Urinary dysfunction is one of many complications after treatment for rectal cancer. The aim of this study was to evaluate the prevalence of patient‐reported urinary dysfunction at the time of diagnosis and at 1‐year follow‐up and to assess the risk factors linked to urinary incontinence.RECT study between 2012 and 2015. Questionnaires from the time of diagnosis and 1‐year follow‐up were analysed, with 1085 and 916 patients, respectively, eligible for analysis. Regression analyses were made to investigate possible risk factors for incontinence. The patient cohort was also compared with a cohort from the Swedish general population.Patients with newly diagnosed rectal cancer were included in the QoLiAt baseline, the prevalence of urinary dysfunction  was similar to that in the general population. At 1‐year follow‐up, 20% of patients experienced urinary incontinence . Emptying difficulties were experienced by 46%  and urgency by 58% across both sexes. Abdominoperineal excision and urinary dysfunction at baseline were found to be independent risk factors for incontinence at 1‐year follow‐up. Among patients who were continent at baseline, risk factors were female sex, physical inactivity at baseline, comorbidity and abdominoperineal excision.Urinary dysfunction is frequent among patients with rectal cancer, with up to a two‐fold increase in symptoms 1 year after diagnosis. Unfortunately, few factors are modifiable and these results stress the importance of informing patients of possible outcomes related to urinary dysfunction after treatment for rectal cancer. It is important to improve our knowledge about possible side effects affecting patients after treatment for rectal cancer. This article shows that urinary dysfunction is common in a large unselected population of patients with rectal cancer, with risk factors for incontinence related to both the patient and the cancer treatment.Rectal cancer is one of the most common cancers in the world. Survival has improved over the last decades Previous studies have shown a prevalence of urinary dysfunction of between 6% and 77% after rectal cancer surgery The underlying mechanism in the development of urinary dysfunction in patients treated for rectal cancer is not completely clear. There are conflicting views on, for example, the impact of preoperative radiotherapy The aim of this study was to investigate the prevalence of urinary dysfunction in patients with rectal cancer prior to treatment and at 1‐year follow‐up. A secondary objective was to identify possible preoperative risk factors for the development of urinary incontinence at 1‐year follow‐up.Quality of Life in Rectal Cancer (QoLiRECT) is a prospective, observational multicentre study of patients with rectal cancer. The study included patients from 16 Swedish and Danish hospitals. All patients above the age of 18 years with a confirmed adenocarcinoma of the rectum, i.e. up to 15 cm from the anal verge, who understood either Swedish or Danish were eligible for inclusion. Patients were asked to participate in the study at the time of diagnosis but before initiation of treatment. Those who gave informed consent were asked to complete a detailed questionnaire. Between February 2012 and September 2015, 1248 patients were included in the study. A total of 1085 patients returned the questionnaire at baseline. Patients were subsequently contacted by the study secretariat and asked to fill out similar questionnaires at 1, 2 and 5 years after the diagnosis. All patients included in the study were contacted at all follow‐up points, regardless of whether they had filled out the baseline questionnaire or not. A total of 920 patients answered the 1‐year questionnaire, including 33 patients who had not answered the baseline questionnaire. This analysis is based on data from the questionnaire at baseline and at 1‐year follow‐up. Cystectomy at index rectal cancer surgery was an exclusion criterion for 1‐year follow‐up analyses, rendering 916 patients eligible for analysis.The questionnaires included items covering socioeconomic background, lifestyle factors, overall quality of life as well as urinary, bowel, sexual and stoma function. The questionnaires were developed using validated and previously described methods In this article, the questions regarding urinary function were analysed. The baseline and follow‐up questionnaires included 12 questions on urinary function During analysis, the 12 questions were divided into four categories: incontinence, bladder emptying difficulties, urgency and distress. Incontinence was defined as ‘incontinence during daytime and/or night once per week or more’. Both bladder emptying difficulties and urgency were divided into ‘never’, ‘up to 50% of the time’ and ‘more than 50% of the time’. The symptom‐associated distress was derived from the question ‘If your urinary function would remain as it is now for the rest of your life, how would you feel about that?’ with a cut‐off between ‘It would not bother me at all’ and ‘It would somewhat bother me’.Questions on smoking, alcohol use and physical activity were also analysed. Patients were regarded as smokers if they answered ‘Yes, I smoke’ regardless of the amount per week. Former and never smokers were merged into one group. Alcohol use was dichotomized between drinking less than or more than 16 standard glasses per week, as has been described in a previous study A reference sample of 3000 people born between 1924 and 1983 was derived from the Swedish tax agency. They were contacted between June 2014 and November 2015 and asked to fill out a questionnaire about their health‐related quality of life. A total of 1078 people  completed and returned the questionnaire. Eight questions related to urinary function corresponded to the questions in the QoLiRECT questionnaires. This allowed for comparison between the QoLiRECT population at baseline and 1‐year follow‐up and the Swedish reference population.Data on sex, age, American Society of Anesthesiologists (ASA) classification, tumour stage according to the Union for International Cancer Control (UICC) classification, chemo‐ and/or radiotherapy, body mass index (BMI), type of surgery , open or laparoscopic technique and perioperative blood loss were derived from the Swedish ColoRectal Cancer Registry (SCRCR) and from the Danish Colorectal Cancer Group (DCCG) registry. Because of the lack of some of surgical and oncological data in the DCCG registry, a clinical record form was developed at the study secretariat and filled out retrospectively by personnel at the participating Danish hospitals. Data regarding pre‐ and postoperative chemotherapy, preoperative radiotherapy and type of surgery in the Danish patient population were derived from this clinical record form. Because of frequent missing data in the SCRCR regarding postoperative chemotherapy, this information was retrieved from the 1‐year follow‐up questionnaire when it was missing in the registry.Prior to analysis, a plan for statistical analysis was developed and finalized. The prevalence of bladder emptying difficulties (more than 50%), day and/or night‐time urinary incontinence (at least once every week) and urinary urgency (more than 50%) were compared with the reference population separately for men and women in an age‐adjusted analysis using the modified Poisson regression approach of Zou In the analysis of potential risk factors for urinary incontinence during day and/or night‐time at 1 year the following variables were considered: incontinence at baseline, gender, age, smoking status, alcohol consumption, physical activity, comorbidity (baseline variables) and ASA classification, type of surgery , technique (laparoscopy versus open), bleeding during surgery, tumour stage (UICC), preoperative chemoradiotherapy, radiation therapy and postoperative chemotherapy (intra‐operative and 1‐year follow‐up variables).It was hypothesized that preoperative incontinence was a descendant of the baseline variables on causal paths and exploratory analysis confirmed that age, gender, smoking status and comorbidity were associated with preoperative incontinence. This was also confirmed in an analysis of the reference population. It was further found that incontinence at baseline and at 1 year was highly correlated. Consequently, in the analysis of incontinence at 1 year, evaluation was restricted to intra‐operative and 1‐year follow‐up variables, and baseline information was assessed solely through preoperative incontinence. In a subgroup of preoperatively continent patients, both baseline, intra‐operative and 1‐year follow‐up variables were included in the risk factor assessment.sas. spss version 25 , sas version 9.4  and r version 3.4.3  were used for calculations and graphics.The variables were evaluated using simple and bivariate logistic regression analysis (urinary continence before treatment being included as a fixed effect). A subset of variables was selected using the purposeful selection strategy for logistic regression with the SAS macro The QoLiRECT study has obtained ethical approval from the Central Ethical Review Board in Sweden (Dnr 595‐11), the Danish Data Protection Agency  and the Regional Ethical Review Board in Denmark (H‐3‐2012‐FSP26).Altogether 1085 and 920 patients were available for analysis at baseline and at 1‐year follow‐up, respectively  and 1‐year follow‐up (29% vs 14%) (Table Urinary incontinence was more common among women than men at both baseline (14% %) Table . Both meBladder emptying difficulties were prevalent to a higher extent in men if all problems were included (43% at baseline and 49% at 1 year) but a more pronounced increase was seen in women at 1 year (28% at baseline and 41% at 1 year) , urgency  and evacuation problems ]. The differences regarding surgical technique were more pronounced in women with regard to urinary incontinence and urgency, but evacuation problems were a little more pronounced in men who underwent abdominoperineal excision. Risk factors for incontinence in the subgroup of preoperatively continent patients at 1‐year follow‐up are shown in Fig. Risk factors for urinary incontinence are shown in Fig. The present study showed that urinary dysfunction is a frequent problem from which many patients suffer a long time after they have received their rectal cancer diagnosis and treatment.Of the various components of urinary dysfunction, urinary incontinence appears to be the most important problem. The study indicates that incontinence shows a two‐fold increase in the patient population following treatment, with approximately one‐third of patients experiencing incontinence at least once weekly. As expected, women had more problems than men (29% compared with 14%), although the increase in incontinence was similar between sexes. There are no data in our study that can explain these differences with regard to tumour stage or surgical technique as this was fairly similar between sexes.Risk factors for urinary incontinence were incontinence at baseline and abdominoperineal excision. Among patients who were continent at baseline, risk factors were female sex, physical inactivity at baseline, higher ASA classification and abdominoperineal excision. Apart from physical inactivity, these risk factors have been reported previously We identified the modifiable risk factor of physical inactivity in our study. This warrants further research on how to increase physical activity before treatment in order to improve recovery and possibly urinary function. The question arises as to whether physical therapy before and after treatment could reduce the number of patients with urinary incontinence.A previous study in 785 patients reported that 38% of patients experienced incontinence and 31% had bladder emptying difficulties 5 years after surgery In a study on 516 women who underwent abdominoperineal excision or low anterior excision in Denmark between 2001 and 2007, it was reported that 63% and 77% of patients reported incontinence and urgency, respectively In the AbdominoPerineal Extralevator Resection study (APER), a Swedish cross‐sectional study in patients who underwent abdominoperineal excision between 2007 and 2009, 46.5% of patients were regarded as incontinent The fact that there is a near two‐fold increase in distress in terms of urinary dysfunction over time clearly indicates that such problems are important to patients and stresses the need to try to prevent and alleviate posttreatment urinary dysfunction. This is of even greater importance when taking into account the fact that one of the risk factors is modifiable.The main strength of this study is its prospective, unselected, multicentre design and that all treatment possibilities are represented, both palliative and curative. As has been previously reported There are some limitations to this study. One is the observational design, which makes it difficult to draw conclusions about causation for the main results. Another limitation is the fact that only patients who had a good understanding of either Swedish or Danish could participate. However, as previously reported, results have shown the present cohort to be representative, indicating that this is only a minor limitation As the results indicate that a substantial number of all rectal cancer patients will suffer long‐term urinary dysfunction, we stress the importance of informing patients of this prior to treatment. In a previous study in the QoLiRECT population In conclusion, many patients treated for rectal cancer develop urinary dysfunction, with substantial distress after treatment. Incontinence appears to be the most relevant problem, with a two‐fold increase compared with baseline levels. It is important to inform patients of possible treatment‐related functional impairments, to identify patients who are at particular risk and to ensure a proper posttreatment follow‐up. Further evaluation of modifiable lifestyle factors is warranted to possibly prevent morbidity after treatment for rectal cancer.None of the authors have any conflicts of interest.


