Animal behaviour is remarkably sensitive to disruption by chemical pollution, with widespread implications for ecological and evolutionary processes in contaminated wildlife populations. However, conventional approaches applied to study the impacts of chemical pollutants on wildlife behaviour seldom address the complexity of natural environments in which contamination occurs. The aim of this review is to guide the rapidly developing field of behavioural ecotoxicology towards increased environmental realism, ecological complexity, and mechanistic understanding. We identify research areas in ecology that to date have been largely overlooked within behavioural ecotoxicology but which promise to yield valuable insights, including within‐ and among‐individual variation, social networks and collective behaviour, and multi‐stressor interactions. Further, we feature methodological and technological innovations that enable the collection of data on pollutant‐induced behavioural changes at an unprecedented resolution and scale in the laboratory and the field. In an era of rapid environmental change, there is an urgent need to advance our understanding of the real‐world impacts of chemical pollution on wildlife behaviour. This review therefore provides a roadmap of the major outstanding questions in behavioural ecotoxicology and highlights the need for increased cross‐talk with other disciplines in order to find the answers. Iet al., 2, habitat loss; Bernhardt, Rosi & Gessner, et al., et al., et al., et al., Chemical pollution represents a leading threat to human health, wildlife, and ecosystems around the world  . Indeed, recent work embracing these innovations has revealed effects of pollutants on behavioural processes that were previously not possible to capture using conventional approaches. These range from neurotoxic insecticide‐induced migration delays in songbirds et al., et al., et al., et al., et al., et al. Given the sheer number of chemicals in commerce, one of the challenges we face is how to identify what potentially behaviour‐modifying chemicals and mixtures are present in the environment and at what levels. There are at least 350,000 chemicals and chemical combinations registered for use around the world (Wang (2)predict how chemicals interact with biological systems, which requires developing predictive approaches to identify and prioritise contaminants and mixtures that are likely (or not) to alter behaviour. In addition to facilitating the analytical chemistry advances discussed previously, computational chemistry can help to identify inherent chemical attributes and properties that are likely to interact with specific biomolecules and elicit downstream biological and behavioural responses in organisms. For example, an explosion of molecular genetic information across phyla is facilitating in silico advances in predictive toxicology and pharmacology during drug development via some direct or indirect mechanism(s) of action, and/or predicted to impact an organism's spatial pollution attraction/avoidance  in question (2)Keeping the above experimental considerations in mind, we next feature a range of future research avenues that, despite being of high ecological significance, have received relatively little attention in behavioural ecotoxicology , with subordinate fish absorbing more of the drug than dominant ones, likely due to higher ventilation and respiration rates . Such observations have been pragmatic from a laboratory experimental design perspective but often ignore behavioural variation. This is concerning because phenotypic plasticity, that is an individual's capacity for phenotypic variation under different environments, is a key determinant of performance under fluctuating conditions within their lifetime  social network structure, including the formation and consequences of dominance hierarchies; (ii) collective behaviours such as group shoaling, flocking, foraging, or collective decision‐making; (iii) how individual traits  affect group or collective behaviour; (iv) animal contests over valued resources ; and (v) classic reproductive behaviours like courtship, mating and alternative strategies, and parental care. This work can also operate beyond a single generation because an individual's behaviour can be shaped by both past and current exposure, as well as past conspecific experiences via indirect maternal/paternal effects . Among species, some of the variation in negative impacts of chemical stressors will be due to differences in physiology that underlie inherent differences in vulnerability to exposure. However, differences in behavioural responses will likely play a major role in explaining dissimilar exposure to chemicals, and in the ability of animals to compensate behaviourally, for example by increasing energy intake or via social buffering. Thus, more accurate behavioural assessments of chemical pollutants will often require a multi‐stressor approach in order to assess the simultaneous or sequential effects of chemicals with other key environmental factors within ecologically relevant conditions.Finally, to reveal patterns of effects of chemicals on individuals, animal groups, and whole community/ecosystem outcomes, a crucial need is to understand the relative impact of chemical stressors and other abiotic and biotic stressors that can have unexpected and complex effects on animal behaviour, that is we need a multi‐stressor approach et al., et al., et al., et al., There is now a tremendous variety of laboratory software and hardware options available to ecotoxicologists for capturing potential behavioural responses to contaminant exposure. For instance, cameras with high frame rates offer the temporal resolution to track behaviours that were previously not possible to capture. This includes recording high‐speed locomotion on land  with pan‐neuronal expression of the calcium indicator GcaMP6, coupled with LSM, allow for functional imaging with sub‐cellular resolution across the whole brain, which has been applied to uncover mechanisms associated with behavioural responses to drug treatments et al., et al., et al., et al., et al., When assessing possible impacts of contaminants on behaviour, a holistic approach is ideal, that is studies relating mechanistic explanations to experiments spanning laboratory, semi‐field, and field contexts. While laboratory assays provide valuable insights in a standardised setting and can be important for validating field observations , semi‐field‐ and field‐based ecotoxicology is crucial for understanding the potential impacts of contaminants in large‐scale, complex, and dynamic natural systems. Encouragingly, experimental and technological innovations continue to emerge that allow for effects of chemical pollution on animal behaviour to be measured in the field with ever‐greater efficiency and accuracy. This includes advances in remote‐sensing technology, which have revolutionised our capacity to gather high‐resolution behavioural and physiological data from animals in the wild et al., via mixed‐modelling approaches, including using movement data in the wild , non‐normally distributed, and highly structured (i.e. containing groups of non‐independent units). Such data sets require statistical approaches that are capable of appropriately partitioning and quantifying behavioural variation, while also considering the hierarchical nature of the data . One increasingly popular approach is mixed‐effects modelling  of either normally distributed response variables  or non‐normally distributed response variables, such as count, binary or proportion data . Mixed‐effects models are a sophisticated statistical tool that can be applied to analyse data that have both fixed effects  and one or more clustering (random) factors  (Bolker (2)et al., versus exposed populations), in parallel with a more ‘traditional’ mean‐focused meta‐analysis  can also be extracted, allowing for meta‐analytical comparisons of differences between the variability in groups  A brief overview of resources available for implementing mixed modelling approaches in behavioural ecotoxicology, and (b) examples of specific research questions and resources for testing potential effects of contaminant exposure on behavioural variation at the individual level.Click here for additional data file.


