Rising levels of psychopathology in the adolescent population have been evidenced in the last few years throughout the Western world. We aim to examine how contemporary neuropsychiatry is changing in Northwestern Italy and how this impacts inpatient services.The present research considered the 1177 admissions to a public neuropsychiatric inpatient service in the 2007–2017 decade. The annual percentual change (APC) was analysed for the total admissions, the number of the neurological vs psychiatric admissions, the length of inpatient stay, and the mean age at admission, also accounting for sex differences. The annual trend was also calculated for each diagnosis.The overall number of inpatient admissions decreased significantly (APC = − 5.91), in particular for children under 12 years of age (APC = − 7.23). The rate of neurologic diagnoses significantly decreased (APC = − 26.44), while the length of the inpatient stay (APC = 6.98) and the mean age at admission (APC = 6.69) increased. Among the psychiatric diagnoses, depression significantly rose (APC = 41.89), in particular among female adolescents (APC = 40.30).These data document a substantial change in the utilization of inpatient neuropsychiatric services for children and adolescents, with a major increase in psychiatric hospitalizations and a parallel decrease in neurological ones. These trends call for greater attention to early preventive intervention in mental healthcare system. Psychopathological problems of the teenagers are growing in Italy as well as in the rest of Western world , 2. A nuThe increase of adolescence psychopathology is crucial because it impairs the current social and relational functioning of the youth with possible consequences for his/her family adjustment, personality development, and academic career . It may The psychopathological expressions of the adolescents require specific therapeutic and management approaches which differ from those of early childhood psychiatry. Often the adolescents display physical characteristics which are similar to those of the adults and their psychopathological expressions are often characterized by self-harming or violent behaviours . It is fFrequently, the increase in the use of emergency services to manage the adolescents with a mental disorder is also consequent to the sense of impotence of the family in containing the adolescent offspring. The contemporary changes in social and relational dynamics leading to a reduction of the role of authority in the familial relationships may have contributed to contemporary inability of parents in establishing relations of authority and hierarchy to contain the adolescent on the affective and regulatory side of the parenting relationship .Current literature evidences that the parents are often thwarted to build and manage a relationship with their children also because personal problems . SometimClinicians perception support rise in psychopathological diagnoses and inpatients admissions among adolescents . At the The present paper reports the picture of 11 years of observation of the inpatient admissions into a Neuropsychiatric Inpatient Service of an Italian paediatric hospital showing the trend of inpatient admissions with respect to the sex and age of admission, diagnosis and the length of inpatient stay. A better insight into this phenomenon may be useful for planning future organization of child and adolescent therapeutic services and also to adopt prevention strategies involving paediatricians, families and child and adolescent psychiatrists.All the admissions to the Neuropsychiatric Inpatient Service of the Regina Margherita Paediatric Hospital (OIRM) in Turin over the eleven years 2007–2017 were examined. This service has a function of hub for the northwest region of Italy called “Piedmont and Valle D’Aosta” (PIVA), where it has been the only neuropsychiatric inpatient service through 2017. The region includes urban, industrial, and rural areas, and is home to about 4.5 million people.The available data consisted in: diagnosis at discharge, patient age and gender at admission, number of admissions for each month of the year, and length of hospitalization.Inclusion criteria: they were considered in the data elaboration 1. all the hospital admissions with a minimal duration of 2 days (48 h); 2. the admissions for which the neuropsychiatric diagnosis at admission was confirmed at discharge. The 48 h stay for admissions is the time-limit for the administration of the hospital for asking reimbursement to health authorities. Admissions with shorter duration are invalidated.During the considered decade the neuropsychiatric inpatient service of the Regina Margherita Paediatric Hospital (OIRM) was the only emergency centre for child neuropsychiatry in the entire PIVA region. So hospital admissions were regulated with an absolute priority for those from the emergency room and a relative priority for those from the hospital's paediatric wards who temporarily admitted neuropsychiatric patients from the emergency room  who found no place in the neuropsychiatric department. All other elective admissions agreed with the territorial services had a lower priority. The present study included all the patients admitted to the inpatient service from any of these possible sources. The decision of admission was entirely based on the severity of the disorder and the impossibility of the other services  to manage it out of the inpatient service. All admitted patients access into the hospital through the Emergency Service where the degree of severity of their disease is evaluated by the neuropsychiatric emergency doctor, so the criteria for inpatient admission are homogeneous. This is why the number of hospitalizations in the neuropsychiatric hospital service is an indicator of the need for emergency neuropsychiatric hospitalizations in the region.The study consisted in analyses of clinical and administrative data that had been collected as part of routine practice. The privacy of the sensitive data was protected during the analyses.. Time-trend analysis was based on annual incidence rates by age groups . The trend over time was estimated as the Annual Percent Change (APC) and relative 95% CI in the incidence rate using Poisson regression analysis separately by sex and adjusted for age [The age-standardized incidence rate  and the relative 95% confidence interval (95% CI) was estimated for each diagnostic category overall and separately by sex (per 100.000). Population data between 2007 and 2017 were obtained from census data and annual inter-census estimates provided by the Evolutionary Demographic Database of the Piedmont Region . Time-tr for age . All theA total of 1177 inpatient admissions were considered in the final analysis. The age at admission ranged from less than one year to 17 years.Overall there were 261 ICD-9 primary diagnoses, which were grouped into 26 diagnostic groups according to ICD-11 classification. We included in a larger group all diagnoses with less than five cases in the considered 11 years .n = 238), Disruptive Behaviour Disorders (n = 114), Somatoform Disorders (n = 103), Psychotic Disorders (n = 97), Personality Disorders (n = 84), Major Depression (n = 63), Self-poisoning (n = 45), Autism (n = 23), Obsessive–Compulsive Disorders (n = 18), Adjustment Disorders (n = 15), Post-Traumatic Stress Disorder (n = 14), Phobias (n = 12), Tourette Syndrome (n = 12), Panic Attack and Agoraphobia (n = 8), Substance Abuse (n = 6), Maltreatment (n = 6), residual psychiatric diagnoses (n = 13).The total number of hospitalizations with a psychiatric diagnosis was 871, subdivided into the following 15 diagnostic groups: Eating Disorders (n = 16), Epilepsy (n = 161), CNS Injuries (n = 38), Neurodevelopment Disorders (n = 18), Traumatic Injuries (n = 13), Visual System Disorders (n = 8), Muscle-skeletal Disorders (n = 8), Headache (n = 6), Rheumatic Chorea (n = 5). Thirthy-three patients were excluded from the analysis for missing data.The total number of hospitalizations with a neurological diagnosis was 273, subdivided into the following 11 diagnostic groups: PNS Injuries  inpatients admissions and the decreasing trend for Autism (APC = − 14.80) inpatients admissions.Among neurological diagnoses, a significant decrease was evidenced for Neurodevelopmental Disorders APC = − 27.17), CNS Injuries (APC = − 16.16), PNS Injuries (APC = − 15.63), and Muscle-skeletal disorders (APC = − 26.01), adolescence Epilepsy (APC = -26.66) and CNS Injuries (APC = − 32.61), and child Visual System Disorders (APC = − 25.17) Table ; Fig. 2.7.17, CNSThe results of these analyses indicate that major changes have occurred in the utilization of child neuropsychiatric inpatient services over the past 10 years at a large paediatric hospital that served as the only inpatient service for an area with about 4.5 million people. The data are not an effective indicator of the total incidence of child neuropsychiatric disorders in the community, but they represent valid indicator of those requiring inpatient treatment in a specialized psychiatric and neurologic (neuropsychiatric) service in this region due to disorders’ severity or to the inability of the territorial services to manage it in security.Hospitalizations for psychiatric disorders have significantly increased, and, in parallel, those for neurological conditions have decreased. Patient age and length of stay in the hospital have significantly increased.A necessary premise in the interpretation of these data is that care for paediatric neurologic and psychiatric disorders is managed in Italy as a unitary medical discipline called child neuropsychiatry. Clinicians are trained in both child neurologic and psychiatric disorders, and neuropsychiatric services, including inpatient, outpatient and day-hospital, are addressed to both categories of disorders.The first evidence obtained by the data analysis is that the age at admission is progressively increasing from the beginning (2007) to the end (2017) of the observation in favour of adolescent admissions with respect to children admissions. This probably doesn’t mean that the new infant and children cohorts evidence a decrease in neuropsychiatric morbidity, since literature suggests a global increase of neurological and psychiatric disorders in infancy .As a