This raises the possibility that dietary emulsifiers might be factors in conditions such as coronary artery disease, type 2 diabetes and Crohn's disease. The potential mechanism behind the observed effects of this emulsifier is uncertain but may be mediated via changes in the gut microbiota or by increased bacterial translocation, or both. It is also unknown whether these effects are generalisable across all emulsifiers and detergents, including perhaps the natural emulsifier lecithin or even conjugated bile acids, particularly if the latter escape reabsorption and pass through to the distal ileum or colon. A major objective of the Medical Research Council (MRC)‐funded Mechanistic Nutrition in Health (MECNUT) Emulsifier project is therefore to investigate the underlying mechanisms and effects of a range of synthetic and natural emulsifiers and detergents in vitro and in vivo, and to determine the effects of a commonly consumed emulsifier (soya lecithin) on gut and metabolic health through a controlled dietary intervention study in healthy human volunteers – the FADiets study. This report provides an overview of the relevant literature, discussing the impact of emulsifiers and other additives on intestinal and metabolic health, and gives an overview of the studies being undertaken as part of the MECNUT Emulsifier project.Emulsifiers are common components of processed foods consumed as part of a Western diet. Emerging  A wide range of surfactants is available, both those that are man‐made  and natural (e.g. lecithin), many of which can also be modified chemically to alter their properties  and a lipophile (fat‐loving) component]. Lipophilic components tend to be similar, but hydrophilic components vary and form the basis for the classification of surfactants as non‐ionic, anionic, cationic and amphoteric. Within the food industry, synthetic non‐ionic polysorbates were introduced in the 1930s, initially incorporated into margarines and then used extensively in the baking industry as preservatives to prevent staling, and enhance firmness and volume of bakery goods  and metabolic syndrome  and not via the paracellular route (i.e. through increased ‘leakiness’ of intercellular tight junctions).Remarkably, there has been little study of the potential harmful effects of ingested detergents or emulsifiers in humans. Whilst investigating the impact of dietary components on bacterial–epithelial interactions relevant to IBD and CRC, we explored the hypothesis that increases in intestinal epithelial barrier permeability to bacteria might result from ingestion of emulsifiers or detergents  mice  has shown no obvious ill effects, though a lowering of plasma triglyceride levels has been reported , formed by microbial dehydroxylation , are known to enhance permeability and uptake of bacteria across the human colonic mucosa   Emulsifier project, incorporating the human Food Additives – do processed Diets impact on gut and metabolic health (FADiets) study, is funded by the Medical Research Council (MRC) (from November 2018 to October 2020) to answer two main questions:What impact do different emulsifiers have on the mucosal barrier, particularly in respect to bacterial translocation and inflammation?Does ingestion of the dietary emulsifier lecithin in controlled diets induce bacterial translocation and affect selected biomarkers of gut and metabolic health in healthy volunteers?The An overview of the proposed approach is presented in Figure MECNUT Emulsifier study will implement a three‐step model approach, examining the effect of treatment or ingestion of a wide range of permitted food emulsifiers, bile salts and household dishwashing detergents  ‘mini‐gut’ organoid cultures;ex vivo human distal ileum tissue explants mounted in Ussing chambers; andin vivo mouse studies.The et al. et al. et al. i.e. entry through cells within the monolayer) will be monitored over 4 hours. Emulsifiers will be added apically to cell monolayers for 30 minutes prior to addition of E. coli or Salmonella, along with low molecular weight (3 kDa) dextran to monitor paracellular permeability (i.e. ‘leakiness’ of cell–cell tight junctions). Transepithelial electrical resistance will also be monitored to provide additional information about the integrity of the tight junctions formed between the polarised cells of the monolayers throughout all treatment stages. Emulsifiers and detergents will be used at concentration ranges found within a typical Western diet, as well as below and up to those that would start to disrupt cell–cell tight junctions . For bile salts, levels to be tested are as defined by Münch et al. , with polysorbate 60 showing less marked ability to effect translocation  and their ethoxylated derivatives (polysorbates 20 to 85)] may enable us to correlate the effect of the head group and hydrophobic tail of the surfactants with their functional behaviour Tadros . We haveet al.  ). Emulsifiers will be microinjected along with enhanced green fluorescent protein (EGFP)‐expressing E. coli and a paracellular permeability dye to monitor organoid epithelium integrity. These ‘mini‐gut’ models will serve to bridge the in vitro and in vivo work. Experiments will be carried out using emulsifiers both in solution (where possible) and as emulsions, in combination with low and high‐fat levels, to resemble more closely food structures as influenced by process and ingredient interactions, and interactions taking place within the intestinal lumen.Key emulsifiers/detergents identified as enhancing epithelial transcytosis of bacteria in the human cell‐line studies will be further studied using ‘mini‐gut’ organoid cultures. Generated from intestinal crypt tissue stem cells, organoids  mimic the complex 3D architecture of the epithelium, with all differentiated cell types being present  and mounted in Ussing chambers as previously described . The primary endpoint will be detection of venous blood bacterial DNA as a marker of microbiota translocation from the intestinal lumen to the circulation and also to the systemic organs such as the liver, spleen and kidneys. Evidence of altered intestinal barrier function  of five emulsifiers  and altered glucose metabolism .The https://clinicaltrials.gov/ Identifier: NCT03842514), in overweight or obese  adults (BMI ranging from 27 to 40 kg/m2), comparing a ‘low‐calorie, low‐emulsifier’ diet, with a ‘low‐calorie, high‐emulsifier’ diet  diet], so that both periods prior to intervention are the same . A high‐profile human dietary intervention study  period [et al. The lecithin supplement to be used is a commercial source of soya lecithin granules [Lamberts® – a food‐grade product, manufactured to the stringent pharmaceutical standards of Good Manufacturing Practice (GMP); composition summarised in Table et al. All study participants will keep a daily weighed food intake diary during the 7‐day baseline and 7‐day washout periods, and complete a gastrointestinal discomfort questionnaire  cause alterations to the gut microbiota and (2) disrupt the intestinal mucosal barrier. Together, these (3) contribute to increased permeability of the intestinal layer and (4) promote the increased translocation of bacteria from the gut to the bloodstream. This results in 5) a state of low‐grade inflammation, (6) glucose intolerance and (7) increased risk of IBD  examining food additives, food processing and changing consumption patterns across populations, may then be better placed to support informed choice for healthier diet planning, not only to better develop during infancy and enjoy a healthy old age, but also including support towards dietary strategies for combating IBD, cardiovascular risk and metabolic disorders, such as metabolic syndrome, type 2 diabetes and obesity.The expectation is that the results of these proposed studies will lead to greater public awareness and reduction where need is identified, in the use of certain emulsifiers in the food chain that have potential to cause harm. The academic nutrition and public health communities, with the scientific advice of key independent food safety authorities , at leading companies supplying the food, nutrition and pharmaceutical (drug formulation and delivery) emulsifier market, and to key providers of further education in agri‐food science, food industry development, technologies and practice. As an example, the Food Additives and Ingredients Association works with both the food industry and consumers, to promote a better understanding of the role of food additives and functional food ingredients in a healthy and safe diet.The data obtained would be of interest to those working in basic scientific fields of nutrition and intestinal biology, and those working in the fields of gut ‘omics’ and gut health. Outcomes would also be of significant interest to formulation scientists working in and around the food industry .in vitro and animal evidence suggests that food additives such as emulsifiers may contribute to gut and metabolic disease development through alterations to the gut microbiota, intestinal mucus layer, increased bacterial translocation and associated inflammatory response. The MECNUT Emulsifier project aims to further explore the mechanistic basis for these relationships across a wide range of permitted dietary emulsifiers and detergents in vitro. As part of this work package, the FADiets study aims to determine the impact of soy lecithin on gut and metabolic health in vivo using a controlled dietary intervention. This growing area of nutritional science may lead to innovative knowledge, which could pave new ways of addressing gut and metabolic health via implementing dietary guidelines directed at food additives.Emerging No conflicts of interest have been declared by any author.This study is funded by the Medical Research Council (MR/P023606/1).FADiets study  will be conducted in compliance with the ‘principles of Good Clinical Practice’ for non‐CTIMP/MHRA studies. In addition to Sponsorship approval, ethical approval has been obtained from the Rowett Institute Ethics Committee . Ex vivo studies using freshly resected macro/microscopically human ileum tissue removed during routine surgery (e.g. for colon cancer) will be obtained following informed written consent and with approval of the Regional Human Ethics Committee; Linköping, Sweden.The human volunteer All authors contributed to the writing and preparation of the manuscript.