This review highlights the potential mechanisms of neuromuscular manifestation of COVID‐19, especially myasthenia gravis (MG).An extensive literature search was conducted by two independent investigators using PubMed/MEDLINE and Google Scholar from its inception to December 2020.Exacerbations of clinical symptoms in patients of MG who were treated with some commonly used COVID‐19 drugs has been reported, with updated recommendations of management of symptoms of neuromuscular disorders. Severe acute respiratory syndrome coronavirus 2 can induce the immune response to trigger autoimmune neurological disorders.Further clinical studies are warranted to indicate and rather confirm if MG in the setting of COVID‐19 can pre‐existent subclinically or develop as a new‐onset disease. The SARIn general, neurological symptoms comprise one of the clusters of COVID‐19 manifestations. Olfactory and gustatory dysfunctions are common presenting symptoms of mild‐to‐moderate COVID‐19 infection  receptors or their components in the postsynaptic membrane at the neuromuscular junction  antibodies  score classification I to II, demonstrating the recommendation to promote vaccination for MG patients during the still expanding COVID‐19 pandemic . The patient was also being administered pyridostigmine, which she had been previously maintained on for 4 years  related to COVID‐19. They have been used experimentally in many COVID‐19 patients and are effective in patients who had either COVID‐19‐related severe pneumonia or ARDS (Aksoy & Oztutgan, Other than myasthenia gravis, the guidelines to treat other neurological manifestations of COVID‐19 are also important to discuss. A guideline has been issued by the German Neurological Society in October 2020, which mentions a wide range of management options specific to the commonly seen neurological complications in COVID‐19 infection. The guidelines pool severe studies and have 90–100% approval rates. Table All authors contributed to the study conception and design. All authors contributed to material preparation, data collection and analysis. The first draft of the manuscript was written by Syed Muhammad Ismail Shah. All authors reviewed and contributed to the intellectual content of the manuscript. All authors read and approved the final manuscript.The authors declare no conflict of interest.https://publons.com/publon/10.1002/brb3.2789The peer review history for this article is available at


School students who are eligible for reduced or free school meals (FSM) – an indicator of economic disadvantage – have lower academic attainment than their peers.We investigated whether identity compatibility – the perceived compatibility between one’s social identities and the stereotype of a high‐achieving student – contributes to this socioeconomic attainment gap, and whether the association between socioeconomic status and identity compatibility is moderated by school context.Our sample was 4,629 students aged 15–16 years old across 29 schools in England.We assessed students’ perceptions of identity compatibility via self‐report questionnaires 8 months prior to them taking national, standardized exams.Multilevel regression analyses revealed a negative indirect effect from eligibility for FSM to exam results via identity compatibility. These effects existed even while accounting for students’ gender and language status, other psychological variables known to predict academic attainment, and their previous exam results. Furthermore, school context moderated the relationship between FSM eligibility and identity compatibility. In line with the identities in context model of educational inequalities, there was a significant negative association between FSM and identity compatibility only for students attending schools in which there was previously a relatively large socioeconomic attainment gap.Our results demonstrate the importance of social psychological variables in explaining educational inequalities, and of the local educational context in determining the educational experience of students from lower socioeconomic status backgrounds. In many Western countries, students from families of lower socioeconomic status attain lower grades in national exams, have lower progression rates to higher education, and consequently have less economically prosperous life trajectories than their wealthier peers  backgrounds in positions associated with educational attainment and prestige  SES backgrounds have been found to perceive less identity compatibility between their backgrounds and the stereotype of a university student, and this in turn predicts lower levels of identification with the university  taken in May, at the end of the same academic year. We also collated Government data on the socioeconomic attainment gap in the previous year for all schools and used this in our multilevel models to directly test our hypothesis that the pre‐existing, school‐level, socioeconomic attainment gap will moderate the association between SES – which we measure using the proxy variable eligibility for free school meals (FSM) – and identity compatibility. Our prediction is specific to the FSM‐identity compatibility association, although, for completeness, we also investigate whether the school‐level socioeconomic attainment gap moderates the FSM to exam results association, and the identity compatibility to exam results association. We expect that it will not moderate these associations.We aim to test the unique role of identity compatibility in explaining the socioeconomic attainment gap, and of the FSM attainment gap variable in moderating the FSM‐identity compatibility slope. To test the specificity of these predictions, we also include in our models two other psychological variables that have been found to robustly and strongly predict academic attainment, namely academic self‐concept and academic effort  – which are often associated with attainment , such that the association will be more strongly negative in schools with larger socioeconomic attainment gaps.Twenty‐nine schools participated in this study.n = 102 to n = 314. The proportion of pupils eligible for FSM also varied across schools, from 10% to 55%. One school was a girls‐only school, and all the others were mixed genders. All were state rather than private schools, three were Christian schools, three were secondary modern schools, and the rest were comprehensive schools.The final sample that was analysed was composed of 4,629 Year 11 students, aged 15–16‐years old, from 29 English secondary schools. Of those, 26.9% were eligible for FSM within the last 6 years, the same as the national average (27%), 51.4% were females , and 8.1% had English as an Additional Language . More information about the initial sample, the analysed sample, the sample who completed the survey, and full descriptive statistics for the analysed sample Table  are provThe following measures that are directly relevant to our hypotheses were included in a larger questionnaire relevant to the intervention. See Table Schools provided us with Unique Student Numbers (UPN) for all participating students, as well as whether students had English as an Additional Language . We used the UPNs to retrieve data from the National Pupil Database  including whether students were eligible for FSM at any point in the last 6 years , gender , and attainment data.n = 5,079 students . We controlled for students’ prior grades by including the mean of their total score in the Standardized Attainment Tests (SATs) for Key Stage 2 (KS2) English and for KS2 Mathematics , taken at age 10–11, labelled KS2 score. We had KS2 mathematics scores for n = 5,046 students  and KS2 English scores for n = 4,999 students .Our primary outcome variable was students’ attainment 8 scores, which are the average grade across eight subjects in their General Certificate of Secondary Education (GCSE) assessments (taken at the end of Year 11), with double weighting for English and mathematics , Neither agree nor disagree (4), and Strongly agree (7). We took the mean of the three items as our measure of identity compatibility. The scale had good internal reliability .We