consequence of the priority rules for hospitalization the mean age of inpatient admissions has been probably influenced by the need to contain disruptive or self-damaging behaviours which are highly prevalent in the adolescent population .The increasing proportion of adolescents’ inpatient admissions accounts for the significant decrease in the number of hospitalizations for younger children. Nevertheless, the number of hospitalized adolescents did not increase significantly. It is the increase in the length of hospitalization, rather than the number of adolescent hospitalizations, that accounted for the changes in inpatient service composition. Among the possible factors contributing to this increase in the length of hospitalization, there may be the severity of adolescent psychopathology and the difficulty to arrange for outpatient treatment .The first hypothesis could be supported by the increasing rate of depression, self-damaging or life-threatening acts in adolescent general population evidenced by literature , 8. In oThe second may be related to a possible inadequacy of the neuropsychiatric outpatient services, whose resources or organization may not be completely updated with respect to the containment of the rising severe adolescent psychopathology . On the n = 216, 91%) and request long periods of inpatient treatment [Another evidence is the progressive gender differentiation, with an increase of female inpatient admissions. This underlines that the depressed female adolescents progressively occupied the inpatient service, excluding the children and also male adolescents. Moreover, female adolescents generally display a higher need for long inpatient treatments. Based on the available data only speculation is possible. The largest diagnostic group in our sample is represented by the eating disorders that are prevalent in female gender n = 216, 1% and rereatment , and alsreatment . Neverthreatment , stalkinreatment , bullyinreatment , and proreatment . Moreovereatment .The final evidence regards the reduction of inpatient treatments for neurological disorders with respect to psychiatric disorders. The authors don’t believe that this means an absolute reduction of neurologic disease, that literature estimates in growth . It is vAs claimed by many authors on large population studies –7 an incAs it concerns the Italian situation, it is evident that the progressive replacement of neurologic patients in the inpatient service poses the question of where the children affected with neurologic diseases needing for inpatient treatments are cared. In the present hospital experience they have been located in general paediatric inpatient services where neuropsychiatrists manage them with consultations. This suggests the need for an overall higher number of beds (and clinicians) dedicated to neurologic patients as suggested by international authors .The long-lasting stay into the inpatient service remarks for another potential field of intervention. Johnson and coworkers  have poiFinally, it needs to be underlined that depressive psychopathology is more prevalent in females starting with puberty, and may require long inpatients treatment in case of significant suicide risk. More research should be addressed to understand the reasons of this emergence in the social context, and adequate preventive interventions on the population should be performed. Moreover they should be more specifically explored the most cost-effective treatments to address adolescent subjects, possibly applying those who were demonstrated as effective in adults and testing those who best fit to adolescent population , but eveThe present study presents some limitations. First, the amount of data presented for the study is limited because they were collected in the database of the paediatric hospital for administrative purposes and not organized for research aims.Second, even though the catchment area for the paediatric hospital that provided the data was the entire Piedmont region, it is still possible that neuropsychiatric inpatient treatments for less severe psychiatric or neurologic disorders were provided in paediatric inpatients services at peripherals hospitals. Thus, the data here presented may not necessarily constitute all the neuropsychiatric inpatient treatments.Third, even though PIVA is a large region, the trend expressed by this research may not be generalizable to other regions of Italy.Fourth, data about inpatient treatment of neurological/neuropsychiatric subjects admitted to paediatric services without a passage through the emergency service of our hospital are not available since the admission/demission diagnosis may not reflect the neuropsychiatric one.Fifth, it is possible that some of the older adolescents with severe aggressive behaviours not manageable in an adolescent unit might have been hospitalized in adult units.In conclusion, from our data it emerges a significant increasing trend in the use of our neuropsychiatric inpatients service for the treatment of female adolescents affected with depressive disorders, and requiring long inpatients stay. The inpatient neuropsychiatric service of an Italian region with the same population of Ireland is no more available for inpatient treatment of children affected with neurological disorders. A re-organization and a significant increase of the inpatient beds for neurological and psychiatric treatments available in this region, and possibly also in other European regions, is needed to accomplish to the increasing needs of care of child and adolescent population . As for The present study may represent a starting point for a collaboration with other neuropsychiatry units in other parts of Italy and can be useful for future comparisons with other child neuropsychiatry facilities.


Inbreeding depression, the reduced fitness of the offspring of related individuals, can affect males and females differently. Although a comprehensive theoretical framework describing the causes of sex‐specific inbreeding depression is lacking, empirical evidence suggests that often one sex tends to be more vulnerable than the other. However, the generality, direction, and degree of sex‐specific difference in inbreeding depression remains enigmatic as studies on this topic have reported conflicting results. Here, we conduct a meta‐analysis to test for sex‐specific differences in the magnitude of inbreeding depression. We synthetised 321 effect sizes of experimental studies across 47 species and found a small difference in inbreeding depression between the sexes: females suffered slightly higher inbreeding depression than males. Furthermore, a higher inbreeding coefficient was correlated with higher inbreeding depression. However, there was a large amount of heterogeneity that remained unexplained, even when considering different factors that could affect inbreeding between the sexes, such as sexual size dimorphism, heterogamety, the type of trait measured and whether animals were tested in a stressful environment. As such, we highlight the need to further explore inbreeding depression across different species to determine the occurrence and causes of sex differences to increase our understanding of the evolutionary consequences of sex‐specific inbreeding depression. Our meta‐analysis across experimental studies found evidence for general inbreeding depression for both males and females and, although the difference between the sexes was not substantial, females were slightly more sensitive to inbreeding depression than males. Our study highlights the need to further explore the effects of inbreeding depression due to intrinsic biological differences between males and females.  Inbreeding depression, the reduction in fitness in inbred compared to outbred individuals, is caused by the expression of deleterious recessive alleles and/or the consequent loss of heterozygous advantage . To address this challenge, sex‐specific inbreeding depression has been hypothesised to be influenced by the accumulation of deleterious recessive mutations in the sex chromosomes Table . In sex Detecting sex‐specific inbreeding depression (if present) likely depends on the conditions and traits being evaluated. For example, inbreeding depression is expected to be more deleterious when individuals mate with more closely related relatives , any elevated costs of inbreeding depression that are associated with increasing inbreeding coefficients should be expressed similarly between the sexes Table . It is aDoes inbreeding depression differ between the sexes? Males are predicted to be more sensitive to inbreeding depression than females due to differences in the strength of sexual selection. (ii) Is sexual size dimorphism associated with sex‐specific inbreeding depression? A corollary of the prediction from question (i) is that the difference in inbreeding depression between the sexes will increase as the difference in the strength of sexual selection between the sexes increases. We therefore predict that differences in inbreeding depression between the sexes will increase with sexual body size dimorphism, a proxy for sexual selection that correlates with the opportunity for sexual selection  is predicted to be more affected by inbreeding depression than the heterogametic sex. (iv) Are males and/or females differently affected depending on their inbreeding coefficient? Inbreeding depression is predicted to be positively correlated with inbreeding coefficients. (v) Are males and/or females more sensitive to inbreeding depression depending on the trait measured? Traits more closely related to fitness  are predicted to be more sensitive to inbreeding depression than traits less closely related to fitness (body size). (vi) Are the sexes affected differently by inbreeding depression when exposed to environmental stress? Inbreeding depression is predicted to be elevated in more stressful environments. For questions iv–vi, whether the sexes will differ remains unclear. We determined and statistically accounted for a number of moderators for each effect regarding these factors that could influence sex‐specific inbreeding depression.Here, we consider two main processes that could explain sex‐specific inbreeding depression  and highlight other factors that could affect our ability to detect sex‐specific patterns