Incidence/prevalence of both conditions was found to correlate with extreme cold geographical regions ; this is not the case for other mental disorders. Our results show a possible genetic link between suicide attempt and cancer and a possible evolutionary connection of both diseases with extreme cold environments. These data are useful for future molecular studies or even for investigation of possible therapeutic protocols.Inuit is the population with the highest incidence of suicide attempt and cancer in the world. Previous studies reported that people attempted suicide have a higher future risk for cancer. In view of these data, the largest available genome wide association studies (GWAS) for four major mental disorder groups were screened here for any common genes with all known cancer associated genes and oncogenes/tumor suppressor genes. A common genetic background came out only between suicide attempt and cancer (cancer associated genes analysis: RR = 1.64, p = 7.83 × 10 In young people, suicide is the second cause of death and suicide rates seem to be on the rise. Similarly, cancer is the second leading cause of death globally with rates also increasing. Both diseases have a strong genetic background, more obvious in cancer but also in suicide4 and mostly attributed to the stressful character of a cancer diagnosis3.The relationship of cancer and suicide has been mainly focused on the effects of a newly cancer diagnosis leading to a subsequent increase in suicide risk. The relative risk for suicide after a cancer diagnosis is higher during the first year, in the presence of advanced cancer stageet al. reported that people who attempted suicide had a higher future risk for cancer as well as higher cancer mortality5. This finding was replicated in a recent Swedish nationwide registry study6. This study was also the first to hypothesize a common molecular pathway between cancer and suicide through a dysregulation of the oxytocin system. Although the main hypothesis was rejected, this study replicated the finding of increased risk for future cancer in suicide attempters. Even though the increased cancer risk was mainly attributed to factors such as alcohol and tobacco use, the authors suggest that common biological pathways such as inflammation may also have an impact6. On the other hand, common confounders between cancer and suicide attempt, associated with lifestyle and personality, cannot be excluded as a possible cause of comorbidity.However, the relationship between cancer and suicide seems to be bidirectional. Lawrence 7 while there is positive relationship between suicide rates and geographic latitude8. Inuit people who have the highest cancer rates, and live in extreme low temperatures, also exhibit the highest suicide rates in the world, among indigenous or not indigenous populations10. Additionally, Alaska indigenous populations have the highest suicide rates in USA12. On the other hand, it is important to say that high suicide rate is observed in many other indigenous populations10. This shows that environmental factors and not only genetics contribute to the high suicide rates in those populations. Moreover, a recent study of human ancestry in Europe, proposed a genetic component related to adaptation to cold in order to explain the observed variation in suicide rates in different countries13.Interestingly both suicide and cancer rates seem to follow a specific distribution in the world. Cancer has high incidence in areas of the world with extreme low temperatures possibly as an effect of evolutionary adaptationTo our knowledge there are no studies hitherto investigating possible common genetic pathways between suicide and cancer. Thus, the aim of this study was to investigate common genetic pathways between suicide and cancer as well as the relationship of suicide and extreme low temperature worldwide.7 found evidence that high cancer incidence (GLOBOCAN-2012 data) is linearly related with extreme low environmental temperatures, either for male or female. The same was found in the present study for Suicide deaths’ incidence , although significance is lower for female . Even more, 1/5 (20%) of all genes that have been found to be associated with suicide attempt are genes that are considered as TSG or OG, this giving a high statistical significance  (Table Cancer associated genes (CAG), Tumor suppressor genes (TSG) and Oncogenes (OG) were compared for similarities with genes that have been associated with mental disorders . Our results show that 11% of the genes that have been found to be associated with suicide attempt are also genes that have been found to be associated with cancer  found in common with suicide associated genes were introduced in Pather v.14 for molecular pathway analysis. Seventeen molecular pathways came out with p-values (FDR) ranging from 9.07 × 101. A significant number of genes that predispose for suicide, are also associated with cancer  or they are oncogenes or tumor suppressor genes . Notably, nearly one fifth of all genes that have been associated with suicide attempt, are oncogenes or tumor suppressor genes. This is not the case for other mental disorders like depression, anxiety and schizophrenia  were compared with genes that have been discovered by polygenic risk score and trios analysis to be associated with suicide attemptIn silico analysis of common genes revealed possible genetic pathways in common between cancer and suicide, like the cadherin signaling pathway and the CCKR (gastrin/cholecystokinin receptor) signaling map. Some of these pathways have already been studied in suicide19. Since these results are coming from a genetic association, functional studies are needed to test further this evidence.22 or (b) genetic variants that contributed to adaptation of humans to cold may also predispose for suicide attempt (no evidence exists yet). Further investigation is needed for clarifying the reasons of this association.It is also very interesting that we found here that extreme low temperatures are related with suicide attempt rates. We believe that there are two possible explanations: (a) low temperatures may activate inflammation pathways in the brain, since such evidence already exists in animal models25. Suicidal patients show increased inflammation with alterations in pro-inflammatory cytokines, have more often metabolic disorders and have more often dysregulation in stress adaptation26. These same factors are also contributing to carcinogenesis and tumor development27. Thus, it is possible that common genes in suicide and cancer mediate the biological vulnerability for both diseases. We believe that these results may be the beginning of a new research effort for identifying cancer patients at suicide risk and people that attempted suicide with high future cancer risk. This could be performed by investigating possible genetic or biochemical biomarkers. Early prevention of such conditions could save many lives from cancer or suicide attempt. Common genetic background of these two medical conditions may be the result of an ancient adaptation to special environmental conditions, like extreme low temperatures. Further studies on common genetic background and common molecular pathways of suicide attempt and cancer could contribute to future pharmacological targeting.In conclusion, genetic association data (GWAS), environmental data (extreme temperatures), prevalence data (Inuit population) and clinical data, suggest a genetic link between suicide and cancer. It is important to notice that there does not seem to be a genetic relationship between other psychiatric diseases and cancer and these common genetic pathways are specific for suicide. Patients with suicidal behavior differ both clinically and biologically from non-suicidal patientshttp://globocan.iarc.fr)28. Cancer incidence for Inuit population was adapted by Young et al.29. Suicide incidence data (ASR) for 2016 were downloaded from “our world in data” database (https://ourworldindata.org/) and from World Health Organization (WHO) website (https://www.who.int/). Mental diseases’ age standardized prevalence data (2016) were downloaded from “our world in data” database (https://ourworldindata.org/).Cancer incidence data (age-standardized Rates – ASR) for all countries were adapted from GLOBOCAN-2012 (https://wmo.asu.edu/) and from reliable sources that are referred in List of weather records (https://en.wikipedia.org/wiki/List_of_weather_records).Extreme Low Temperature data for 87 countries were retrieved from Arizona State University climate extremes archive 30 was used for downloading all genes that have been associated with cancer through GWAS studies  and tumor suppressor genes (TSG). Oncogenes list was downloaded from oncogene database33. This list  is based on analysis of next-generation sequencing (RNA-seq) data. As the authors state, at least one variant of these genes is expressed in all tissues uniformly. Analysis was performed by comparing this list for any common genes with genes under selection, under the same logic that it is described below. The housekeeping genes’ list and all comparisons performed can be found in Supplementary Table A separate analysis was performed with housekeeping gene (HG). Housekeeping genes’ list was adapted by Eisenberg and Lavanon38, like the UK-biobank and the Psychiatric Genomics Consortium  were adapted from GWAS studies that have been performed using the largest sample cohorts that exist since today7.Every excel sheet of Supplementary Table 39. Statistical approach is a 2 × 2 table: [(n1) cancer genes]/[(z) mental disease genes – (n1)] Vs [(n2) all cancer genes – (n1)]/[20479 – z – (n2-n1)]. The methological approach that has been described above is similar of this applied by Voskarides7.Human genome genes were considered to be 20479Please see previous section for a detailed description of the data analysis approach. All statistical analysis needed for this work was performed though the statistical package STATAv.14 . Basic statistical analysis included univariate linear regression, Fisher exact test for 2 × 2 tables and bar plots for incidence or prevalence presentation of various populations. Significant level alpha was set to 0.05.Software Panther v.14[22] was applied for finding significant pathways overrepresented in the 169 common genes (Supplementary Table Supplementary Table 1Supplementary Table 2Supplementary Table 3