adapted measures of identity compatibility used in previous research  and academic self‐concept  had good internal reliability.We measured academic effort using the mean of slightly adapted versions of the four items from the Student Approaches to Learning questionnaire, and measured academic self‐concept using the mean of the three items from the same questionnaire  regarding the percentage of disadvantaged (FSM) and non‐disadvantaged (not FSM) 15–16‐year‐old students in each school who were awarded A* to C grades inclusive for English, Mathematics, and at least three other subjects in the GCSE exams taken in May and June 2016 (the year before our survey and attainment measures). The percentage of students at a school achieving A* to C grades is typically used by the UK Government as its criterion for good academic attainment. We computed the gap between disadvantaged and non‐disadvantaged students for each school by subtracting the percentage of disadvantaged students who achieved A* to C grades from the percentage of non‐disadvantaged students who achieved these grades. This is, therefore, a school‐level variable that we include in our models below as a school‐level predictor and in cross‐level interactions .To test our hypothesis regarding school context, we collated data from the UK government’s website  that regressed attainment 8 scores on the individual‐level variables FSM, female, EAL, and KS2 score. The results showed that all the predictor variables were associated significantly with attainment 8 scores. Confirming H1, students eligible for FSM had lower attainment 8 scores than students not eligible for FSM. In addition, females had higher attainment 8 scores than males, students for whom English was an additional language had higher scores than students for whom English was not an additional language, and KS2 score was associated positively and strongly with attainment 8 score  to attainment 8 via these psychological variables. Confirming Hypotheses 2–4, FSM negatively predicted identity compatibility, identity compatibility positively predicted attainment 8 scores, and there was a significant and negative indirect effect from FSM to attainment 8 via identity compatibility. Identity compatibility was significantly associated with attainment 8 over and above student characteristics and the other psychological variables, and was the only psychological variable to be associated significantly with FSM.In addition, EAL positively predicted identity compatibility, EAL and female positively predicted academic effort, EAL positively predicted academic self‐concept, and female negatively predicted academic self‐concept. Academic effort and academic self‐concept also predicted attainment 8 scores. We also observed significant indirect effects from EAL to attainment 8 via identity compatibility and academic self‐concept, and from female to attainment 8 via academic effort and via academic self‐concept Table .Across the next few models, we allowed the FSM‐identity compatibility, FSM‐academic effort, FSM‐academic self‐concept, FSM‐attainment 8, and identity compatibility‐attainment 8 slopes to vary across schools. To maximize power, we specified one random slope per model. All the slopes varied significantly across schools.We report the first empirical evidence that the socioeconomic gap in academic attainment is partially explained by lower levels of identity compatibility among low SES students. Previous research has found that identity compatibility helps to explain the relationship between college students’ SES and the ranking of the university they plan to apply to (Nieuwenhuis et al., It is important to note, however, that we also found that the association between FSM and identity compatibility was moderated by school context. The results showed that FSM students reported lower levels of identity compatibility than their peers, but only when they attended schools that had relatively large socioeconomic attainment gaps in the previous academic year. In schools with small or non‐existent socioeconomic attainment gaps, there was no association between FSM and identity compatibility.Interestingly, while the other associations in our model varied across schools, it was only the FSM‐identity compatibility slope that was moderated by the size of the socioeconomic attainment gap. These results provide support for the identities in context model of educational inequalities (Easterbrook & Hadden, Although this study was primarily testing theoretical predictions, it is worth considering the practical implications for interventions. Our results suggest that interventions that can reduce identity incompatibility – such as interventions that develop academic possible selves and/or raise the visibility of ingroup role models (Andriessen et al., As well as a group’s historical performance, the identities in context model stipulates that negative stereotypes, the visibility of academically successful role models, representation in positions and institutions associated with academic success, and a group’s cultural orientation towards education can all moderate the association between students’ group membership and their sense of threat and perception of identity compatibility (Easterbrook et al., Besides the findings related to our theoretical predictions, we also found evidence for a gender attainment gap, in which girls outperformed boys, which was partly accounted for by greater self‐reported effort among girls Yeung, . HoweverThere are several noteworthy strengths of the current research. We utilized a large sample of students across 29 schools and analysed the English Government’s preferred measure of academic attainment, attainment 8 scores. We also controlled for students’ gender, EAL, academic effort, academic self‐concept, and, crucially, prior academic performance within our models, allowing us to demonstrate that identity compatibility is uniquely associated with academic ability over and above these other variables. The survey measures were collected some 8 months before the exams that comprised our outcome measures, implying that the effects associated with students’ identity compatibility persist at least over the course of one full academic year.There were also some limitations of our research designs that could be improved in future research. Our results are based on correlational data and so do not allow us to draw conclusions about causality. However, the fact that identity compatibility was measured before the exams that our outcome measures were based on – by 8 months – does confirm the directionality of the relationships, if not their causal nature. We also could not include ethnicity in our models, and so can make no conclusions about whether identity compatibility plays a role in ethnic attainment gaps. This is an important gap in our knowledge that should be addressed in future research.psychological disadvantage because of social cues in the local context that are perceived as indicating that their social identity is incompatible with academic success. Our work suggests that treating academic success as something everyone can achieve may help to make educational opportunities less unequal.In summary, our results demonstrate the importance of social perceptions in explaining educational inequalities, and of understanding the role of the local educational context in determining which groups, if any, may be experiencing psychological barriers to their educational success. Students who are members of groups which have historically underperformed may be at a All authors declare no conflict of interest.Matthew J. Easterbrook: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Visualization; Writing – original draft. Marlon Nieuwenhuis: Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Writing – review & editing. Kerry J. Fox: Data curation; Investigation; Project administration; Writing – review & editing. Peter R. Harris: Conceptualization; Funding acquisition; Project administration; Writing – review & editing. Robin Banerjee: Writing – review & editing.Appendix S1. Supplementary Information.Click here for additional data file.