Table . As it iscimeetr in R  of zero, and so studies using inbred strains where “outbred” (i.e. parents unrelated) individuals were used as a reference were excluded as F was higher than zero. We focused exclusively on studies that examined inbreeding depression in traits that are present in both sexes and therefore comparable: morphological traits , mating traits , reproductive traits  and survival (or longevity), even if the same study did not test both sexes. We thus targeted studies where inbreeding depression was available for males and females separately and excluded those where the sexes were combined. For example, to compare inbreeding depression in reproductive success between the sexes, we only included effect sizes where one sex at a time was inbred and tested against outbred individuals. That is, inbreeding depression in reproductive success of females would be the effect size of the difference in reproductive success between an inbred female paired with an outbred male compared to an outbred female with an outbred male. We focused on experimental studies and thus excluded non‐experimental field studies and experimental correlational studies (e.g. correlations between an inbreeding coefficient and a trait of interest). Wild studies often use genetic marker‐based pedigrees that provide correlational data that give their own set of limitations as their accuracy depends on the number and variability of markers available . All authors were asked if they could provide additional data that could be used in our analysis. Three out of six authors replied to our data request and these studies were therefore included in our meta‐analysis. A total of 28 studies were excluded because essential statistics were missing. A list of studies included and studies that did not fulfil our selection criteria are listed in the We extracted data from studies that met our inclusion criteria. Foremost, an experimental comparison between outbred and inbred individuals was required based on an established pedigree‐based familial relationship. Outbred individuals were assumed to have an F = 0) and inbred (F = 0.25–0.8) individuals for each male‐male or female‐female combination. Inbreeding depression was coded such that higher values represented higher inbreeding depression . Thus, effect size estimates obtained for relationships such as latency to mate were multiplied by −1 so that positive estimates indicated outbred individuals being of higher ‘quality’.We quantified inbreeding depression as the difference in fitness components  were converted into Hedges g using the equations in Borenstein et al. , and whether individuals were measured under stressful conditions  which was coded as a binary response . We additionally included whether the male or the female are the heterogametic sex, and an estimate of sexual size dimorphism (SSD) following , and paper identity as random effects to account for nonindependence of the data from the same studies. Phylogeny was incorporated into all models as a random effect using a variance‐covariance matrix. The phylogeny used to compute a phylogenetic covariance matrix was constructed using the Open Tree of Life package rotl  following Nakagawa and Schielzeth (ß) and 95% confidence intervals for each factor level of a moderator from meta‐regressions by removing the intercept. Point estimates were considered statistically significant from 0 when their 95% confidence interval did not overlap zero.We fit meta‐analytic and multi‐level meta‐regression models using the d Santos . For modhielzeth . We obtamQ’, provided by metafor) of meta‐regressions with intercepts. The omnibus test is a Wald‐type χ2 test, which tests whether the coefficient(s) of factor level(s) differ from zero (H0: ß1 = iß = 0). If the null hypothesis cannot be rejected, it means that none of the factor levels differ from the intercept and the moderator as a whole is not statistically significant . To test the statistical significance of the interaction, the omnibus test was used as above but while setting the argument ‘betas to test’ (‘btt’) to the coefficients containing the interaction following the metafor package documentation. Combining these fixed factors into a single model could obscure potential effects given the reduction of sample size per category, so emphasis on the significant effects should be interpreted with caution.We first calculated the overall mean effect size by running a model with just the random effects listed above. To examine the effect of the moderator variables, we then ran meta‐regressions. Models included the same random effects as above, but now also included each categorical moderator as a fixed effect in separate models . Statistical significance of moderators was inferred from ‘omnibus tests’ , but where males and female estimates remained the same as when not including it . We retrieved 138 effect sizes associated with reproduction, 82 with body size, 71 for survival, and 30 with mating . The total heterogeneity (I2) among the random factors was 93.19%; with most of the variance attributed to between‐species differences (47.3%), while phylogeny, variance attributed to between‐study differences, and observational study‐differences were similar . We found evidence of sex‐specific inbreeding depression, with a (weak) difference in overall inbreeding depression between males and females . Note that this effect was similar when only including species where estimates were available for both sexes and under the same conditions .Homogametic species did not differ from heterogametic species in inbreeding depression Table , nor wasβ [95% CI] = 0.85 ; Table R2 = 2%). When exploring this effect further, we did not find a significant interaction between sex and the inbreeding coefficient (Table We found a positive correlation between the coefficient of inbreeding (when treated as a continuous covariate) and effect size estimates of inbreeding depression , with insects showing inbreeding depression , a trend that was evident on the full dataset. Note that this study focused on different Drosophila species, highlighting the taxonomic bias found in the current meta‐analysis. The results of these analyses are provided at https://osf.io/tvx7q/.One study in our dataset . As there is a taxonomic bias in our study—arthropods were overrepresented in our data—evidence from additional species is necessary in order to generalize this result. Our study highlights the need to further explore the effects of inbreeding depression due to intrinsic biological differences between males and females.Could sexual selection explain the differences between male and female sensitivity to inbreeding depression? Sexual selection is expected to purge deleterious mutations more efficiently in males as males generally experience more intense sexual selection than females , while birds and butterflies having heterogametic females (ZW). Differences in the expression of genes and selection pressures experienced by individuals may build up the inbreeding load differently by each sex  underlying sex‐specific inbreeding depression, and why females may be more sensitive remains elusive. Nevertheless, there could be far‐reaching consequences of sex‐specific inbreeding depression. Population growth is often constrained by the number of females, not males, and if indeed females suffer more from inbreeding depression, this may in fact be beneficial for population growth if deleterious alleles could be exposed and be purged faster in females. However, purging being higher in females was not supported in our data as we found inbreeding depression to be slightly higher in females. Conversely, female inbreeding depression may limit population growth as the detrimental effects of inbreeding may affect how much they can invest in reproduction. This may be particularly relevant in small populations where inbreeding is more likely; a key link to be explored in future research. Another consequence is that females may be more driven to avoid inbreeding than males, potentially modulating sexual conflict. This could be linked to females typically making a higher investment per offspring when compared to males  which are easy to culture, may be well‐adapted lab populations, and where measuring traits in both sexes is easier (and faster) than in other systems. Consequently, there was also bias for internal over external fertilisers and egg‐laying over live‐bearing species. The difficulty of assessing fitness in adult traits in both sexes further complicates our ability to understand how inbreeding impairs performance in males and females. Given the somewhat limited taxonomic breadth of effect sizes included in our study, our results should be interpreted with caution. For general patterns across animals to be apparent, more studies are needed, particularly so in vertebrates. This will help us gain a broader perspective about the nature of inbreeding depression by examining a larger set of species and under variable environments.The mechanisms behind sex‐specific inbreeding depression may be too system‐specific to identify general patterns. For example, the effects of inbreeding depression may vary with population demography, genetic composition, stress and levels of sexual conflict across species or even populations. Such system‐specific variance makes generating predictions challenging. However, by comparing different species we have tried to identify some of the main causes of differences in inbreeding depression between males and females. The taxonomic gaps in the literature are reflected in our meta‐analysis, with a general focus on model systems . More empirical data from heterogametic systems is therefore needed before heterogametic effects in sex‐specific inbreeding depression can be ruled out conclusively. Moreover, studies investigating inbreeding depression in a specific environment cannot be used to infer the long‐term effects of inbreeding (Kristensen et al., RV‐T and RAdB designed the study, collected the data, performed the analyses and wrote the first draft. AK and JLF edited further versions of the manuscript.The authors declare no competing interests.https://publons.com/publon/10.1111/ele.13961.The peer review history for this article is available at Supplementary MaterialClick here for additional data file.