To investigate the knowledge and practices of Chinese doctors in the management of osteoporotic fractures after the Chinese osteoporotic fracture guidelines update and aseries of medical education in 2017.This was a cross‐sectional survey of doctors in 71 cities across Mainland China. Based on the 2017 Chinese guidelines for the diagnosis and treatment of osteoporotic fractures, a questionnaire was designed and pre‐tested for reliability and validity. Doctors were surveyed with the questionnaire after scientific meetings during February 2017 to January 2018 through WeChat or conference digital platforms or in paper form. Descriptive statistics was used to analyze the responses to the questionnaire.Overall, 314 valid questionnaires were confirmed. Regarding diagnosis, 77% agreed that osteoporosis could be diagnosed once an osteoporotic fracture occurred; 83% believed that the bone mineral density criteria for osteoporosis diagnosis would be T ≤ −2.5 SD. For treatment, almost all (99.7%) agreed with anti‐osteoporosis treatment being one of the basic principles of osteoporotic fracture treatment; 71.6% considered bisphosphonates as the most commonly used anti‐osteoporosis drug; 97% believed that patients who have used anti‐osteoporosis drugs should reassess osteoporosis after osteoporotic fractures instead of discontinue; 95% thought that the patients who did not use anti‐osteoporosis medications before osteoporotic fracture should be treated with anti‐osteoporosis drugs after fracture treatment as early as possible; 89% agreed that the standard use of bisphosphonates after osteoporotic fracture would not affect bone healing adversely; 59% believed the course of bisphosphonates treatment for osteoporosis would be 3–5 years, and 27% considered it to be 1–3 years. The patient follow‐up rate was poor: 46% selected follow‐up rate <30%; only 20% selected follow‐up rate >50%. Only 31% of the hospitals had long‐term management programs for osteoporotic fractures.Doctors generally adhered to the updated Chinese guidelines for osteoporotic fractures; frequent participation in medical education can help doctors to increase their awareness of osteoporosis as well as their acceptance and practice of the guidelines. Osteoporosis is one of the most common skeletal diseases. It can occur at any age but is more common in postmenopausal women and older menTo standardize the diagnosis and treatment of osteoporotic fractures, guidelines on osteoporosis and osteoporotic fractures have been developed in various countries; the Chinese osteoporotic fracture guidelines was first released in 2008 and was updated in 2017. However, the prevention and treatment of osteoporosis and osteoporotic fractures have not improved since the release of the guidelinesFurthermore, multiple pathogenic factors are related to osteoporosisTo investigate the treatment given to osteoporotic fracture patients by orthopaedists at major hospitals in China, a nationwide survey among Chinese senior orthopaedists was conducted in 2014, and the results were published in 2016This was a cross‐sectional study conducted in Mainland China. Based on the 2017 Chinese guidelines for the diagnosis and treatment of osteoporotic fracturesDoctors who were from departments related to bone or aged patients, such as orthopaedics, trauma, endocrine, rheumatism, geriatrics or osteoporosis, and who attended medical scientific meetings were eligible to participate in this survey Table . There wDoctors were surveyed with the questionnaire during or after non‐promotional medical scientific meetings held by Medical Affairs Sandoz China during February 2017 to January 2018 through WeChat or conference digital platforms or in paper form. Completed questionnaires were excluded if they had >10% missing data or essential information was missing.2‐test and percentages of the total were used for analysis. Additional sub‐analysis by cohort based on the respondents’ job title and frequency of attending medical education was also performed.Descriptive analysis of the questionnaire data was performed using SPSS 20.0 software . Pearson's χA total of 316 questionnaires were completed by participants from 24 provinces, including 71 cities across Mainland China. Of these, 314 (99%) responses  were used for the analysis; another 2 responses were excluded due to the exclusion criteria.The characteristics of the respondents are shown in Table In response to the question “Do you agree that osteoporosis can be diagnosed clinically by the occurrence of fragility fractures?” most (77%) of the respondents chose “agree”; 15% disagreed and 8% were not sure. Sub‐group analysis showed that the percentage of respondents who chose “agree” increased with the frequency of attending medical education: 70%, 82%, and 87% in groups of <3 times, 3–7 times, and >7 times respectively. When analyzed according to job title, the percentage of respondents answering yes was 59%, 77%, 82% and 83% among resident physician, attending physician, deputy chief physician and chief physician groups, respectively , and 15% believed it should be −2.5 SD < T < −1.0 SD. Seventy‐five percent thought procollagen type I N‐terminal propeptide (P1NP) and collagen type I crosslinked C‐telopeptide (S⁃CTX) should be the specific bone turnover biochemical markers recommended by the International Osteoporosis Foundation.With regard to the characteristics of osteoporotic fractures (Q3), the majority of respondents had good awareness; the selection percentage of option A, B, C, D, E, and F was 96%, 93%, 93%, 89%, 90%, and 91%, respectively. Almost all (99.7%) agreed that anti‐osteoporosis treatment should be one of the basic principles of osteoporotic fracture treatment; the percentage of respondents who picked “reduction,” “fixation,” and “functional exercise” was 87%, 88%, and 90% respectively. The rates of respondents regarding the spine and hip as the most common sites of osteoporotic fractures were 97% and 92%, respectively, while the rates of those choosing distal radius and proximal humerus were 83% and 67%, respectively.Among the respondents, 52% recommended that the daily dosage of calcium and vitamin D early after osteoporotic fractures should be 1000 mg and 800 IU, respectively; 20% thought the daily dosage should be 1200 mg and 800 IU, respectively  of the respondents agreed that standardized use of bisphosphonates after osteoporotic fractures would not adversely affect fracture healing. For the question on the application scenarios of anabolic drugs, 63% would use this kind of drug for patients with osteoporotic fractures treated with anti‐bone resorption drugs for many years, and 26% would use it many times for postmenopausal women who have osteoporotic vertebral fractures or hip fractures.Regarding the effects of bisphosphonates on fracture healing and internal implants (Q13), most of the respondents agreed on their positive effects . Regarding the duration of bisphosphonates treatment, 59% of the respondents suggested the reasonable duration for osteoporosis treatment should be 3–5 years, and the option of 1–3 years was chosen by 27% of the respondents. With the frequency of medical education increased, more respondents agreed that the duration of bisphosphonates treatment should be 3–5 years, as recommended by the guidelines, and fewer respondents would prescribe for less than 1 year. Meanwhile, more respondents in the chief physician and deputy chief physician group agreed on 3–5 years compared with the group of attending physicians and resident physicians  of the respondents had a follow‐up rate of <30%, and 20% had a rate of >50%. A larger percentage of respondents in the group attending medical education >7 times had a patient follow‐up rate >50% compared with the groups attending medical education 3–7 times and <3 times . The chief physician group had the largest percentage (27%) of patient follow‐up rate >50%. The patient follow‐up rate was higher in hospitals having long‐term management programs for osteoporotic fractures than in hospitals with no related program or with programs at planning or preparatory stage   . At the same time, the attending physician group tends to have the largest proportion of bisphosphonates prescriptions for 1–3 years, while the prescription by resident physicians has the largest proportion within 1 year. The reasons may be related to the differences in the degree of doctors’ knowledge, the degree of patients’ conviction, and prescribing authority.Compared with the survey published in 2016, more respondents agreed that standardized bisphosphonates therapy has no adverse effect on fracture healing after osteoporotic fractures 89% 3%) Fig. . The maj3%) Fig. . More re9% 3% FigAnti‐osteoporosis treatment is one of the basic principles of osteoporotic fracture treatment; however, patient compliance has been a problemThrough comparison of the results of the survey published in 2016, we found that the awareness and the level of diagnosis and treatment of osteoporosis of doctors have been improved. The diagnosis and treatment of osteoporosis and long‐term management of osteoporotic fractures should be based on doctors’ knowledge and patient compliance. We believe that such results are meaningful; they are also helpful for government and enterprises to develop policies and strategies on osteoporosis management. Meanwhile, we call for strengthening medical education for both medical staff and the general population to prevent osteoporosis and reduce fracture incidence.This questionnaire survey was conducted mainly through WeChat and online methods, which improved the rate of valid questionnaires and avoided interference caused by human factors in the face‐to‐face questionnaire form. However, as this was a cross‐sectional survey with treatment data retrieved from doctors’ subjective clinical concepts instead of clinical records, personal biases may exist and affect the results.The results of this survey demonstrated that doctors knowledge about osteoporosis and osteoporotic fractures improved in relation to diagnosis, bisphosphonates and bone healing, timing of medication and long‐term treatment, and generally adhered to the updated Chinese guidelines for osteoporotic fractures. Frequent medical education can help doctors to enhance the awareness of osteoporosis and osteoporotic fractures as well as the acceptance and practice of guidelines. Long‐term management programs for osteoporotic fractures in hospitals may be useful for improving patient compliance and optimizing disease management.