All UK H&I laboratories and transplant units operate under a single national kidney offering policy, but there have been variations in approach regarding when to undertake the pre‐transplant crossmatch test. In order to minimize cold ischaemia times for deceased donor kidney transplantation we sought to find ways to be able to report a crossmatch result as early as possible in the donation process. A panel of experts in transplant surgery, nephrology, specialist nursing in organ donation and H&I  assessed evidence and opinion concerning five factors that relate to the effectiveness of the crossmatch process, as follows: when the result should be ready for reporting; what level of donor HLA typing is needed; crossmatch sample type and availability; fairness and equity; risks and patient safety. Guidelines aimed at improving practice based on these issues are presented, and we expect that following these will allow H&I laboratories to contribute to reducing CIT in deceased donor kidney transplantation. The workshop, organized by the British Society for Histocompatibility and Immunogenetics (BSHI), was convened on 22 March 2019 in order to provide guidance on crossmatching for kidney transplantation from deceased donors in the United Kingdom. The brief was to resolve differences in crossmatch practices in relation to when a result becomes available (but not how crossmatching is performed). The overall aim was to minimize cold ischaemia time (CIT) and improve patient outcomes by agreeing ways to enable a crossmatch test to be performed as early as possible in the donation process.The United Kingdom has a single kidney offering policy that all transplant units follow . These two factors are of course related; highly sensitized patients have tended to wait longer than less sensitized patients. This means less concern with HLA mismatches, which is supported by evidence showing a reduced influence of HLA matching on transplant outcomes . Compatibility can be determined directly by testing the reaction in a crossmatch (XM) between recipient serum and donor cells, typically leucocytes (LXM). The LXM can be performed using cells from donor lymph nodes or spleen, or donor peripheral blood lymphocytes (PBLs). Lymph nodes and spleen are only available after organ retrieval, whilst PBLs can be taken from the potential organ donor prior to removal of the kidneys. Alternatively, HLA antibody compatibility can be assessed by prediction when a recipient's HLA‐specific antibodies have been sufficiently characterized and the donor's corresponding HLA alleles have been identified .All UK H&I laboratories regularly test waiting list patient samples from the transplant units they support  assays, as summarized in a review by South and Grimm . The incParallel to this, HLA typing methodologies have evolved with the introduction of rapid DNA‐based testing, such as PCR‐SSP, PCR‐SSOP and subsequently, real‐time PCR (or q‐PCR), which permit typing of HLA‐A, ‐B, ‐C, ‐DRB1/3/4/5, ‐DQ and –DP, enabling a detailed characterization of HLA for deceased donors in a rapid timeframe. More recently, methodologies that can provide DNA sequencing in the required time frame have been developed  XM with no day of transplant sample testing required. Others will perform a day of transplant Luminex antibody test to facilitate a VXM. In all situations, the effective use of a VXM is dependent on correct and adequate donor HLA typing together with up to date information regarding the potential recipient's HLA antibody screening and sensitization history ‐specific antibodies is currently problematic for two main reasons. If a target cell is used, then this must be known to express the relevant antigen or antigens. This approach has been tested for potential endothelial cell markers but the evidence that such a test is predictive of rejection or transplant outcome is mixed  alloantibodies, a specific incompatibility cannot be deduced as, currently, deceased donors are only typed for HLA, ABO and Rh. Pre‐transplant testing of these antibodies, whether allo or auto, is also required to reliably interpret a XM, and essential for a VXM, but this is not routinely undertaken in the United Kingdom as the level of evidence was insufficient at the time of development of the relevant guidelines  system has been used to rate the strength of evidence and the strength of recommendations .Grade B evidence means moderate‐quality evidence from randomized trials that suffer from serious flaws in conduct, consistency, indirectness, imprecise estimates, reporting bias or some combination of these limitations, or from other study designs with special strength.Grade C evidence means low‐quality evidence from observational evidence, or from controlled trials with several very serious limitations.Grade D evidence is based only on case studies or expert opinion.For each recommendation the quality of evidence has been graded as A (high), B (moderate), C (low) or D (very low):Level 1 (we recommend)Level 2 (we suggest)For each recommendation, the strength of recommendation has been indicated as one of:Not graded Level 1 recommendation is a strong recommendation to do (or not to do) something where the benefits clearly outweigh the risks (or vice versa) for most, if not all patients.A Level 2 recommendation is a weaker recommendation, where the risks and benefits are more closely balanced or are more uncertain.A 3Objective 1. Address the impact of the reporting time of a crossmatch on the overall time in the transplant pathway. The key issues identified are, first, where a prospective crossmatch is required; a transplant cannot proceed until said crossmatch is completed. Second, in the United Kingdom, the positive crossmatch rate is around 2.5% (based on data between 2010 and 2015) (ODT Statistics and reports) and the organs in these cases require re‐offering and potentially a further crossmatch. Third, there are logistical issues around access to theatres for transplantation with kidney transplantation not always being given sufficient priority for operating theatre availability. Therefore, the availability of a crossmatch result ahead of organ arrival is an aid to surgical planning.3.1To overcome this, we recommend that a crossmatch result (either VXM or LXM) for a particular recipient must be reported before the organ arrives at the transplant centre, both LXM and VXM procedures will allow this (Grade 1B).If a VXM is not possible then we recommend that where possible, pre‐retrieval donor blood samples must be used when a LXM is required (Grade 1B).Objective 2. Overcome concerns around quality assurance and accuracy of deceased donor HLA typing and virtual crossmatching strategies. It is now recognized that alloantibodies can be stimulated by all the classical, polymorphic HLA proteins   is generally required for crossmatch interpretation , or where the intended recipient has known donor HLA‐specific antibodies, a pre‐transplant LXM must be performed (Grade 1B).A retrospective LXM (e.g. using cells from the donor spleen or lymph node) may be undertaken when a pre‐transplant VXM has been used. However, if an audit of sufficient cases shows concordance between the initial VXMs and subsequent LXMs then the latter can be safely omitted (Grade 2B).Objective 3. Address issues relating to donor sample availability and quantity. The timeliness of reporting a prospective crossmatch will depend on early taking of donor blood samples arranged in advance between the laboratory, clinical and donation teams. There are many demands for donor blood samples and anecdotal evidence suggests that excessive blood taking may be harmful to the donor and compromise their donated organs.3.3We recommend that peripheral blood for crossmatch testing must only be requested and sent on demand. Therefore, when a VXM is to be used, crossmatch samples must not be taken from the donor pre‐transplant (Grade 1B).When PBLs for LXM are required, up to a maximum of 40 ml of peripheral blood in EDTA should be requested unless there are exceptional circumstances. In this scenario, the H&I laboratory can request a volume as required for locally validated procedures (Grade 1B).Pre‐retrieval crossmatch donor blood must be taken and sent as expeditiously as possible (Grade 1B).Spleen or lymph node samples must be taken at the time of organ retrieval in all cases  (Grade 1A).It should be noted that geographical considerations may need to be taken into account when considering feasibility of use of PBLs for LXM, namely time and cost taken to ship the samples, particularly where long distances are involved.Objective 4. Ensure fairness and equity for all potential transplant recipients as immunologically high‐risk cases tend to wait the longest for a transplant. The interpretation of a crossmatch in such cases tends to be complex, requiring more information. A comprehensive and up‐to‐date HLA serological history, according to national and other guidelines .The crossmatch test should be regarded as an enabler of safe transplantation, rather than primarily a tool to prevent transplantation, particularly for sensitized patients and local policy developed with this in mind . This can be achieved through the development of good working relationships between the clinical team and the laboratory, and the process documented in local policy.Non‐HLA donor‐specific antibodies are outside the scope of this guidance (Grade 2D).All authors participated in the working group, contributed to these guidelines, and have read and approved the final manuscript. SP and DB prepared the following text.