The usefulness of duckbill‐type anti‐reflux metal stent (DMS) in self‐expandable metal stent‐naïve pancreatic cancer (PC) patients has not been well‐studied. This study aimed to evaluate the efficacy and safety of DMS in such patients.We analyzed consecutive patients with unresectable PC who received a covered metal stent (CMS) as the initial self‐expandable metal stent at our institution. Technical success, functional success, causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), adverse events (AEs), and reintervention rates were compared between DMS and conventional CMS (c‐CMS).p = 0.009), while non‐occlusion cholangitis tended to be more common in the c‐CMS group . Median time to RBO was similar between groups . The anti‐reflux valve of DMS was found torn in 56% of patients. Endoscopic reintervention was successful in all cases, despite failed stent removal in 88% of patients in the DMS group.A total of 69 patients were included . Technical success, functional success, and AEs were similar between groups. Tumor ingrowth was more common in the DMS group (18% vs. 0%, DMS was not associated with longer time to RBO compared to c‐CMS in self‐expandable metal stent‐naïve patients. Distal malignant biliary obstruction (MBO) is a common complication of pancreatic cancer (PC). Endoscopic biliary drainage using self‐expandable metal stents (SEMS) is the standard of care, due to their longer stent patency compared to plastic stents.Duckbill‐type anti‐reflux metal stent (DMS) is a novel fully covered laser‐cut type ARMS. Several studies including ours have reported the efficacy and safety of this stentWe conducted this retrospective study to evaluate the efficacy and safety of DMS in comparison with c‐CMS as the initial SEMS in patients with unresectable PC.This was a retrospective study of consecutive patients with unresectable PC who received a CMS (DMS or c‐CMS) as the initial SEMS for distal MBO at our institution between January 2020 and November 2021. Only patients who received a CMS across the papilla were included in this study. The following were excluded: (1) patients who had a history of biliary SEMS placement, (2) patients with SEMS placed above the papilla, (3) patients with surgically altered anatomy, and (4) patients with concomitant hilar biliary obstruction. The selection of the type of SEMS was mainly based on the time period in which a given patient underwent initial SEMS placement. In general, c‐CMS was used between January 2020 and November 2020, while DMS was used between December 2020 and November 2021. Written informed consent for the procedure was obtained from every patient. This study was conducted in accordance with the Declaration of Helsinki and was approved by the ethics committee of our institution .The ARMS used in this study was a fully covered laser‐cut type SEMS with a 12.5 mm duckbill‐shaped anti‐reflux valve (ARV) attached to the distal end . All stents had diameters of 10 mm and lengths of 60, 70, or 80 mm.All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) using a therapeutic duodenoscope  under conscious sedation. Endoscopic sphincterotomy was generally performed before SEMS placement and prophylactic rectal nonsteroidal anti‐inflammatory drugs (NSAIDs) were used at the discretion of the endoscopist. Some of the patients had previously undergone plastic stent placement at the referring institution. A SEMS was deployed under fluoroscopic and endoscopic guidance in the first session when the diagnosis of PC had already been confirmed and cholangitis was not present, otherwise, an endoscopic nasobiliary drainage (ENBD) tube was placed in advance and a SEMS was deployed in the next session. Before December 2020, we performed ERCP first and subsequently performed endoscopic ultrasound‐guided fine‐needle aspiration as needed in obstructive jaundice cases without pathological confirmation of cancer. From December 2020 onward , we switched to a strategy of performing endoscopic ultrasound‐guided fine‐needle aspiration before ERCP unless the patient's condition made it preferable to perform ERCP first. Achieving a pathological diagnosis of cancer before ERCP allowed for SEMS placement in a single session, instead of requiring biliary drainage with a plastic stent or ENBD before SEMS placement. The length of SEMS was selected based on cholangiographic findings, and the distal end of the metal part of DMS was placed 5–10 mm below the papilla to completely expose the ARV into the duodenum.Outcomes of SEMS placement were generally defined according to Tokyo Criteria 2014.p‐Values < 0.05 were considered statistically significant. All statistical analyses were carried out using the EZR software version 1.40.Continuous and categorical variables are expressed as medians with ranges and absolute numbers with proportions, respectively. Categorical variables were compared using the Chi‐square test or Fisher's exact test as appropriate, while continuous variables were compared using the Mann‐Whitney U test. Time to RBO and OS were estimated using the Kaplan‐Meier method and were compared using the log‐rank test. The cumulative incidence of RBO was estimated using the competing risk analysis and was compared using Gray's test.p = 0.002). Other baseline characteristics including duodenal invasion, concomitant duodenal metal stent, presence of moderate to severe ascites, and peritoneal dissemination were not different between the two groups. Stents used in each group were generally 8 cm in the DMS group and 7 cm in the c‐CMS group. Endoscopic sphincterotomy was performed before SEMS placement in all patients, except for one patient in the c‐CMS group who underwent endoscopic papillary balloon dilation because of a previously deployed duodenal metal stent placed across the papilla. Prophylactic NSAIDs were administered more frequently in the DMS group .A total of 69 patients were included in this study . The baseline and procedural characteristics of the two groups are summarized in Table Table p = 0.430). Of the five patients who developed pancreatitis, four patients underwent SEMS removal on the following day (two patients in each group).AEs occurred in four patients in the DMS group  and three patients in the c‐CMS group . Tumor ingrowth was more frequently observed in the DMS group , while non‐occlusion cholangitis tended to be more frequent in the c‐CMS group . Of the five patients who presented with tumor ingrowth in the DMS group, tumor ingrowth was evident at a median follow‐up period of 202 days.Overall RBO rates were not significantly different between the two groups  and TRBO  were similar between the two groups. The cumulative incidence of RBO was also not different between the two groups , even when accounting for competing risks  with stent occlusion. Stent removal was attempted in eight patients, but was successful in only one patient (13%). Of the seven unsuccessful cases, tumor ingrowth was present in five and DMS was torn during the removal attempt in two. Biliary cannulation was achieved in all seven unsuccessful cases through the stent mesh (one patient) or the torn ARV of DMS (three patients), or by trimming the distal part of DMS (three patients) using argon plasma coagulation and/or a loop cutter . Reintervention was successfully performed in all 12 patients. Seven patients whose stents could not be removed underwent CMS placement in a stent‐in‐stent method. Three patients underwent CMS replacement after successful stent removal or stent migration, one underwent plastic stent placement in a stent‐in‐stent method , and one underwent plastic stent placement after successful stent removal.Nineteen patients in the c‐CMS group experienced RBO, of which nine resulted from stent occlusion, four from stent migration, and six from non‐occlusion cholangitis. Stent removal was successful in all attempted cases . Reintervention was successfully performed in all 19 patients. Fourteen patients underwent CMS replacement, one underwent simultaneous duodenal stenting and endoscopic ultrasound‐guided choledochoduodenostomy, one underwent endoscopic ultrasound‐guided hepaticogastrostomy, one underwent plastic stent placement, and two underwent endoscopic nasobiliary drainage.p = 0.915). Reasons for RBO differed between the two groups, with a higher rate of tumor ingrowth in the DMS group  and a tendency of a higher rate of non‐occlusion cholangitis in the c‐CMS group . Overall rates of AEs were similar between the two groups, with acute pancreatitis being the most common AE. The ARV of DMS was found torn in five of the nine patients (56%) who experienced RBO due to stent occlusion. Although stent removal of DMS was unsuccessful in most patients (88%) mainly as a result of tumor ingrowth, endoscopic reintervention was successful in every patient using the stent‐in‐stent method.This retrospective study evaluated the efficacy and safety of DMS in comparison with c‐CMS for distal MBO in SEMS‐naïve unresectable PC patients. DMS was not associated with longer TRBO compared to c‐CMS , the rate of stent occlusion was somewhat higher in the DMS group , resulting in similar overall RBO rates between the two groups. The negative results of our study could be due to several reasons including patient characteristics and the durability of the ARV and covered membrane. First, patients who would most benefit from ARMS are those who are at high risk of duodenobiliary reflux, including those with duodenal invasion and those who have indwelling duodenal stents.In the present study, DMS was not associated with longer TRBO compared to c‐CMS in SEMS‐naïve unresectable PC patients. Although the rate of stent migration was similar between the two groups (11% vs. 10%) and the rate of non‐occlusion cholangitis was lower in the DMS group (0% vs. 15%, Reintervention after RBO of the initial CMS is becoming an important issue, as the prognosis of PC patients has improved due to recent advances in chemotherapy. Although stent removal of DMS was unsuccessful in a majority of attempted cases in this study, biliary cannulation was successfully achieved through the stent mesh or the torn ARV of DMS, or by trimming the distal part of DMS using argon plasma coagulation and/or a loop cutter. As a result, endoscopic reintervention was successful in every patient. Conversion to endoscopic ultrasound‐guided intervention is also a possible salvage method after RBO of DMS.The current study has several limitations. This was a retrospective study from a single institution with a limited sample size. Although consecutive patients with unresectable PC were included in this study, selection bias cannot be completely avoided. Patient characteristics were different in some aspects including the presence of prior biliary drainage and prophylactic rectal NSAID use. This was mainly due to changes in the treatment strategy for undiagnosed PC patients with obstructive jaundice; endoscopic ultrasound‐guided fine‐needle aspiration was more frequently performed before biliary drainage in the DMS group. The exact rate and timing of tearing of the ARV are unknown because we only evaluated patients who experienced RBO.In conclusion, DMS was not associated with an extended duration of TRBO compared to c‐CMS in SEMS‐naïve patients. Further modifications of the present DMS, including the design of the ARV and the covered membrane, may be needed before using this stent as the first‐line biliary drainage for distal MBO in unresectable PC patients.None.