This study aimed to quantify the associations of regional fat mass and fat‐free mass with systolic blood pressure.This analysis combined individual participant data from two large‐scale imaging studies: UK Biobank and Oxford BioBank. In both studies, participants were interviewed and measured, and they underwent dual‐energy x‐ray absorptiometry imaging. Linear regression was used to relate systolic blood pressure to anthropometric measures of adiposity  and dual‐energy x‐ray absorptiometry–derived measures of body composition .Among 10,260 participants , systolic blood pressure was positively associated with visceral android fat  and fat‐free mass , but there was no evidence of an association with subcutaneous android or gynoid fat. Associations of systolic blood pressure with BMI were slightly steeper than those with waist circumference or waist to hip ratio; these associations remained unchanged following adjustment for fat‐free mass, but adjustment for visceral android fat eliminated associations with waist circumference and waist to hip ratio and more than halved associations with BMI.This analysis indicates that visceral fat is the primary etiological component of excess adiposity underlying the development of adiposity‐related hypertension. Adiposity is an established risk factor for vascular disease, and this association is known to be mediated in part by raised blood pressure. Randomized controlled trials of weight loss interventions (and Mendelian randomization studies of blood pressure in relation to adiposity‐related genetic variants) support the causality of the relationship between adiposity and blood pressure 2 higher is typically associated with approximately 1‐mmHg higher systolic blood pressure Previous studies of adiposity and blood pressure have mostly used indirect measures of adiposity, such as BMI, waist circumference, or waist to hip ratio. The etiological relevance of general adiposity (as measured by BMI) and central adiposity (as measured by waist circumference or waist to hip ratio) has been inferred from these findings. Overall, BMI has been found to be more strongly related to blood pressure than measures of central adiposity Measures of body composition that directly quantify regional fat distribution  can overcome some of these limitations. However, it has only recently become feasible to conduct large‐scale studies with whole‐body imaging scans. Evidence for the associations between regional body composition and blood pressure is, therefore, limited to a small number of studies, none of which was sufficiently large to reliably estimate the independent effect of different fat deposits on blood pressure levels This study examines the cross‐sectional associations of DXA‐derived measures of regional fat mass with systolic blood pressure, known to be more strongly predictive of vascular disease than diastolic blood pressure In 2006 through 2010, 503,000 adults (aged 40‐70 years) were recruited from the general population in the United Kingdom into a prospective cohort study In 1999, the Oxford BioBank study recruited 5,425 adults (aged 29‐55 years) from the general population of Oxfordshire, UK In both studies, DXA imaging scans were used to estimate fat mass in four mutually exclusive regions of the body: visceral android fat, subcutaneous android fat, subcutaneous gynoid fat, and other fat mass. Android, gynoid, and visceral fat were provided as automated output from the device, as estimated by using proprietary algorithms n = 335), 10,260 participants from both studies were available for analysis (Supporting Information Table r). Linear regression was used to estimate the mean differences in each DXA‐derived measure of body composition  per 1‐SD difference in the levels of each anthropometric measure of adiposity.A meta‐analysis of the individual results from the UK Biobank and Oxford BioBank was performed. After excluding those with missing or extreme values of adiposity measures or systolic blood pressure (n = 657), linear regression was also used to relate systolic blood pressure to each DXA‐derived measure of body composition  and to each anthropometric measure of adiposity (with and without further adjustment for selected DXA‐derived measures of body composition); these analyses were further adjusted for height (sex‐specific fifths) and alcohol consumption (five groups) based on theoretical importance and significant contributions to the model.After excluding participants on blood pressure–lowering therapy (r) between repeat measures at imaging and resurvey (2.1 years prior to imaging) in 2,063 UK Biobank participants (Supporting Information Table r.Because of measurement error (or within‐person variability over time), regression analyses that use measurements of anthropometry on a single occasion may systematically underestimate the strength of the associations between anthropometric variables and other factors such as blood pressure (a phenomenon known as “regression dilution bias”) Sensitivity analyses were conducted to assess the effect of blood pressure–lowering medication on the findings and to assess the effect of potential confounding by other lifestyle factors, such as smoking and physical activity. Analyses were also repeated by using log‐transformed, DXA‐derived variables. Ethics approval was obtained from the Oxford Ethics Committee and the Ethics and Governance Council for the Oxford BioBank study. The UK Biobank study received ethics approval from the National Information Governance Board for Health and Social Care and the National Health Service North West Multicentre Research Ethics Committee. All participants provided written informed consent. All analyses were conducted by using SAS version 9.3  and R version 3.3.1 .After exclusions, 10,260 participants contributed to the main analyses Table . Almost On average, men had higher BMI, waist circumference, and waist to hip ratio than women. The mean difference in weight between men and women (approximately 15 kg) was almost entirely due to differences in fat‐free mass. The distribution of body fat also differed between the sexes, with men having on average less subcutaneous fat in android and gynoid regions but more than twice the amount of visceral android fat (1.4 kg in men vs. 0.6 kg in women).r = 0.87 in men and 0.86 in women), and both measures were less strongly correlated with waist to hip ratio , and there were more modest correlations of these variables with visceral android fat (r = 0.46‐0.72). Fat‐free mass was only weakly correlated with DXA‐derived measures of regional body fat mass (r = 0.28‐0.53).BMI was strongly correlated with waist circumference  have described cross‐sectional associations between blood pressure and regional fat mass or fat‐free mass The relation between systolic blood pressure and the anthropometric measures of adiposity used in the present report have been well described in previous studies The associations of systolic blood pressure with each of the anthropometric measures of adiposity were strongly attenuated when adjusting for visceral android fat, with complete attenuation of the associations with central adiposity (waist circumference and waist to hip ratio). This indicates that the relation between central adiposity and systolic blood pressure is mediated largely by visceral android fat  and suggests that there are additional mechanisms by which general adiposity (as measured by BMI) may influence blood pressure. Visceral fat is known to have distinct biological properties compared with body fat stored elsewhere, but the mechanisms by which it may influence systolic blood pressure are not clear; potential mechanisms involve abnormal renin‐angiotensin‐aldosterone regulation and sympathetic nervous system activation The key strengths of the present study include its large sample size; the high‐quality measurements of body composition, blood pressure, and potential confounders; and the repeated surveys in a subset of UK Biobank participants to allow correction for measurement error of anthropometric variables. However, the cross‐sectional study design limits the ability to infer causality. There were rigorous quality‐control procedures for the DXA machines and digital sphygmomanometers in both studies. Importantly, however, regional fat was estimated using proprietary algorithms, and although externally validated, different DXA models used by the two studies may have produced estimates of varying accuracy. Furthermore, DXA imaging technology is unable to quantify ectopic fat within internal organs (such as the heart and liver), of which others have shown stronger correlations with metabolic disease, independently of total visceral fat Some of the observed variability of anthropometric measures may reflect real temporal variation in addition to measurement error. However, similar self‐correlations were observed between baseline and imaging visits (approximately 7 years apart; Supporting Information Table Adiposity is an established risk factor for vascular disease, and this association is considered to be largely mediated by blood pressure, insulin resistance, and cholesterol  Click here for additional data file.


Vitis vinifera L. cv. ‘Portugieser’). All treated plants prove to exhibit significantly fewer symptoms several weeks after treatment, and their condition is monitored for 5 years (2014–2018), proving a long‐term curative effect of this NC treatment. This study proves the efficacy of this NC‐mediated drug delivery for agriculture, using a minimum amount of fungicides. It is believed that this concept can be extended to other plant diseases worldwide to reduce extensive spraying of agrochemicals.Nanocarrier (NC)‐mediated drug delivery is widely researched in medicine but to date has not been used in agriculture. The first curative NC‐based treatment of the worldwide occurring grapevine trunk disease Esca, with more than 2 billion infected plants causing a loss yearly of $1.5 billion, is presented. To date, only repetitive spraying of fungicides is used to reduce chances of infection. This long‐term treatment against Esca uses minimal amounts of fungicide encapsulated in biobased and biodegradable lignin NCs. A single trunk injection of <10 mg fungicide results in curing of an infected plant. Only upon Esca infection, ligninolytic enzymes, secreted by the Esca‐associated fungi, degrade the lignin NC to release the fungicide. The specific antifungal activity is confirmed in vitro and in planta (in  This disease is called EscaPhaeomoniella chlamydospora (Pch) and Phaeoacremonium minimum (Pmi).Instead of extensive spraying, we provide a fungicide, encapsulated in a protective NC by a single injection into the trunk. Even with a minimum amount of less than 10 mg fungicide per plant, the disease symptoms were reduced significantly. Esca is associated with the occurrence of several fungi, including the tracheomycotic FigureThe lignin NCs were prepared by crosslinking methacrylated Kraft lignin in the presence of a nonsystemic drug pyraclostrobin by a combination of miniemulsion polymerization and solvent evaporation.2Synthesis of Lignin NCs: In order to allow the encapsulation of the hydrophobic fungicide pyraclostrobin, we modified the hydroxyl groups of the hydrophilic Kraft lignin with methacrylic groups by the reaction with methacrylic anhydride ; reduction of the hydroxyl vibration (—OH) at 3000–3800 cm−1 after the reaction, indicating a high degree of functionalization). 