Similar intracellular inclusions of ACC have also been observed in prokaryotic organisms. These comparable biomineralization processes involving phylogenetically distant microorganisms are not entirely understood yet. This review gives a broad vision of the topic in order to establish a basis for discussion on the possible molecular processes behind the formation of the inclusions, their physiological role, the impact of these microorganisms on the geochemical cycles of AEM and their evolutionary relationship. Finally, some insights are provided to guide future research.An unsuspected biomineralization process, which produces intracellular inclusions of amorphous calcium carbonate (ACC), was recently discovered in unicellular eukaryotes. These mineral inclusions, called  Biomineralization is a biologically controlled process by which living organisms form minerals from the selective extraction of certain chemical elements present in their environment Mann, . Some auA large number of organisms form minerals (from prokaryotes to pluricellular eukaryotes) and this process can take place at different locations: (i) in the extracellular space (outside the cell), (ii) in the intercellular space (between cells), (iii) in the epicellular space  or (iv) in the intracellular space (inside the cells) Mann, . For sim3O4) or greigite (Fe3S4), acting as geomagnetic field sensors  shells, known as frustules, that act as exoskeletons and confer protection against mechanical stress and UV light .Calcium carbonate biominerals are the most abundant and widespread minerals among organisms  that produce calcium carbonate to form respectively, epicellular shells and scales that act as protective structures  : from cyanobacteria  during a routine examination of plankton using scanning electron microscopy (SEM)  has been identified as the organism forming Sr‐rich ACC inclusions in Lake Geneva  and Scherffelia (including a single freshwater species)  Fig. .et al., et al., T. striata, T. chui, T. levis, T. suecica and T. tetrathele explains the four longitudinal alignments of micropearls appearing at the apical pole of the cell (observed as three equidistant lines in the SEM because one line is hidden at the other side of the cell) since the inclusions are occupying the interlobular spaces of the chloroplast  observation of ultra‐thin cross‐sections of different Chlorodendrophyceae algae shows that the inclusions are located close to the cell surface, under the plasma membrane Fig.   show a similar distribution pattern of the micropearls   tend to be colonial and form sessile structures.There also appears to be a relationship between the habitat of the organisms and the shape and distribution pattern of the micropearls  Fig. . In addic.) Fig.  and 3C, c.) Fig. . Chlorodet al., SEM observation of the organisms forming Ba‐rich ACC inclusions in Lake Geneva indicates that they are unicellular eukaryotic organisms with cell sizes varying between 10 and 20 μm and two flagella emerging from one cell pole Fig. . The smaet al., et al., TEM‐energy‐dispersive X‐ray spectroscopy analyses of ultra‐thin cross‐sections of Ba and Sr‐rich micropearls, obtained by focused ion beam technology (FIB), reveal internal concentric zonation (nanometric concentric layers of different atomic masses) corresponding to variations in the Sr/Ca and Ba/Ca ratios around a rod‐shaped nucleus Fig. . In bothTetraselmis strains: T. desikacharyi micropearls present the highest Sr/Ca ratio compared with the culture medium composition (>300 times higher), while T. contracta and T. cordiformis are the strains showing the lowest Sr accumulation capacities   had revealed in 2012 the presence of intracellular ACC bioprecipitates in the early‐branching microbialite cyanobacterium , et al.  showed tG. lithophora were observed using SEM (in secondary electron and backscattered electron modes) as bright and spherical inclusions with an average diameter of 270 ± 44 nm  presented a different distribution pattern of intracellular ACC inclusions, lying at the cell poles and, sometimes, in the middle of the cells Ca6Mg(CO3)13). Ba/Ca and Sr/Ca atomic ratios were respectively 1370 and 86 times higher than in the growth medium, suggesting the implication of active import mechanisms to selectively concentrate these elements  can be composed of pure Ca, pure Ba, or almost pure Sr compounds, while the outer part  can be composed of either one or more layers, each enriched in one of these elements.SAED showed the amorphous structure of the inclusions of et al., et al., et al., G. lithophora cultures with an initial concentration of 250 μM of Ca, 50 μM Sr and 50 μM of Ba, a decrease of Ba in solution is noticed first, followed by the decrease of Sr and finally of Ca. However, Cyanothece sp. does not show the selective incorporation of Sr and Ba under the same culture conditions as G. lithophora, and the layered structure of the carbonate inclusions is not observed, suggesting that the preferential uptake of Sr and Ba is not a common feature to all ACC‐forming cyanobacteria  and can constitute temporary storage deposits, a stiffener of certain tissues, or a precursor phase of a crystalline mineral  shot up the growth rate. In non‐ACC‐forming cyanobacteria, the growth is barely affected by an initial Ca deficit. Hence, it has been suggested that a high Ca accumulation is essential for the growth of ACC‐forming cyanobacteria , and changing the swimming direction of the cells  to brackish water and seawater . Lifestyles are also varied among the different strains: they can be found in the sediments (i.e. T. contracta) or the water column , as temporary sessile colonies or as free‐swimming organisms , most of the cyanobacteria known today to form carbonate inclusions were obtained from culture collections . The origin of the collected strains was very diverse: from German soils to rice fields in Senegal and hot springs in the USA and Japan  shows the capacity of this organism to buffer the dissolved Ba/Ca and Sr/Ca ratios at low values , which causes their spontaneous transformation into calcite  since both genera form micropearls .The eukaryotic organisms forming intracellular Ba‐rich ACC inclusions observed in Lake Geneva remain a mystery and not much can be said about their phylogenetical position. However, there are certain similarities between these organisms and the ciliates described by Fauré‐Fremiet and Gauchery , some ofet al., et al., et al., et al., Achromatium is the only genus included in the class Gammaproteobacteria that is known to date to form intracellular ACC inclusions , relying on different molecular processes. Then, this biomineralization capacity may have been subsequently transmitted to species included in the same clade through a common ancestor. For instance, this could explain why ACC inclusions in microalgae have only been observed in the class Chlorodendrophyceae, and why some differences in the shape and distribution patterns of micropearls have been noticed between species, as