Dental disease is common in wild and captive koalas. Effective treatments are limited and dental disease may not be recognised until it is quite severe. We describe the appearance of varying severities of dental disease on computed tomography (CT) images in a case series of six koalas. This case series demonstrates the use of CT to detect both mild and severe dental disease in koalas. The study also documents the normal CT appearance of the nasolacrimal duct in the koala. The only clinical abnormality in koalas with the mildest dental disease was ocular discharge. Computed tomography findings associated with ocular discharge were periapical lysis of first maxillary incisors, lacrimal canal remodelling and subsequent nasolacrimal duct obstruction. Dental disease should be a differential diagnosis for ocular discharge in koalas and CT examination enables visualisation of early stages of dental disease. Phascolarctos cinereus) with a previous study reporting the prevalence of 86% and 50% respectively.Dental disease is common in wild and captive koalas  to characterise the extent of dental disease in a sample of captive koalas. We hypothesise that ocular discharge is an early clinical sign of dental disease, and that CT would enable detection of lacrimal canal abnormalities secondary to dental disease.To document the normal pathway of the nasolacrimal duct, a positive contrast computed tomographic dacryocystogram was conducted on a mature free‐range koala undergoing necropsy for an unrelated reason. The cadaver had a grossly normal head, with no palpably loose teeth or evidence of dental disease such as tooth discoloration or fractures identified on visual inspection. A transverse plane CT was acquired using 16 slice CT scanner . A survey CT scan of the head was reconstructed for bone, 1.0 mm thick slices. The distal opening of the right nasolacrimal orifice was catheterised near the nares, using a 24G intravenous catheter, 2 mL of Iohexol 240 mg/mL  was injected by hand, and acquisition was repeated. CT data were reconstructed as standard three plane multiplanar reformats, curved parasagittal multiplanar reformats to follow the course of the nasolacrimal duct, and a three‐dimensional model was developed. The course of the nasolacrimal duct and relationship to dental structures was described.Koalas who had a CT examination of the head conducted at U‐Vet Werribee, Australia, were identified by searching the imaging database . Over the 14‐year duration of the imaging database, between July 2007 and November 2021, six koalas were identified. All were captive or free ranging animals referred from two local zoos. Patient demographic features, history including indication for CT examination of the head, and clinical findings were recorded. Imaging findings were recorded by review of the report generated at the time of imaging, and consensus review by a resident in veterinary radiology (AB) and a registered specialist in veterinary radiology (MM).During the study period, one CT examination was conducted on a single slice CT scanner , with images only available as transverse plane 1 mm thickness bone window images. The remaining five CT examinations were performed on a 16 slice CT scanner , with both soft tissue and bone window images available in orthogonal multiplanar reformats with slice thickness of 1 to 3 mm.Features of dental disease visible on CT were recorded as teeth that were normal, absent, if periapical lysis was present, if widespread alveolar bone lysis was present encompassing multiple teeth or tooth roots, if teeth were fractured, and if an oronasal fistula was present.Lacrimal canals and nasolacrimal ducts were compared to the contralateral side to assess for normality, or if bilateral disease was suspected the study was compared to a study of a koala with a normal head, undergoing CT for reasons unrelated to the dental or ocular systems.The entire nasolacrimal duct was visualised with CT dacryocystogram Figure . The ducThe nasolacrimal duct length approximately 45.0 mm .Nasolacrimal duct diameter Dorsal canaliculus – 0.8 mm in diameter.Osseous portion – 1.0 mm in diameter.Membranous portion – 1.1 mm in diameter.The measurements of the duct size via dacryocystography were consistent with an anatomical study reference values:Six koalas were identified who had a CT examination of the head during the study period. There were four captive male koalas, one captive female and one free‐ranging female koala. Koalas were aged between 3 and 8 years, with median age of 6.5 years. One koala, a 6‐year‐old captive female (Case 1) had a head CT acquired 21 months prior for an unrelated clinical problem. The head was normal at that earlier examination, and this normal study was used for comparison in the other cases.Two koalas presented with right‐sided ocular discharge; one of these koalas also had blepharospasm. In both, ocular discharge was the main presenting complaint, without clinical evidence of underlying dental disease. In the other four koalas, dental disease was suspected or directly observed; one koala had a discoloured right maxillary incisor tooth, one had a history of dental‐associated osteomyelitis and presented with facial swelling responsive to antibiotics, one presented with weight loss and an oronasal fistula at the left maxillary first molar tooth, and the other had chronic weight loss without the observable dental disease. Details of signalment, presenting signs, and a summary of CT findings are provided in Table In all koalas, peri‐apical bone lysis was observed in one or both first maxillary incisor teeth. In all koalas, there was alteration to one or both lacrimal canals, which comprised focal expansion of the distal portion of the lacrimal canal to varying extents with filling of the canal with soft tissue, and soft tissue swelling at the distal nasolacrimal puncta. One koala (Case 1) had transverse plane bone window images reconstructed with 3, 2 and 1 mm slice thickness; soft tissue change at the distal nasolacrimal puncta were difficult to appreciate with the 3 mm thick slices, but readily seen on 1 mm thick slices.  had peri‐apical lysis of the right maxillary first incisor tooth, with soft tissue swelling at the distal nasolacrimal puncta; this was catheterised and dacryocystography was performed, which confirmed partial obstruction of the duct by soft tissue.One koala (Case 4) presented with chronic osteomyelitis and facial swelling. The right first, second and third maxillary incisor teeth were all absent with a large area of lysis of the incisive bone, peri‐apical lysis and a fractured root of the left maxillary first incisor tooth, and bilateral dilation of the lacrimal canals, worse on the right side.Periodontal disease of the cheek teeth was only identified in one koala (Case 5), a 7‐year old male with poor body condition. In addition to peri‐apical lysis of right and left maxillary first incisor teeth, that koala had an absent left maxillary first molar tooth with an oronasal fistula, peri‐apical lysis of the left maxillary third and fourth molar teeth with a diastema, and an absent left mandibular first molar tooth.Computed tomography allowed visualisation of nasolacrimal duct disease secondary to dental disease in every koala in this case series. The koala nasolacrimal anatomy could be easily documented after CT dacrycystogram. Similar to rabbits, the terminal portion of the Koala nasolacrimal duct and orifice are in close proximity to the root of the first maxillary incisor.In our case series koalas presenting with clinical signs such as facial swelling and weight loss or poor body condition had more extensive periodontal disease and lacrimal canal changes. Cases 4, 5 and 6 (Figure Although dental radiographs can be used to diagnose periapical lysis associated with dental disease, CT has the advantage of being able to reformat images in multiple planes and eliminate the superimposition of structures. Computed tomography also has superior contrast resolution for soft tissue compared to radiographs. Both factors contribute to the superior ability of CT compared to dental radiographs to visualise periodontal disease and the nasolacrimal ducts in the koala. The use of CT‐dacryocystography is also a useful technique to document patency or occlusion of the nasolacrimal duct.The availability of transverse images at different slice thicknesses as seen in Case 1 highlights the importance of reconstructing CT data with as thin slices as possible, as subtle lesions were not clearly visible on 3 mm thick reformats. The entire length of the nasolacrimal duct could also only be confidently traced on the 1 mm thick slices. The termination of the nasolacrimal duct could be visualised on the 2 mm thick slices but it was difficult to trace the entire duct. The authors recommend 1 mm thick reconstructions or thinner to permit complete assessment of the nasolacrimal duct and the apex of the first maxillary incisors in the koala.This study has several inherent limitations due to its retrospective nature. The tooth wear class was not available on review of the koala's history and some histories of more chronic cases were incomplete, lacking information on the incipient signs of disease. The normal CT dimension of the koala nasolacrimal duct is not published and so an interpretation of dilation or obstruction is based on comparison with the contralateral duct or a presumed normal animal. The study also lacks histopathologic verification of the CT diagnosed nasolacrimal duct pathology.This study illustrates the use of CT as a valuable diagnostic tool for the examination of nasolacrimal and dental pathology in koalas. In this case series, we found CT was able to detect nasolacrimal duct obstruction secondary to maxillary incisor dental disease, even in cases with occult dental disease. Epiphora is a readily detectable clinical sign which can be seen with early dental disease. Early detection is key to further our understandings of dental disease in koalas and developing effective treatments. Therefore, it is proposed that koalas with ocular discharge or epiphora of an unknown aetiology undergo a CT examination to rule out maxillary incisor dental disease.The authors declares no financial or personal conflict of interests.


Ortho‐sulfonyl anilines are important building blocks for a range of applications. We report the discovery of an aromatic rearrangement reaction of O‐(arenesulfonyl)hydroxylamines which leads directly to ortho‐sulfonyl anilines through formation of a new C−N bond with excellent levels of regiocontrol for the ortho position(s) over all others. We establish that the rearrangement is proceeding through an intermolecular mechanism and propose that the regiocontrol observed is the result of attractive non‐covalent interactions occurring during the C−N bond‐forming step. Importantly, this method is complementary to classical aniline sulfonation in terms of the variously substituted regioisomers that can be obtained and it is also applicable to O‐(benzylsulfonyl) hydroxylamines. ortho‐sulfonyl anilines from simple starting materials is reported. This is achieved through formation of a new C−N bond with excellent levels of regiocontrol for the ortho isomer(s), which is proposed to be the result of attractive non‐covalent interactions occurring during the C−N bond‐forming step.An aromatic rearrangement of hydroxylamine derivatives that leads directly to  O‐benzene and O‐benzyl sulfonyl hydroxylamines. An iron catalyst improves yields in many cases and the reaction provides valuable ortho‐sulfonyl aniline products under simple reaction conditions. Our aminative approach is complementary to the main route presently used, through formation of the C−S bond during arene sulfonation. Mechanistic experiments suggest an intermolecular mechanism for the rearrangement, and we propose that the excellent regioselectivity for the ortho position is the result of a combination of ionic and hydrogen bonding interactions between the incoming radical cation and the anionic aryl sulfonate substrate. A limitation to overcome is that selectivity cannot currently be obtained if there are two available ortho positions that lead to different regioisomers. This study serves to highlight the powerful ability of attractive non‐covalent interactions to control regioselectivity in radical reactions.In summary, we describe the discovery of an aromatic rearrangement reaction of The authors declare no conflict of interest.As a service to our authors and readers, this journal provides supporting information supplied by the authors. Such materials are peer reviewed and may be re‐organized for online delivery, but are not copy‐edited or typeset. Technical support issues arising from supporting information (other than missing files) should be addressed to the authors.Supporting InformationClick here for additional data file.