1H NMR spectroscopy proved the attachment of the methacrylic group by the distinctive resonances of the vinyl group at 5.88 and 6.22 ppm. The diffusion‐ordered NMR spectroscopic 1H NMR analysis confirmed a covalent coupling of the vinyl groups to the polymeric lignin , as the two protons of the vinyl group were detected at the same diffusion coefficient as the lignin backbone at approximately 1.7 × 1010 m2 s−1. The number of methacrylates was determined by the method of Balakshin and Capanema using 2‐chloro‐4,4,5,5‐tetramethyl‐1,3,2‐dioxaphospholane as a phosphorylation agent and found to be 5.5 mmol g−1 .e Figure A. Both N13C NMR spectroscopy of the freeze‐dried product proved the covalent crosslinking of the NCs .Lignin NCs were prepared by crosslinking the methacrylated lignin in miniemulsion droplets: methacrylated lignin was dissolved together with the fungicide pyraclostrobin in chloroform to generate the dispersed phase. The solution was then mixed with the aqueous phase containing either sodium dodecyl sulfate  or Lutensol AT50 ‐based surfactant) as a stabilizer. A stable miniemulsion with homogenously distributed droplets was prepared by ultrasonication of the hydrophobic and the hydrophilic solutions. By using a microfluidizer instead of a sonication tip, the process was scaled easily to the liter‐level Figure B. AfterwDepending on the preparation conditions, NCs with diameters between ≈200 and 700 nm  were obtained. The sizes of the NCs were varied by adjusting the concentration of lignin‐MA in the droplets and the amount and type of surfactant . The addition of pyraclostrobin to the miniemulsion did not result in any significant change of the NC size, compared to “empty” lignin NCs. Transmission electron images show the spherical morphology of all fungicide‐loaded lignin NCs . After mixing an NC dispersion with the filtrate of a 72 h well‐grown culture from the Esca‐associated fungus Pch, more than a third of the encapsulated fungicide was released to the medium, proving that the segregated lignolytic enzymes can induce the degradation of the NC matrix , which does not produce lignin‐degrading enzymes, was used as a control fungus.Pch and Pmi, however, which produce lignin‐degrading enzymes, were able to release the drug and their growth was suppressed completely. An additional proof that the lignin NCs act as nutrient for these fungi is obvious, when “empty” NCs were incubated with Pch and Pmi: the fungal growth was even higher after the addition of the NCs without encapsulated fungicide Figure A. ImportVitis callus cultures (DSMZ‐ PC‐1137). No effect on the viability of the callus cells in the presence of the lignin NCs was observed . In contrast, a positive control (the herbicide glufosinate‐ammonium) causes the cell death of the Vitis callus cells. These experiments prove that the lignin NCs (loaded with the fungicide pyraclostrobin and “empty”) are nonphytotoxic to plant cells, making them attractive candidates to treat various plant diseases.Whereas the NCs should kill the Esca fungi, they should not harm plant cells in general. To elucidate the phytotoxicity of the lignin NCs on plant cells, the dispersions were tested on In Planta Studies: Up to now, there are only two injection‐based drug delivery systems for plant protection: i) injection of soluble systemic insecticides in loblolly pine trees against southern pine bark beetles.Venturia inaequalis) and powdery mildew (Phyllactinia sp.) was able to reduce disease severity.FigureVitis vinifera L. cv. ‘Portugieser’ plants in a vineyard in Forst an der Weinstraße, Germany. An early symptom of Esca is necrotic yellow‐brownish tissues around the leaf veins described as “tiger stripes”  showed a significant improvement in their conditions after 3 months and up to 4 years. In the first year, the overall Esca severity was reduced <1 . Treatment with F500 resulted in an initial improvement (2016) of the symptoms .Into the plant's trunk, a hole was drilled  and the aqueous NC dispersion was injected (≈1 wt% solid content) via a microinjection system  over a period of several hours Figure C. AfterwTo our knowledge, the herein reported lignin NCs is the first report of an injection system based on long‐term active and stimuli‐responsive NCs for drug delivery inside of living plants. In addition, these results prove that lignin NCs, loaded with a hydrophobic fungicide and injected into the trunk of wine plants, act as a curative treatment for Esca‐infected grapevine plants. Together with the in vitro studies, we also suppose no release of the fungicide in a noninfected plant, as only the laccase segregated from the fungi, would open the NCs. The lignin NCs are an effective cure to treat already Esca‐infected grapevine plants. All plant protection product treatments that are currently available in the market, only aim a preventive fungal infection, but are not custom made for GTD (grapevine trunk disease) pathogens or other trunk diseases, e.g., in plums, peaches, or almonds and are futile after the infection and colonization in the plant occurred. Since GTD pathogens grow mostly in the xylem vessels, we assume that the introduced injection method is capable to reach the fungal mycelium inside the plant.FigureAnother important advantage of the proposed method is the significant reduction of the amount of fungicide applied per plant. This drastically reduces the release of fungicide to the ecosystem. The amount recommended for one foliar application in conventional viticultural farming of a strobilurine derivative in a German vineyard is at least 70 mg (after blossom) but up to 640 mg (at full foliation) per year and plant depending on the month of spraying.−1 boscalid was detected in the samples. Also, other fungicides such as iprovalicarb and indoxacarb were detected in the same samples. In another test series 1.01 mg kg−1 of iprodione; 0.78 mg kg−1 of procymidone; and 0.37 mg kg−1 of vinclozolin were detected in grapes.Another important finding was that after the treatment with the lignin NCs no pyraclostrobin was found in the harvested grapes . In contrast to the injected NCs, it was reported that sprayed fungicides remain in/on the grapes after harvesting: e.g., Angioni et al. proved the presence of boscalid in grapes and wine.3In conclusion, this work presents a general approach for NC‐mediated drug delivery in living plants. Although using minimal amounts of fungicide compared to a preventive spraying strategy, this concept successfully acted as the first curative treatment for a GTD “Esca.” With lignin as the matrix of the NCs, the Esca‐associated fungi degraded the trunk of the grapevine plant and the NC sufficiently, which results in an enzyme‐responsive drug release. These NCs, loaded with pyraclostrobin, were prepared via a miniemulsion polymerization, providing an aqueous NC dispersion with adjustable drug loading and high encapsulation efficiency. The enzyme‐triggered fungicide release was demonstrated by in vitro experiments. Thereafter, we injected this aqueous dispersion into the trunks of infected and symptomatic grapevine plants using a ready‐made injection system. The NCs were nonphytotoxic and do not release the drug unless an Esca‐associated pathogen (Pmi and Pch) secretes lignin‐degrading enzymes. Furthermore, a single trunk injection resulted in a significant reduction of Esca symptoms monitored in plants over a period of 5 years. This concept provides as curative treatment against Esca, but might be extended as a preventive treatment as no drug is released without an Esca infection. Hence, by transferring the controlled drug delivery approach from medicine to agriculture, we envision establishing an inexpensive and targeted technique for advanced plant protection. This general strategy will be extended for various plant diseases such as plum and peach infections and will contribute to decreasing untoward environmental effects from pollution of agrochemicals.The authors declare no conflict of interest.SupplementaryClick here for additional data file.


Randomized trials in patients with hospitalized heart failure (HHF) continue to frustrate the cardiology community. Promising haemodynamic, structural and biomarker findings from phase 2 studies consistently fail to deliver substantive benefits in larger outcome trials. What underlies these recurrent failures? Why are persistently high readmission and post‐discharge mortality rates not being reduced? Challenging any pre‐conceived ideas about the existence of a ‘typical’ acutely decompensated heart failure patient is fundamental, as is the adoption of a carefully personalized approach. These individuals come from a remarkably heterogeneous group. Surely precise phenotyping should translate to a more successful therapeutic approach?FigureTableIn our opinion, it is unrealistic to expect a change in outcomes until a personalized approach is adopted Figure. This inPatients who present primarily with dyspnoea at rest comprise up to 42% of ‘real‐world’ patients with HHF in registriesDifferentiation of those with a slower ‘sub‐acute’ decline in their condition from those with ‘acute’ breathlessness has only recently received attention.HFrEF and heart failure and preserved ejection fraction (HFpEF) represent different cardiac phenotypes that are likely to respond to distinct therapeutic interventions. However, providers may be criticized for failing to think ‘beyond the ejection fraction’. For example, a patient with HFrEF as a result of a large prior myocardial infarction and scar could respond differently to a therapy than might a patient with HFrEF due to an acute toxic insult, myocarditis, or poorly controlled systemic hypertension. Establishing the incremental benefits of such phenotypically‐targeted therapies  would require stricter trial inclusion criteria.Many clinical trials in HHF have investigated short‐term infusions of vasoactive therapiesTable 1) could lead to trials of new therapies in tightly defined groups. Studies of catheter ablation for atrial fibrillation could be launched in both HHF secondary to HFrEF, HFpEF, or both. Trials of coronary revascularization with percutaneous intervention or coronary artery bypass grafting are overdue and could be performed in HHF – again in HFrEF, HFpEF, or both. Impressive benefits of transcatheter mitral valve intervention have been demonstrated in very carefully selected patients with chronic HFrEF.Exciting times may lie ahead. Careful phenotyping  inhibition in diabetic patients with HHFMany of the co‐morbidities found in patients with HHF have not been perceived to fall within the purview of cardiology but recognizing them may improve outcomes. Perhaps early diagnosis of cognitive impairment or psychological conditions could provide benefit. Establishing the social environment of a patient can reveal obvious ways to influence readmission.Outcomes remain poor after discharge from an admission with heart failure.A key focus should be to improve equity of access to heart failure management programmes, including follow‐up by a heart failure nursing team and allied health practitioners. By taking this more comprehensive approach, the psychological, social and economic issues that might negatively influence outcomes should become clearer. Research to address many of these questions is overdue and the bulk of currently available evidence is based on subgroup analysis which is, therefore, hypothesis‐generating and not definitive.Durable ventricular assist devices (VADs) remain a niche therapy for few and highly selected patients in a small number of centres in the United States, Germany and some other countries. Notwithstanding the considerable cost of these devices and substantial resources required to care for patients post‐implant, there is a major opportunity to test durable VADs against conventional HHF treatment in patients towards the sickest end of the spectrum. The mainstay of therapy for these patients is inotropes – some of which are known to increase rather than decrease mortality. A trial of durable VADs vs. inotropes in countries where VADs are not used or funded would potentially lead to convincing evidence of the benefit of these devices as destination therapy .Trials in HHF have resulted in failure. The ‘typical’ HHF patient does not exist. A change of direction is necessary with a new era of personalized assessment. Management of these complex patients requires assessment that is not limited to the presenting features but extended to the nuances of aetiology, precipitants of decompensation and co‐morbidity. Only by doing so will we identify phenotypically similar groups of patients with HHF who can enter trials to understand which pharmacological, monitoring or device therapies might finally lead them to a brighter prognosis.Conflict of interest: none declared.