a result of adaptation to different environments (divergent evolution) (Martignier 90Sr remain crucial to investigate the feasibility of using ACC‐forming microorganisms for the development of new bioremediation methods. Further comparative genomic analyses are necessary to identify the molecular mechanisms involved in the formation and stabilization of the ACC inclusions. Experiments involving isotope labelling could also provide insight into the cellular pathways related to their formation. In addition, the detection of culture conditions affecting the formation of the ACC inclusions could shed light on their biological role. Finally, future molecular phylogenetic studies are essential to understand the origin of these processes and their diversification among microorganisms.Future research efforts to describe the biomineralization processes leading to the formation of intracellular ACC inclusions in microorganisms are needed to answer unresolved questions. In‐depth analyses of the variations in the chemical composition of the media where the ACC‐forming microorganisms are cultured will provide additional information on the AEM uptake kinetics and their impact on the geochemical cycles. Moreover, additional experiments involving cultures with added 90Sr pollution, also because they can be found in very different living environments. The biological functionality of the ACC inclusions, as well as the molecular processes involved in their formation, is not clear yet and require more in‐depth research. The occurrence of intracellular ACC inclusions in phylogenetically distant groups of microorganisms suggests an independent evolution leading to similar biomineralization processes.Originally, the biomineralization of calcium carbonate was mainly thought to be an extracellular process in microorganisms; however, recent studies have shown that the formation of intracellular ACC inclusions is a widespread phenomenon in both prokaryote and eukaryote unicellular organisms. These inclusions can be observed using SEM and TEM, with an appropriate preparation and DIC optical microscopy for living organisms. Many of the organisms possessing this newly discovered biomineralization capacity can concentrate Ba and/or Sr and may thus have an impact on the geochemical cycle of AEM. This peculiar feature makes these microorganisms to be considered interesting candidates to develop new bioremediation technologies regarding Ba and radioactive


This led to the development of polygenic risk scores (PRS) that can be used to stratify populations at risk for the development of common diseases. Recent studies using data from the UK Biobank and the USA Million Veteran's studies provided reliable PRS that can be applied to identify individuals at risk for the development of commonplace diseases such as diabetes, hyperlipidaemia and cardiovascular disorders. Integrated risk scores combine PRS with demographics, anthropometrics and clinical measurements to estimate specific disease risk based on these established risk factors.2The rapid development of metabolic syndrome complications in the transplant setting provides a more expedition and unique opportunity to test whether PRS can identify individuals at risk, set up preemptive protocols for the prevention of complications and determine whether changing the genetic environment via the introduction of the donor PRS can alter the clinical outcomes. Clinical studies using large databases demonstrated that within 12 months after transplantation, the incidence of new onset diabetes in all recipients is 15%–30%.3n = 1146) and kidney (n = 533) transplant recipients for whom both recipients’ and their paired donors’ DNA were available, and for whom we had appropriate pre‐ and post‐transplant medical records which allowed the confirmation of the new onset of T2D.In our recent manuscript published in Nature Medicine,At first, we confirmed the association of T2D‐PRS for the diagnosis of T2D prior to transplant among kidney or liver transplant candidates. Next we tested whether T2D‐PRS are able to predict the development of PTDM in all transplant recipients Table . To foll4It was equally important to determine whether donor‐specific T2D‐PRS are transferred with the donor organs. Our analyses demonstrated that kidney donors’ genetic risks do not impact the recipients’ risk for the development of T2D. However, the transplanted liver grafts do appear to carry the donors’ genetic risks into the recipients, modifying the probability of developing PTDM. This should be expected finding, considering the involvement of the liver in regulating hepatic glucose output and its crucial role in the maintenance of normal glucose homoeostasis.5The novel findings from our study set the stage for designing prospective randomized studies in the transplant setting to determine whether the application of T2D‐PRS, which was explored in the population‐level, can indeed predict outcomes in individual recipients. Studies in this area would be an excellent proof of principle of whether genetic testing can or should be used on more routine basis in any clinical setting. The high incidence and rapid expression of complications following transplantation that are predictable using PRS allows for the practical design of clinical trials to test the hypothesis in relatively small cohorts over the short time of post‐transplant follow‐up.Cost–benefit analyses of preemptive treatment strategies should be aimed at obtaining GWAS using Single nucleotide polymorphism (SNP) arrays in all transplant candidates. This would be an achievable goal with a relatively inexpensive test that can provide sufficient genetic data to determine multiple PRS for common metabolic and cardiovascular diseases. This valuable information will allow for a personalized approach to the management of immunosuppression, such as use of a steroid‐free protocol in order to reduce the incidence of T2D, more intense monitoring of glucose levels in the higher T2D‐PRS recipients or the avoidance of mTOR inhibitors in those who are found to have higher lipid‐PRS.Our observations could also have significant implication in the living donor setting where prospective donor genetics can be analysed before donation and may be considered part of a selection process to determine which donor has the most favourable compatibility impacting the well‐being of the recipient. For example, it may be questioned whether it is appropriate to test T2D‐ and/or lipid‐PRS in the case where two adults wish to donate a liver segment for a child, as selecting the individual with a more favourable PRS may save the child from long‐term cardiovascular complications that are transferred with the liver segment.Our recent explorations present the potential for a unique and realistic application of PRS in prospective randomized studies in the transplant setting, and the relative short‐term follow‐up that is needed will provide an important proof of principle data to determine the utility of PRS in precision medicine.