Transmission of biological hazards capable of causing disease in livestock can occur through a wide variety of direct and indirect routes. In swine production, there are a large number of possible routes of exposure of a pathogen into a susceptible population. African swine fever virus (ASFV) has been a significant challenge for Southeast Asia since first detected in China in 2018 and has spread through many countries within the region. In order to understand potential transmission pathways within an ASFV endemic region, a diagnostic investigation was performed to determine the level of contamination on a wide variety of surface types within a live animal production, feed manufacturing, and feed distribution system located in Vietnam. All diagnostic testing was performed locally by the production system's internal diagnostic laboratory using real‐time polymerase chain reaction (rt‐PCR) analysis. Early in the diagnostic investigation, it became clear that feed trucks were a common site of ASFV surface contamination detection. This information resulted in biosecurity‐focused actions for feed trucks arriving back at the feed mill, including decontamination of interior truck cab surfaces and washing of exterior truck surfaces with high‐pressure water prior to application of surface disinfectants. Additionally, a low number of rt‐PCR positive samples were detected within the feed production system, with the greatest number coming from transient surfaces such as high traffic areas and worker clothing. This illustrates the importance of managing employee traffic through procedures such as zoning and separation between clean–dirty areas to reduce the likelihood of pathogen transmission. In conclusion, this report illustrates the importance of routine data capture regarding efficacy of biosecurity procedures which allows for real‐time updates and improvement as biosecurity gaps are identified. The virus is a member of the Asfarviridae family  upon arrival at the facility for all incoming trucks. Trucks were not washed with high‐pressure water, but the disinfectant mist was applied to all incoming vehicles. The disinfectant was allowed to air dry prior to arriving at the finished feed loading area within the feed mill complex. No downtime was required between uses of the trucks and no procedures were in place to disinfect the cabs in the early stages of this investigation. Access to the mill is generally restricted to employees of the company, truck drivers, and management with minimal access permitted to visitors. In the event visitors do enter the facility, they are required to don disposable coveralls, change footwear, and don disposable shoe covers upon arrival at the entry gate to the feed mill. Then, all visitors and employees would walk through a disinfectant mist  as they entered the compound. The facility has no formal requirement for downtime away from swine for visitors and personal items such as cellular phones are permitted within the facility with no formal disinfection procedure in place. Facility employees wore company‐provided clothing to and from the facility and there were no clothing change procedures in place upon arrival.A high percentage of feed manufactured in the facility was pelleted, and a subset of feed manufactured was treated with a commercial formaldehyde‐based feed additive at the labelled dose  beginning approximately 1 month prior to initiation of the sampling investigation. Nearly all feed manufactured and distributed from this facility was prepared in bag form (25 kg) and was hand stacked in the back of tarp‐enclosed flatbed trucks for delivery to swine farms. Upon delivery of feed to the swine farms, the exterior surfaces of feed trucks were disinfected at selected sites (sow farms and gilt multiplication growing facilities), but not all sites. Once at the farm, the delivery trucks would park next to feed storage area and the bags were manually unloaded. In the early stages of the sampling investigation, it was determined that feed truck drivers were exiting the trucks at the farm to assist the farm staff unload the bagged feed, although the official policy was for feed truck drivers to remain within the cab of the truck during the unloading process. Feed trucks did deliver feed to known ASFV‐positive sites, and immediately following delivery would be washed and disinfected prior to entering the feed mill complex.The market animal transfer facility has two separate entrances and there is no cross‐traffic between company‐owned live animal transport vehicles bringing market‐ready pigs to the facility and customer‐owned live animal transport vehicles arriving at the facility to pick up market‐ready animals. The exterior surfaces of all customer‐owned transport vehicles were disinfected when arriving at the market pig transfer station . All employees of this transfer station are employees of the herein described production company. Pigs are housed at this facility for a short period of time before being transferred onto customer trucks for delivery to market. The facility is washed and disinfected daily using water followed by application of a commercial disinfectant . No known ASFV‐infected animals, animals from a known ASFV‐infected site, or animals within clinical signs of ASF were transferred to this market animal transfer station.2.2Throughout the investigation, a variety of samples were collected including 1) feed and feed ingredient samples, (2) surfaces associated with feed manufacture and delivery, (3) surfaces on company‐owned pig transport vehicles, (4) surfaces at a company‐owned transfer station where market pigs are aggregated prior to shipment to customers, and (5) surfaces on customer‐owned pig transport vehicles when arriving at the transfer station to load pigs. Within samples collected from the feed mill environment, feed delivery vehicles, and live animal transport vehicles, a classification scheme was developed to facilitate standardization across sampling locations in terms of risk of surface contamination  and placed in a clean sealable plastic bag. For each swab sample, the sampling technician used a new sterile glove when handling the swab. At the pre‐determined sampling location, the pre‐moistened swab was used to sample an area approximately 20 × 20 cm2.3The diagnostic laboratory was owned and operated by the collaborator and was established to perform routine diagnostic testing for the live animal production enterprise. All samples were processed and analyzed locally, and no material whatsoever was transported out of the region. For analysis of feed and ingredient samples, the sampling bag containing the feed or ingredient sample was manually agitated to ensure an even mix, and then the bag was opened aseptically to collect a representative subsample of 5 g of material. The 5‐g subsample was then placed in a sterile container and 25 ml of PBS was added, agitated for 1 h, and the supernatant liquid was collected for real‐time polymerase chain reaction (rt‐PCR) analysis. Environmental swabs were processed by adding 20 ml of PBS to the swab, lightly agitated, and the liquid was collected for rt‐PCR analysis. If samples were not able to be analyzed within approximately 24 h due to high laboratory submission load, samples were placed in −80°C freezer until time of analysis.All samples were analyzed using a commercially available rt‐PCR assay  designed to detect the p72 viral genome of ASFV following manufacturer recommendations. Amplification was performed using a Stratagene MX3005P qPCR system . A total of 40 PCR amplification cycles were used, and if any sample did have detectable ASFV DNA it was considered rt‐PCR positive. If a sample did contain ASFV DNA, values are reported as cycle threshold (Ct).2.4P > .10) and therefore was excluded from the final model. For each sampling location, the overall percentage of samples that were rt‐PCR positive was calculated using the FREQ procedure. Mean probabilities for rt‐PCR positive status are reported along with 95% confidence limits.Data were analyzed using linear models using the GLIMMIX procedure in SAS 9.4 . Data were categorized in a binary manner based on rt‐PCR result  and fit using a binary distribution, logit link, Laplace approximation, and ridge‐stabilized Newton–Raphson algorithm as described by Magossi, Bai, et al.  and Mago33.1P ≥ .986). During the first set of samples collected , there were four samples with detected ASFV contamination (Table P = .413) or sampling month (P = .878).As an initial assessment of the potential detection rate of ASFV DNA, the feed supply chain was selected as the sampling location of importance due to the highly connected structure among farms. For all sampling locations, there was no evidence of sampling zone × month interaction . Overall, nine total environmental samples were rt‐PCR positive within the feed mill . Within the feed mill, the first rt‐PCR positive sample was found in September 2019 from a high‐traffic surface where truck drivers congregate once returning to the mill. The first feed contact surface with evidence of ASFV contamination was in February 2020, and was followed by two additional rt‐PCR positive samples on feed contact surfaces in April 2020. Worker clothing was identified as a source of contamination in March 2020 and this worker was located in the finished bagged feed handling area and another rt‐PCR positive was detected on worker clothing in July 2020. Due to the concerns identified with possible contamination of clothing and inability to definitively determine the origin of the contamination, a policy was implemented where employees working in the finished feed bag handling area were required to change clothing upon arrival at the mill. The goal of this policy was to help reduce the likelihood of bringing contamination into the facility and in contact with bags of feed which are directly transported to swine farms. The final rt‐PCR positive sample collected from within the feed mill was found on an exterior surface of a mixer in September 2020.There was no evidence of a difference in detection of ASFV contamination between feed contact, non‐feed contact either less than or greater than 1 m from feed contact surfaces, or transient surfaces . Of the 22 rt‐PCR positive samples, 18 were from live animal transport vehicles . There was no evidence of a difference in the percent of samples positive for ASFV DNA based on sampling location . Data recently published indicate that when using feed manufacturing equipment in a controlled research setting to mix feed inoculated with ASFV, the virus can be found on a number of different surface types even after multiple subsequent batches of feed are mixed (Elijah et al., In the current investigation, several key areas of environmental contamination were identified including high‐traffic areas and worker clothing. Likewise, the greatest area for contamination within the live animal transfer infrastructure sampled was live animal transport vehicles, specifically the cabs of these vehicles. When evaluating the semi‐quantitative Ct values, there are very