling peptide nanofiber hydrogels show great promise for future protein delivery applications.8Successful gene therapy requires suitable vectors for local or systemic delivery of therapeutics to the desired sites. For example, the therapeutic efficiency of DNAs that encode for antigenic protein may be limited by rapid enzymatic degradation and fragmentation of DNA during the long circulation time and the poor cell permeability that results from the highly negatively charged phosphate backbone. Viral vehicles and non‐viral delivery systems such as gene gun, nanoparticles, and liposomes have been widely explored.Considering the high viscosity and low mobility of nanofiber networks, the local delivery of gene therapeutics through self‐assembling peptide hydrogels can largely facilitate the accumulation of genes in the tissue to which it is applied. Medina et al. studied the in vivo immunostimulatory potential of plasmid DNA encapsulated into β‐hairpin peptide hydrogels Figure .145 SimiC‐terminal methylamino modification of G‐NMe causes a structural transformation of the self‐assembled nanofibers from right‐handed structures to left‐handed, on which the DNA could be effectively condensed (Figure Tian et al. reported the delivery of a DNA vaccine using a peptide‐based nanofibrous hydrogel to optimize the efficacy of HIV vaccine.d Figure d. As staExtensive efforts have been focused on virus vectors such as murine leukemia virus for clinical gene therapy.9In this review, we discussed the design principles of peptide‐based supramolecular hydrogels in the context of protein delivery and gene therapy. The great diversity of amino acid sequences provides the possibility to fine‐tune supramolecular interactions to form hydrogels of various properties. These hydrogels possess a great potential as effective biologics carriers due to their inherent biocompatibility and tunable biodegradability. Compared to the extensive studies focused on the protein delivery, little was done on the use of self‐assembling peptide hydrogels for gene delivery. For future development of peptide‐based hydrogels for clinical translation, there are a few noteworthy points. First, the toxicity and biocompatibility of peptide‐based hydrogels should be evaluated in a comprehensive manner since the biocompatibility is the basic requirement for in vivo applications.Lastly, self‐assembling peptide hydrogels have been mostly used in local delivery due to their high viscosity and low mobility. Although local delivery is able to attain higher concentrations of the biologics at the desired sites without necessarily involving a targeting strategy, systemic delivery is sometimes the more preferred approach due to its ease of administration, low invasive property, and better patient compliance. For this purpose, more effort should be devoted to investigating the peptide‐based nanogel system for systemic delivery, as inspired by the recently developed polymeric nanogels. The nanogels are nanosized crosslinked networks mostly composed of synthetic polymers and are very promising as biologics carriers because of their high loading capacity, high stability, and responsiveness to environmental factors.


This Erratum to our article  aims at Indeed, the comparison of the GH and [GH + anastrazole] treatments was based on the randomization of patients’ files to be analyzed, not on randomization of treatments themselves, as could be felt when reading our publication. Thus no treatment was dictated by randomization.To perform our study, we randomly allocated a list of ordered numbers to treatment by GH or [GH + anastrazole]. For example, number 1 would be GH, number 2 [GH + anastrazole], number 3 [GH + anastrazole], number 4 GH, etc. This list kept by the PI was concealed to the physicians in charge of the patients. Children with very short stature who came in our clinic were simply given a number from 1 to 50 per order of arrival at the clinic. The choice of the clinicians in charge for using GH alone or [GH + anastrazole] was not influenced by these numbers. The use of anastrazole was inspired by publications showing a delay of epiphyseal maturation with this product.At time of analysis, we used the numbers to retrieve only the patients’ files where randomly allocated treatment matched the treatment that had been actually decided by their doctor. In many cases, files did not match and were thus not used for the comparison, whereas the matching files allowed us to perform the randomized comparison. This original method allowed the study to combine the advantages of randomization while remaining entirely observational, and is best suited for comparing two treatments of current practice.