In magnetic resonance elastography (MRE), a series of time‐shifted images is acquired at specific phase offsets in relation to an induced mechanical excitation. To efficiently gather the set of phase offset images and to overcome limitations due to prolonged TEs and related susceptibility artifacts at low‐frequency MRE, we developed an improved displacement encoding with a stimulated echoes (DENSE) method.The proposed multiphase DENSE‐MRE acquisition scheme allows full sampling of the wave propagation in 1 encoding direction during each TR using multiple readouts at specific phase offsets. With this approach, all phase offsets can be imaged in 1 TR without the need for whole sequence repetitions at time‐shifted offsets relative to the excitation motion. We tested this technique in phantom experiments with 60 Hz and in the brain of 4 volunteers using 20‐Hz harmonic excitation.Three‐dimensional wave propagation could be acquired in 7 minutes 30 seconds. Following background phase elimination, clear wave images were obtained, showing the propagation of the waves over time. Calculated shear modulus maps of the phantom matched well to the maps obtained by conventional gradient‐echo MRE. In the brain, low‐frequency DENSE‐MRE images were free of susceptibility‐induced artifacts and the calculated maps showed a median global complex shear modulus magnitude of 0.72 kPa and phase angle of 1.03 rad across volunteers.The proposed multiphase DENSE approach allows efficient low‐frequency MRE with short TEs and is well‐suited for low‐frequency MRE of the human brain. To achieve TEs shorter than the vibration wave period, fractional encoding of the harmonic motion was proposed, in which the motion‐encoding gradient duration is decoupled from the wave period.When assessing lower vibration frequencies with conventional motion‐encoding MRE sequences, however, this results in longer TEs and therefore in a signal loss due to TThe application of stimulated‐echo MRE was already proposed by Plewes et al for breast cancer investigationsIn this paper, we provide a detailed description of the multiphase offset readout concept in DENSE‐MRE as an efficient acquisition scheme for multislice MRE. We test it in phantom experiments and compare the obtained results with those generated using a conventional GRE‐MRE sequence. Furthermore, we demonstrate the applicability of the multiphase DENSE‐MRE approach to brain MRE first with results from investigations in healthy volunteers.22.1The concept of stimulated‐echo MRE and DENSE‐MRE has been well described.1 relaxation, which influences the magnitude images only, the displacement information is not subject to the T1 relaxation because it is encoded in the phase images. However, because the noise in the phase images is related to the magnitude images, a variable flip angle schemeTo sample the mechanical waves in MRE, a set of images is acquired that shows the wave propagation at several equidistant points in time over a complete wave period.2.2The multiphase DENSE‐MRE sequence was implemented and tested on a 3T whole‐body MR scanner  using a 20‐channel head coil.Mechanical excitation was achieved using a high‐power wave generator  and a piezoelectric actuator . The actuator was placed on the feet end of the MR scanner’s patient table. Using a rigid rod, the vibration was transmitted to a head rocker. The phantom was placed within the rocker and fixated to achieve good mechanical coupling. A continuous sinusoidal vibration with a frequency of 60 Hz was applied throughout the sequence execution. To guarantee steady state and synchronous vibration conditions during the whole acquisition, the multiphase DENSE‐MRE sequence was synchronized with the control unit for the actuator. The actuator was triggered by the MR sequence at integer multiples of the applied excitation wave period.The multiphase DENSE sequence was tested on an elastic phantom constructed inside a stiff plastic box. The elastic material consisted of agar  in different agar/water concentrations. Two stiff inclusions with 0.6% agar (0.6 g agar stirred in 100 mL water) were placed inside a soft‐surrounding 0.3% agar gel matrix. Various geometrical shapes were defined for the 2 inclusions with individual lengths. The rectangular inclusion occupied almost the whole length of the phantom, whereas the cylindrical inclusion ranged over just a part of the phantom, to investigate also partial‐volume effects in the multislice acquisition.Five transversal slices and 4 phase offsets per slice were acquired using the proposed acquisition scheme. Together with a TR of 2500 ms and interleaved multislice image acquisition, this allowed capturing the same sampling points in time of the wave field in all slices.i to 8 ms, 20.5 ms, 33 ms, and 45.5 ms ); thus, it additionally removed the few phase wraps of the raw phase images and no further phase unwrapping of the wave images was needed. To extract the frequency component corresponding to the excitation frequency, discrete Fourier transform was performed from time to frequency domain along the wave‐sampling point axis. A complex wave image was extracted as first harmonic of the Fourier transformed data at the excitation frequency component. The MRE processing was performed using a 2D multifrequency dual elasto visco (MDEV) inversion algorithm,3 was assumed for the shear modulus estimation. During inversion, the images were smoothed using a 2D Gaussian filter .−1 suppressed higher wavelengths within the processed images as described in Ref 7. As a result of the inversion, the complex shear modulus G* was computed in terms of its magnitude |G*|  and phase angle φ .× 5 pixel kernel. Regions of interest (ROIs) were drawn manually on each slice of the T2‐weighted images for the higher agar concentrated inclusions as well as in the lower agar concentrated surrounding area. The resulting ROIs of all slices were then combined (for the inclusions and surrounding area separately). The ROIs were copied to the |G*| and φ maps to assess the mean values for the agar phantom and its inclusions. To compare the G* maps from the multiphase DENSE‐MRE to the maps from the GRE‐MRE, MDEV inversion was additionally performed using just the z‐motion encoded data set. The GRE‐MRE phase offset images were processed to G* maps using the same MDEV inversion and filtering as described for the multiphase DENSE‐MRE images. Regional assessment of the underlying values was done using the same ROIs copied to the respective maps.The following processing steps were performed for each slice and motion‐encoding direction of the multiphase DENSE‐MRE images. First, the raw phase images were converted from DICOM integers to radians. Then, a rearrangement of the data set along the time axis was performed to achieve a temporally ascending wave sampling order, as outlined in Table 2.4−1 as in Ref 10, and no median filtering of the G* maps was performed. For all subjects, the mean values of the magnitude and phase angle of the complex shear modulus were assessed. Global mean |G*| and φ were measured across all slices covering gray and white matter and excluding the ventricles. The outline of the brain was defined on the DENSE‐MRE magnitude images using a threshold, and the T2‐weighted images were used to manually exclude the ventricles from the regions. Additionally, ROIs were manually defined on the T2‐weighted images in the white matter of the frontal and occipital lobes, the centrum semiovale, and in the deep gray matter (putamen) of both hemispheres. The regions were copied to the |G*| and φ maps for evaluation, and the values of both hemispheres were averaged. The ROIs were also used to assess the SNR within the raw multiphase DENSE‐MRE magnitude images. The SNR of each phase offset time step was evaluated. Separate evaluation was performed for each motion‐encoding direction and subject. The SNR was thereby calculated as the ratio of the mean to the SD of the magnitude signal intensity within the ROIs and averaged over all ROIs. The average SNR of all subjects and motion‐encoding directions was calculated for all 4 phase offset magnitude images.Four healthy volunteers  were investigated to evaluate the in vivo performance of the multiphase DENSE‐MRE acquisition scheme. The study was approved by the local ethics committee and all subjects gave written informed consent. In these investigations, 5 slices were acquired using the same setup and acquisition protocol as in the phantom experiments except for the excitation frequency, which was reduced to 20 Hz. However, the mixing times of the 20‐Hz in vivo acquisitions still matched the mixing times of the 60‐Hz phantom experiments. Thus, for the in vivo as well as for the phantom experiments, the same sequence‐parameter settings were used for the multiphase DENSE‐MRE acquisition. Combined with the same TR of 2500 ms, the acquisition time of 2 minutes 30 seconds per motion‐encoding direction also did not change between phantom and in vivo investigations. Postprocessing was performed as described previously for the phantom experiment with only slight adoptions. Because the mixing times correspond to the ascending order of the wave sampling points Table , no rear33.1A representative set of images from the multiphase DENSE‐MRE phantom experiments is shown in Figure z‐motion‐encoded data were analyzed. Figure 2‐weighted images  than the presented approach. However, DENSE provides a fully refocused echo that is free of EPI distortions and susceptibility artifacts. Future multiphase DENSE‐MRE studies could benefit from fully exploiting the number of interleaved slice acquisitions without a change in scan time. Additionally, the advantages of the proposed approach could likely be even more relevant when investigating organs with short T2 and T2* values. Furthermore, future studies should explore whether combining the multiphase DENSE‐MRE approach with EPI readouts may allow a further reduction of the acquisition time, and whether a conventional motion‐encoding EPI‐based MRE sequence was still more efficient than the proposed approach.With the proposed multiphase approach, the total acquisition time can be reduced. As all phase offsets are acquired at once, the total acquisition time shortens by the factor of the number of phase offsets compared with repeated single phase‐offset acquisitions. Hence, the acceleration in this work was by a factor of 4. Higher acceleration factors come along with lower flip angles, resulting in lower signal intensities for each readout block. Consequently, the SNR reduces with higher acceleration factors. Additionally, variations of T5In this study we showed the feasibility of acquiring all MRE relevant phase‐offset scans using a DENSE approach with a multiphase acquisition. Our results demonstrate that the sequence is well‐suited for low‐driving frequencies and that the images do not suffer from susceptibility artifacts. With the multiphase expansion, the total acquisition time can be significantly shortened, which allows efficient multislice MRE of the brain in a clinical setting.