Urachal cancer is a rare non‐urothelial malignancy that involves the urachus, often occurring at the junction of the urachal ligament and the bladder dome. It accounts for less than 1% of all bladder tumours. Cancer during pregnancy is rare, with the incidence of all cancers in pregnancy estimated to be 25–27 per 100 000 pregnancies. Urachal cancer in pregnancy is an even rarer phenomenon, with only a handful of case reports published to date. After a systematic review, only five cases have been reported in the English literature. We aim to review the cases presented in the literature and to examine the outcomes of the management of urachal cancer in pregnancy to date. Urachal tumours display adenocarcinoma histology and are believed to originate from residual enteric rests during embryological development or from metaplastic change of the urachus.Historically, the prognosis of urachal cancer was reported as dire due to its aggressive nature and diagnosis at advanced stages, with up to 21% of patients with primary metastatic disease at time of diagnosis.Cancer during pregnancy is rare, with the incidence of all cancers in pregnancy estimated to be 25–27 per 100 000 pregnancies.2This review was performed according to the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) statement and PRISMA checklist. Three databases were searched including Pubmed, Medline, and Embase. The search was conducted on the articles of the last with no year restrictions. Search terms included were [‘urachal cancer’ OR ‘urachal mass’ AND ‘pregnancy’]. A language restriction to English papers was applied.All age groups were included. Duplicate studies and non‐English studies were excluded. The abstracts reviewed by the four authors  independently for inclusion and exclusion criteria. Disagreement resulted in exclusion of the articles. Articles that met the inclusion and exclusion criteria after the three independent authors review were included, the selection process outlined in Figure Data extracted include patient details, gestational age at diagnosis, method of diagnosis, termination of pregnancy status, management, and outcomes.3The average age was 34 and ranged from 28 to 42. The average gestational age at diagnosis was 21 weeks and ranged from 8 to 38 weeks. Two of the patients presented with gross haematuria,A summary of these cases will be provided in Table 4n = 4/24) with urachal cancer had positive urine cytology, whereas Ashley et al. showed only 34% of their patients (n = 13/38) had positive urine cytology.Urachal cancer in pregnancy is rare but can be associated with poor outcomes if presenting with advanced disease regardless of pregnancy status, common given patients are often asymptomatic in initial stages. Therefore, early recognition and definitive treatment is paramount in obtaining good outcomes. Urachal cancer should be suspected in pregnant patients presenting with gross haematuria, abdominal pain or recurrent urinary tract infections which shows concordance with presentations in non‐pregnant patients.n = 45/142) had CT findings of calcifications therefore the absence of calcification does not necessarily rule out urachal adenocarcinoma.Imaging is an invaluable tool for diagnosis. The use of ultrasonography (US) is safe in pregnancy can reveal a supra‐vesical mass contiguous with the dome of bladder. The most common finding is a mass with low‐attenuation component with calcifications reflecting the mucinous content of the tumour.n = 47), it was shown that cystoscopy under regional or general anaesthesia is indicated and has been safely performed if suspecting bladder cancer regardless of gestational age.In addition to clinical examination and imaging, cystoscopy is the most important diagnostic tool for urachal cancer. In a systematic review done by Szarvas et al. in 2016, from 276 patients with data on cystoscopy, a positive finding was demonstrated in 245 of these patients (89%).The recommended treatment for nonmetastatic urachal cancer is surgery. Both partial and radical cystectomy provide comparable oncological results. As partial cystectomy provides a higher quality of life given its organ‐preserving nature, it should therefore be the preferred option.Systemic chemotherapy in urachal cancer is mainly empirical due to the lack of randomized studies in such a rare malignancy. Siefker‐Radtke et al. have demonstrated that the highest response rates in patients receiving 5‐fluorouracil (5‐FU)‐based and cisplatin‐based therapies with a combination of the two providing the most favourable response in metastatic urachal cancer, with a suggestion of 30–40% radiographic response rates.It is important to state that uncertainty exists regarding the junction between second and third trimester pregnancies, on whether to perform surgical resection with risk of premature delivery or miscarriage versus delay in treatment leading to progression of disease. Ultimately, the decision is a shared process between the patient and their family, the urologist and the obstetrician.5In summary, urachal cancer is a rare occurrence in pregnancy but can pose a management conundrum even for the most experienced urologists. Urachal cancer is an aggressive form of cancer that needs to be promptly diagnosed and managed, preferably with a multi‐disciplinary team. Pregnancy should not be a contraindication to patients undergoing radical operative management aiming for curative intent for urachal cancer. Surgery during all trimesters can be performed safely, whereas systemic chemotherapy can be safely administered in the second or third trimester, although this has not been proven to improve outcomes. More prospective data are required to determine optimal chemotherapy regimens and outcomes of treatment of urachal cancer specifically in pregnancy, perhaps in the form of a registry.No potential competing interest was reported by the authors.Figure S1. PRISMA flow diagramClick here for additional data file.