high Ct values near the limit of detection for rt‐PCR assays therefore repeatability is a concern. We acknowledge these assays were developed to detect ASFV DNA in biological tissues of infected animals. However, the detection noted in this study indicates the need for development of assay methods that have lower and more consistent detection limits. In general, these data illustrate that surface contamination with ASFV is possible within a region of ongoing transmission.The stability of ASFV in the environment is somewhat unknown. There have been reports that environmental survival is relatively short (Olesen et al., It is important to consider limitations of the current investigation. One limitation is that there was no measure of sample infectivity. Detection of ASFV DNA via rt‐PCR gives no indication that a sample is infectious. Therefore, it is not possible to infer the likelihood of infection in a naïve population of pigs if either direct or indirect contact is made. There are several advantages of using rt‐PCR compared to other diagnostic assays including the flexible sample types which can be analyzed and rapid turnaround time (Rodriguez et al., Another limitation of the current study is the nature of the investigation was to identify biosecurity gaps with the goal of implementing corrective improvements in biosecurity. Therefore, the biosecurity practices of the system were adjusted as more data were generated and these data are not true estimates of prevalence of ASFV DNA detection within this system over time. It is also important to consider that changes in ASFV DNA detection over time could be attributed to biosecurity improvements, but also could be due to changes in disease prevalence within the region. This system also incorporated a high level of biosecurity within many areas of live animal production as well as feed manufacture and delivery, which means extrapolation to other situations may not be appropriate or provide an accurate assessment of risk. The feed mill in the current investigation also pellets all diets and uses a commercially available formaldehyde‐based feed product in a subset of manufactured diets. Therefore, it is not possible to extrapolate these results beyond these particular conditions, and the rate of ASFV DNA detection may differ under different conditions.This investigation has illustrated the value that environmental sampling can bring to a system's biosecurity assessment and protocol development. Environmental sampling can also serve as a method of indicating the source of a disease outbreak and its directionality through fomite transmission. Most feed safety research is based on the theory of forward transmission, with a contaminated ingredient being mixed into feed and causing an initial outbreak in animals. However, the evidence in this case instead suggests the possibility of backward contamination, where an outbreak on the farm led to contamination of feed trucks which transferred the contamination back to the feed mill. In summary, a wide variety of factors must be considered to reduce the likelihood of disease transmission and this information provides baseline understanding in a real‐world setting which can be used as a foundation for future investigations to build upon.The authors declare no conflict of interest.The authors confirm the ethical policies of the journal have been followed. All samples collected and analyzed in the current report were not derived from live animals and were diagnostic in nature.


Emotionally focused therapy (EFT) is an empirically supported intervention for relationship distress with an established model of supervision. This study examined whether incorporating video feedback (VF) software into EFT supervision would improve therapists' level of development compared to traditional EFT supervision in a university training clinic. A concurrent multiple‐baseline across subjects design, along with a thematic analysis of qualitative data, were used in this proof‐of‐concept study of the new supervision component. Overall, quantitative findings suggested that using VF in EFT supervision resulted in some improvement to therapists' development, while qualitative findings showed that all participants supported the incorporation of VF into EFT supervision. Future research on VF is needed to provide additional insight into the use of video review supervision. Emotionally focused therapy (EFT) is an empirically supported intervention for relationship distress that is informed by attachment theory and draws on experiential and emotional processes. Therapists learn to deliver EFT by facilitating therapeutic change through a three‐stage process, which involves deescalating negative cycles of interactions, restructuring interactions, and consolidating change Johnson, . EFT theWhen EFT therapists access and process clients' intense emotions in session, clients are able to engage in corrective emotional experiences and complete key therapeutic change events that lead to better clinical outcomes for couples  is a technology‐assisted approach that has been used to enhance professional training in a range of applications such as surgery, nursing, and education  doctoral‐level practicum focused on learning EFT. Therapist interns were each asked to select one focal couple with whom to deliver EFT and receive EFT supervision on throughout the study. The clinical supervisor in the study was a licensed marriage and family therapist with expertise in EFT. Participants were randomly assigned to different baseline lengths to control for potential biases. During the baseline phase, participants were supervised using the EFT model of supervision with the same couple following the plan–observe–feedback format; in this format, therapist interns received case report and live supervision. During the intervention phase of the study, the model and format of supervision continued, except that VF supervision was added. For the VF supervision component, therapist interns were asked to watch specific moments in their therapy sessions that were electronically flagged during live supervision by the supervisor and read the supervisor's observations pertaining to the video segments. The baseline phase of the study coincided with the start of a semester‐long practicum course that aimed to train students in EFT.Participants were assessed after each session with their focal couple throughout the baseline and intervention phases. The primary outcome in this study was therapist development measured by the Supervisee Level Questionnaire—Revised . This software affords the supervisee the opportunity to playback important segments of the therapy session and return to the emotional field of the moment while reflecting on the supervisory feedback. In addition to providing general feedback, the supervisors could flag video segments according to specific preprogrammed hot keys or keyboard shortcuts in which supervisors could efficiently type one letter on the keyboard to code a segment in a specified way . The preprogrammed markers in this study included: (a) alliance, (b) interactional pattern, (c) reframe, (d) pursuer softening, (e) withdrawer re‐engagement, (f) enactment, (g) blocking, (h) emotional experiencing, (i) consider being more active, (j) client showing growth, (k) adverse event discussed, and (l) bring to supervision.The therapist‐in‐training was instructed to watch video segments of their sessions that were electronically flagged by the supervisor and read the supervisor's feedback before the next planning session. Therapists‐in‐training could also filter the electronic feedback based on the specific marker types to efficiently review, for example, all video segments and supervisory feedback that the supervisor identified as needing to discuss or those related to opportunities for or effective facilitation of deep emotional experiencing. Pooling the supervisory feedback on specific markers over the course of therapy with a couple offered opportunities to highlight patterns in practice and reflect on ways to shift patterns that were not conducive to facilitating change.Never) to 7 (Always), with a possible range of 25–175 for the total score. We reverse coded the professional insecurity subscale items such that higher scores always reflected more desireable levels of developmentparti; we refer to this subscale as professional security in this article for ease of interpretation. The SLQ‐R has good internal consistency  How has discontinuing VF affected your ability to integrate lessons learned from therapy and advance your EFT skills? (2) How has your progress in EFT been affected by being involved in this study? and (3) Would you recommend the use of VF in clinical training programs?A combination of visual and statistical methods was used to evaluate the supervision intervention. In the current study, the data were visually inspected for consistent trends within and between each phase, including limited variability within each phase .Figure half of the time) to 6.48 (6 = most of the time), indicating that therapist interns demonstrated a moderate to high level of therapist development during the baseline phase. Participant 1 had a baseline average of 4.67, indicating that she had the most to gain during the intervention phase. Concerning baseline trends, all participants had at least five time points which met requirements to test a baseline tend. Participants 1 and 2 had generally stable baseline trends while participant 3 demonstrated an increasing baseline trend, indicating that he had improvements in his therapist development leading up to the intervention phase. There were no overlapping data between the baseline phase and the intervention phase. In evaluating the immediate effect , there was a small and noticeable positive intervention trend for participants 1 and 2, but a generally stable intervention trend for participant 3. Overall, participant 1 indicated a positive intervention trend across all time points. However, intervention trends were not consistent enough across the three participants to suggest a causal relation.Visual inspection of predictable baseline patterns revealed that participants had moderate to high baseline averages ranging from 4.56  to 6.77 , indicating that the therapist interns demonstrated a moderate to high level of therapist self‐confidence during the baseline phase. Most noticeably, participant 1 had a baseline average of 4.34, indicating that she had the most to gain in professional self‐confidence during the intervention phase. Concerning baseline trends, all participants had at least five time points which met requirements to test a baseline tend. Participants 1 and 2 had generally stable baseline trends while participant 3 demonstrated an increasing baseline trend, indicating that he reported improving in therapist self‐confidence during the baseline phase. There were no overlapping data between the baseline phase and the intervention phase. Evaluating the immediate effect , there was a moderate positive intervention trend for participant 1, but a generally stable intervention