Balaenoptera physalus) in the northern Gulf of St. Lawrence in the context of anthropogenic pressures and changing environmental conditions. A long‐term data set, consisting of 35 years of photo‐identification surveys and comprising more than 5,000 identifications of 507 individuals, formed the basis of this mark–recapture study. Based on model selection using corrected Akaike Information Criterion, the most parsimonious Cormack–Jolly–Seber model included a linear temporal trend in noncalf apparent survival rates with a sharp decline in the last 5 years of the study and a median survival rate of 0.946  0.910–0.967). To account for capture heterogeneity due to divergent patterns of site fidelity, agglomerative hierarchical cluster analysis was employed to categorize individuals based on their annual and survey site fidelity indices. However, the negative trend in survivorship remained and was corroborated by a significant decline in the estimated super‐population size from 335 (95% CI 321–348) individuals in 2004–2010 to 291 (95% CI 270–312) individuals in 2010–2016. Concurrently, a negative trend was estimated in recruitment to the population, supported by a sharp decrease in the number of observed calves. Ship strikes and changes in prey availability are potential drivers of the observed decline in fin whale abundance. The combination of clustering methods with mark–recapture represents a flexible way to investigate the effects of site fidelity on demographic variables and is broadly applicable to other individual‐based studies.Estimates of abundance and survivorship provide quantifiable measures to monitor populations and to define and understand their conservation status. This study investigated changes in abundance and survival rates of fin whales ( Small pWell‐established analytical frameworks are available to generate robust estimates of abundance and survival from suitable data to inform decision‐making Hammond, . HoweverBalaenoptera physalus) is a long‐lived and wide‐ranging baleen whale requiring large‐scale, long‐term monitoring programmes to identify population trends. Several national and multinational large‐scale surveys  during 2004 to 2010 that applied mark–recapture models to photo‐identification data estimated the population at 328 individuals  of 306–350; Ramp et al., Megaptera novaeangliae) whales to their feeding ground in the GSL has been related to earlier winter sea ice break‐up linked to a warming climate  linked to reduced ice cover , located between Anticosti Island and the North Shore in the northern part of the GSL  is a method in which individual animals are recognized from images of their natural markings, providing capture histories of individuals Hammond, . Photo‐IIn this study, every fin whale was considered individually identifiable from high‐quality photographs of the shape of the dorsal fin and the pigmentation patterns. After each survey, the best photos of the right side dorsal and right side chevron were chosen for each individual based on sharpness, angle, coverage, and light conditions (contrast). Based on photo quality, pictures were graded from A to D and only individuals with pictures from the highest quality (A and B) categories were matched against the catalogue. In an initial step, researchers matched individuals to individuals already seen during the same season to check for internal duplicates, before matching the individuals seen in a season to the whole catalogue of previously identified individuals. The judgment of three researchers, two of whom had to be experienced in fin whale matching, was required to confirm a match or designate a new individual in order to minimize the chance of mis‐identification of individuals. Calves were excluded from mark–recapture analyses because observations of calves are conditional on the presence of their mother.2.3The complete sighting history for each individual was used to calculate two site fidelity indices: (a) annual sighting rates as the total number of years an individual was seen as a proportion of the total number of years since the first sighting of the given individual and (b) survey sighting rates as the total number of days an individual was seen as a proportion of the total number of survey days carried out since the first sighting of the given individual. Thus, an annual sighting rate of 1 indicated that an individual had at least one confirmed identification each year since the first sighting. The survey sighting rates were related to seasonal residency patterns; individuals identified multiple times in a single season scored higher than individuals sighted only once. Individuals first identified after 2011 were excluded from the analysis because insufficient time had passed to estimate a robust site fidelity index.hclust function in R  analysis was used to categorize individuals based on the two site fidelity indices using the As a complement to the above analyses, confirmed opportunistic matches of fin whales between the JCP and adjacent areas were considered as a means to improve the understanding of the ranging capacities of the animals within and among seasons.2.4p), and the POPAN formulation for the Jolly–Seber model  tests implemented in the software U‐CARE  the probability that an individual survives from occasion t to t + 1 and (b) the probability that the individual returns to the study area (site fidelity). Candidate models were built based on different combinations of effects on survival and recapture probabilities following the notation of Lebreton et al. (t), linear temporal trend (T), sex (s), and trap‐dependence (m). The inclusion of immediate trap‐dependence in the models of recapture probabilities was justified by the lack of fit in the Test2.CT component of the GOF test . The effect of trap‐dependence was incorporated as an individual time‐varying covariate using dummy variables (0 and 1), which allowed capture probabilities to vary depending on whether the individual was captured on the previous occasion or not  or over‐dispersion  was detected in the data. In addition to the strictly linear temporal trend, a more flexible temporal trend with multiple inflection points (knots) was explored using the bs function in the R splines package ) as identified by the AHC analysis. CJS models were fitted to the categorized capture histories from all noncalf individuals (sexed and unsexed) from 1990 to 2016. As was the case for the AHC analysis, individuals that entered the data set during the last 5 years of the study were excluded.N using POPAN. In addition to the apparent survival Φ and recapture p probability parameters, the POPAN formulation also estimates the probability of entry (pent) from the super‐population into the study area, as a result of immigration and/or birth. We hereafter refer to this as recruitment. The parameters Φ, p, and pent were allowed to be constant (·), time‐dependent (t), or to follow a linear temporal trend (T). A CJS model was used as an approximation for GOF testing, because U‐CARE does not support GOF tests of POPAN models. While there was no evidence for an effect of trap‐dependence , the GOF tests indicated the presence of transients in the dataset . To account for a potential transient effect due to the inclusion of all individuals, we fitted models with separate survival for the interval following the first sighting of a whale by creating a time‐varying covariate called trans  and estimated standard errors were adjusted accordingly. Additive (+) and interaction (:) effects were also considered for the survival model (Φtrans + T and Φtrans:T). Because the estimate previously published by Ramp et al. , sighting histories from all noncalf individuals (sexed and unsexed) identified during 2010 to 2016 were used to provide an abundance estimate of the super‐population p et al.  did not C and Quasi‐likelihood AICC  and survey  sighting rates between the two categories. The core regulars comprised 31 females and 63 males, compared to 37 females and 58 males among the occasional visitors. These sex ratios did not differ significantly between the two groups .The AHC analysis separated individuals into two distinct categories Figure . Out of 3.2n = 129) of the individuals were identified in at least two areas in the GSL. Fifty‐one individuals were recorded in multiple areas in the same year.Limited photo‐identification data from outside the JCP were available to gain an insight into the movement patterns of fin whales in the GSL Table . Despite3.3tp + m (models 5–12) had no support. The two models for survival based on temporal trends (models 1 and 3) had more support than the equivalent model without a trend (models 2 and 4). Survival models without sex (models 1 and 2) carried more weight than those with sex (models 3 and 4). Model‐averaged estimates of apparent survival and recapture probabilities are shown in Figure Model support (weight) was limited to four candidate models  than comparable models without the transient effect (models 10–12), highlighting the importance of this additional parameter. The probabilities of apparent survival and recruitment steadily decreased over time, with recruitment almost reaching zero probability by the end of the time series , reflecting the estimate of abundance of the population which contributed individuals to the study area during 2010 to 2016. The same models fitted to the 2004 to 2010 data resulted in a model‐averaged super‐population size of 335 (95% CI 321–348) from 2004 to 2010  a negative trend in recruitment from 2010 to 2016, (b) a significant decline in the super‐population size from an estimated 335 (95% CI 321–348) animals in 2004 to 2010 to 291 (95% CI 270–312) animals in 2010 to 2016, and (c) a sharp drop in the number of reported calves since 2008 with almost none since 2013. Before discussing possible explanations and implications of these findings, we first assess to what extent individual heterogeneity in site fidelity and movement patterns  could have influenced these results.t) has the same probability of recapture (tp) and (b) all marked individuals have the same survival probability from one sampling occasion to the next , the inclusion of a transient effect did not alter the estimate of the super‐population size from 2004 to 2010 , but was slightly more precise.Open population models, such as the CJS and POPAN models used in this study, make two assumptions that require close scrutiny: (a) every marked animal present in the population at time  only approximately adjusts for temporary emigration because recapture probabilities are made dependent on sightings during the previous capture occasion  are not applicable, the proposed categorization of individuals using cluster analysis offers a flexible alternative to minimize bias while providing additional insights into population demography. The grouping based on AHC analysis may also offer an alternative to “time since marking” (TSM) or 2 age‐class models. TSM models have been proposed to account for transients  by estimating different survival rates for the first sampling interval compared to subsequent intervals . While the drop in apparent survival estimates in the later years of the study is likely subject to some terminal bias, the inference of a deterioration in population status is supported by the negative trend in recruitment and the significant decline in super‐population size, implying that a lower number of fin whales used the JCP at any point between 2010 and 2016 compared to 2004 and 2010. The decline in survival could partly be the result of higher rates of permanent emigration compared to immigration rates.The median unisex estimate of survivorship of 0.946 (95% CI 0.910–0.967) was comparable to the estimate provided by Ramp In the period of 2004 to 2010, 20 dead fin whales were reported in the GSL, compared to six animals for 2010 to 2016 . These numbers are underestimates of true mortality rates because an unknown number of carcasses were missed or unreported. A documented cause of fin whale mortality is vessel collisions. Fin whales are the most commonly reported species in the current global vessel‐strike data set maintained by the Scientific Committee of the International Whaling Commission  of the observed decline, which we hypothesize to be the result of anthropogenic mortality events , changes in prey availability, or a combination of these factors. Failure to address these issues could result in an ongoing decline of fin whales in the GSL with unknown impacts on the balance of the GSL ecosystem.AS, CR, RS, PSH conceived the initial ideas of the study and designed the methodology; AC, CR, JD, MB, PJP, and RS collected photo‐identification data and/or skin samples; MB and PJP conducted the analysis to sex the individuals; JD, AC, CR, RS processed the photo‐ID data; AS analyzed the data; AS and PSH led the writing of the manuscript. All authors contributed critically to the drafts and gave final approval for publication. Click here for additional data file.