Ecological resilience has become a conceptual cornerstone bridging ecological processes to conservation needs. Global change is increasingly associated with local changes in environmental conditions that can cause abrupt ecosystem reorganizations attending to system‐specific resilience fluctuations with time (i.e. resilience dynamics).Here we assess resilience dynamics associated with climate‐driven ecosystems transitions, expressed as changes in the relevant contribution of species with different life‐history strategies, in two benthopelagic systems.a concentration more than any other stressor. The response in Northern Spain indicated a more overarching regime shift than in the Alboran Sea. Opportunistic fish were unfavoured in both ecosystems in the recent periods, while invertebrate species of short life cycle were generally favoured, particularly benthic species in the Alboran Sea.We analysed data from 1994 to 2019 coming from a scientific bottom trawl survey in two environmentally contrasting ecosystems in the Western Mediterranean Sea—Northern Spain and Alboran Sea. Benthopelagic species were categorized according to their life‐history strategies , ecosystem functions and habitats. We implemented an Integrated Resilience Assessment (IRA) to elucidate the response mechanism of the studied ecosystems to several candidate environmental stressors and quantify the ecosystems’ resilience. We demonstrate that both ecosystems responded discontinuously to changes in chlorophyll‐The study illustrates that the resilience dynamics of the two ecosystems were mostly associated with fluctuating productivity, but subtle and long‐term effects from sea warming and fishing reduction were also discernible. Such dynamics are typical of systems with wide environmental gradient such as the Northern Spain, as well as systems with highly hydrodynamic and of biogeographical complexity such as the Alboran Sea. We stress that management should become more adaptive by utilizing the knowledge on the systems’ productivity thresholds and underlying shifts to help anticipate both short‐term/less predictable events and long‐term/expected effects of climate change. The study demonstrates that similar primary productivity shocks in the Western Mediterranean triggered benthopelagic community shifts in neighbouring ecosystems exhibiting contrasting resilience dynamics and contribution of species with different life‐history strategies. Here, we focused on the demersal and megaepibenthic community of the continental shelf , sea surface temperature (SST) and an integrated Regional Hydroclimatic Index (RHI). These variables were selected attending to observed species‐specific responses and low trophic level effects in previous studies in the same areas, in both pelagic and demersal ecosystems .With regards to environmental data, we focused on three potential drivers of the biological system: chlorophyll concentration  for 1992–2019. Anomaly fields were retrieved at a monthly scale for air temperature, sea surface temperature, atmospheric sea level pressure, 500 hPa geopotential height and precipitation rates. The RHI quantifies an integrated hydroclimatic variability at regional scale synthesizing the aforementioned variables by means of the first axis of a Principal Component Analyses (PCA). High RHI values are associated with higher atmospheric sea level pressure and 500 hPa geopotential height, and negative values with high precipitation rate, both in Northern Spain and in Alboran.To calculate a Regional Hydroclimatic Index (RHI), several environmental variables were obtained from the NCEP‐DOE Reanalysis 2 fields provided by NOAA  coupled to the General Estuarine Transport Model (the GETM 3D hydrodynamic model), as described in Macias et al.  using an orthogonal transformation of the data to a new coordinate system , modified to account for temporal autocorrelation  retained to be further analysed within the IRA was selected based on its capacity to capture directional changes and non‐overlapping states, and on the degree of its coupling with the environmental variables. To identify the key species driving the community trends through time, the contributions of all species on PC‐scores (loadings) of the retained PCs were checked.a, SST and RHI), the fits of relevant generalized additive models (GAMs) and non‐additive threshold GAMs (TGAMs) at 0‐ to 2‐time lags were compared. The effect of the stressors on the system was examined at 0‐ to 2‐year lags to account for a potential delay in the environmental effect on the community sampled given that environmental effects typically influence spawning and early life stages, while the sampled biomass is usually dominated by specimens older than 0 years old. This maximum of 2 years is in line with previous Mediterranean studies . Crustaceans and cephalopods have life cycles of 2–3 years and 1 year, respectively.To investigate the type of the relationship between the biological system, as captured by PC1 or PC2, and each of the environmental stressors  in a specific year supporting the occurrence of a regime shift , the sum of the horizontal distance of each annual system state from the tipping point of its regime minus the vertical distance of each annual system state from its fitted attractor (TGAM branch) was used . The stability landscape with its alternate basins of attraction emerged through linear interpolation of all rResy values onto a 100 × 100 grid.In both Northern Spain and Alboran, the branches of the respective optimal TGAMs identified earlier  were considered as the attractors forming the fold bifurcations, in accordance with the theory of critical transitions  and unfavoured (‘losers’) during 1994–2019 with regards to their taxonomy, habitat, life‐history strategies and temperature preferences, we calculated a range of different biomass indicators using the same set of species as in the optimal PCAs described in Section Conger conger and species of gadoids such Merluccius merluccius and Phycis blennoides, and also monkfish species (Lophius spp). The equilibrium strategy characterizes species with long length and life span and high trophic level, low fecundity but large offspring size and high parental care, such as most elasmobranchs. This strategy is favoured in more stable, less impacted and more predictable environments. Pecuchet et al.  being relatively more influenced by environmental variability. Prior to the calculations, to give an equal weight to all species and avoid a higher influence of species with higher mean biomass, log‐transformed biomass of each species was standardized (mean of 0 and standard deviation of 1).AQUAMAPS database (https://www.aquamaps.org) to extract the optimal temperature of the habitat distribution for each species, using only the area of distribution of species with probability of occurrence higher than 50% and weighing the temperature by the probability of occurrence. For the few species for which the information was not available in AQUAMAPS, we calculated their preferred temperature based on the mean value of the presence data recorded in the Ocean Biodiversity Information Systems . Finally, we calculated the community‐weighted mean temperature , in which the errors are allowed to be correlated attending to their level of autocorrelation structure. In most cases, this structure takes the form of an autoregressive process of order 1 (i.e. corAR1)—that is, an autoregression mode that forecasts the model errors using a linear combination of their past values, being lagged one year in the case of corAR1. Only those models with statistically significant trends were identified and presented in the relevant figures.All the time series of life‐history contributions, taxonomic groups and CWMT were explored in relation to the putative regime shifts identified. In addition, temporal trends were statistically tested in all the species’ indicators fitting linear models using generalized least squares . The biomass of benthic cephalopods also increased after ca. 2007, with a progressive increase also observed in the benthic crustaceans , mainly referring to sparids and carangids  is critical at the community level. While the two areas studied here are associated with different productivity regimes with a higher spatial complexity of the phytoplankton blooms in Alboran  can be facilitated by a long‐term continuous anthropogenic degradation, warming or other major ecosystem reorganization. This can be the case in the long‐lasting multi‐impacted Mediterranean Sea where a major reorganization in species composition occurred in the mid‐1990s , attributed to the combination of sea warming and changes in major hydroclimatic modes (Alheit et al., The regime shifts described in this study comply with the properties defined by the theory of critical transitions in complex ecological systems (Scheffer et al., Most marine stewardships worldwide are currently working towards climate resiliency in ecosystems management (e.g. Holsman et al., The authors have no conflict of interest to declare.M.H. and P.V. designed the study; A.E. and C.G.‐R. collected the field biological data; E.G.G. extracted the chlorophyll data; P.V. and M.H. analysed the data, prepared the figures and lead the writing. All authors contributed substantially to the concepts and revising of the manuscript and approved the final version.Supplementary MaterialClick here for additional data file.