trend for participants 2 and 3. Participant 1 indicated a positive intervention trend across all the time points, but this was not consistent enough across the three participants to suggest a causal relation.Similar to the total scores, visual inspection of predictable baseline patterns revealed that participants had moderate to high baseline averages ranging from 4.07 (4 = often) to 6.81 , indicating that therapist interns reported moderate to high levels of therapist security. Participant 1 had a baseline average of 5.11, indicating that she had the most to gain in professional security from the intervention. Concerning baseline trends, all participants had at least five time points which met requirements to test a baseline tend. Participants 1 and 2 had generally stable baseline trends, while participant 3 demonstrated a noticeable increasing baseline trend, indicating that he improved in therapist security during the baseline phase. There were no overlapping data between the baseline phase and the intervention phase. Evaluating the immediate effect , there was a small noticeable positive intervention trend for participants 1 and 2, but there was a small and noticeable negative intervention trend for participant 3. Overall, the consistent intervention trends among participant 1 and 2 may suggest a causal relation.Similar to the total scores, visual inspection of predictable baseline patterns revealed that participants had moderate to high baseline averages ranging from 5.00 , which confirms the visual inspection of a baseline trend we noted earlier. Participants 1 and 2 did not have a significant baseline trend . A significant tau‐U test revealed that the intervention had a positive effect on increasing participant 1's therapist development . However, there were no significant effects between the baseline and intervention phases for participants 2 and 3, even after accounting for a corrected baseline for participant 3. Consistent with the visual inspection, we cannot suggest a causal relation as there was only one significant intervention effect.Baseline tests revealed that participant 3 had a significant and positive baseline trend  and 2 . Although our visual inspection indicated a potential baseline trend for participant 3, this trend did not reach significance . A significant tau‐U test revealed that the intervention had a positive effect on increasing participant 1's professional self‐confidence . However, there were no significant effects between the baseline and intervention phases for participants 2 and 3. Consistent with the visual inspection, we cannot suggest a causal relation with only one significant intervention effect.There were no significant baseline trends for participants 1 , which confirms the visual inspection of a baseline trend we noted earlier. Participants 1 and 2 did not have a significant baseline trend . Significant tau‐U tests revealed that the intervention had a positive effect on improving the professional security of participant 1  and participant 2 . However, there was not a significant effect between the baseline and intervention phases for participant 3 even after accounting for a corrected baseline. These findings suggest a causal relation, which is consistent with the visual inspection.Baseline tests revealed that participant 3 had a significant and positive baseline trend .”Forgetting learned skills. Over time, participants missed the benefit of VF. As one participant shared, “I am beginning to forget some of the skills gained due to not receiving ongoing VF supervision…I feel the use of VF really affected the quality and usefulness of supervision.” The use of VF also helped one participant to “improve [her] memory and made it easier to recall some of the feedback in future sessions.”Most participants articulated positive changes to their clinical EFT skills as a result of being involved in this study and receiving VF as part of their supervision. Three subthemes were identified by participants: confidence in using EFT, strengthening EFT skills, and observation and reflection.Confidence in using EFT. One participant said VF helped her become more confident in going deeper emotionally with clients and exploring heightened emotions, because “VF highlighted things that went well in sessions and increased my confidence in continuing those things.” Another participant said that she had not attempted to use EFT with clients before participating in this study. VF helped her to “move EFT from an abstract theory to a useful intervention.” Another participant also indicated that VF helped her go from feeling “novice to partially competent” in using EFT.Strengthening EFT skills. In addition to building their confidence, VF also helped participants strengthen their clinical skills in using EFT. One participant said that VF “enhanced the timing of my interventions, as well as my delivery…and my ability to use key interventions  improved as a result of the study.” Participants also noted that VF was useful in helping them learn and “successfully implement EFT ” because VF helped EFT “come to life.” Another participant said VF helped “heighten or expand experiences and show places where deeper work would be possible.” VF helped participants gain more insight into their work, thus improving their clinical EFT skills with clients. One participant stated that he had understood the EFT interventions in theory before the study; however, participating in this study helped him to implement and execute the interventions appropriately.One participant found that VF was particularly helpful in Stage 2 of EFT because “it made me more aware of my presence in the room while also giving me clues and ideas on how to expand my work.” The same participant began to see more intense and complex couple cases after the study had finished and she expressed that it would have been helpful to continue VF supervision in her Stage 2 work with these cases.Observation and reflection. One of the most useful features of VF was that it allowed therapists to watch key moments of their work in session. This enabled therapists to observe their own actions and behaviors during key segments and provided an opportunity for deep reflection on their therapeutic work. One participant found that VF helped her in that she “became more aware of [her] presence in the room, eye contact, body language, and places where [she] was stuck.” Another participant found that VF “allowed for deep reflection and processing.” Additionally, VF enabled supervisors to pinpoint times when the therapist did well, and this feedback was also affirming for therapists' learning and reflection. One participant said that using VF was analogous to “a musician listening to a recording of him or herself,” because it helped her to reflect on how well or poorly she implemented EFT interventions.This study investigated whether adding VF to EFT supervision improved therapists' level of development in a university training clinic focused on learning EFT. A concurrent multiple‐baseline across subjects design was used to evaluate the additional component of supervision by introducing VF to different participants at different points in time for the purpose of testing intervention effects. Participants completed quantitative surveys after each EFT session with their focal couple and responded to qualitative surveys at the end of the intervention phase and 4 months after the intervention to discern participants' perceptions of the appropriateness and their satisfaction with the supervision intervention. Overall, we found that participants demonstrated high levels of therapist development on the SLQ‐R at the start of the study, indicating the potential for a ceiling effect. Findings for the SLQ‐R total score and professional self‐confidence subscale showed an effect for one of three participants, and therefore, do not meet the minimum standards to suggest a causal relation. Two of three participants showed a significant improvement on the professional security scale, which suggests the supervision intervention had a desirable effect on professional security.In the qualitative responses, all participants reported positive experiences of the incorporation of VF into supervision. Qualitative findings indicated that participants felt VF facilitated the development of therapeutic confidence and competence in implementing EFT interventions. They were able to witness the impact of their delivery of EFT while receiving positive and corrective feedback from their supervisor that highlighted their strengths and target areas for improvement  to six data points (to meet standards) for each phase (Kratochwill et al., We sought to understand whether adding VF to EFT supervision resulted in further growth in therapists' development. This proof‐of‐concept study used a concurrent multiple‐baseline across subjects design in which participants served as their own controls. In addition, qualitative responses were analyzed using thematic analysis. Findings demonstrated promise for adding VF to EFT supervision. Quantitative findings may have been affected by a ceiling effect, but the highly positive qualitative responses offer social validity data in support of VF. Future research on the efficacy of the supervision intervention component is needed to provide additional insight into the use of VF supervision.


After this article  was publThere are undeclared image splice lines in Figs 1F and 2B.The whole organ images of the BCG immunized liver and spleen in Fig 5 were duplicated as representing liver and spleen of the BCG immunized group in mms immunized group in The whole organ image of the BCG immunized spleen in Fig 9 was duplicated as representing the spleen in the MtbΔThe authors provided image data for Figs 1F and 2B  which clThe authors also noted that the whole organ image duplications arose due to errors in preparing PLOS ONE’s Editorial Board reviewed the updated figure and the underlying data provided. The Academic Editor advised that further pathological and histological analyses and disease readouts are needed to clarify the nature of the lesions observed in vivo and to support claims made in the article about organ structure and pathology. The corresponding author disagreed and commented that the methods used in the study are suitable for evaluating TB disease pathogenesis.A member of The following issues were also identified in the post-publication assessment:Claims about lack of infection (e.g. “No bacilli were detectable…”) are based on bacillary load data for partial organs and may not be representative of whole organ bacillary loads.mms was sufficiently attenuated for growth in the host tissues and could be safely used as a vaccine candidate.”“…it appeared that as a result of deletion of the phosphatase genes, MtbΔmms mutant appeared to be safe for its use as a vaccine candidate”“the MtbΔmms as well as BCG inoculated animals appeared to be similar with no apparent damage indicating that the mutant was safe to be used as a vaccine candidate.”“…at 10 weeks post inoculation, the organs of MtbΔClaims about whether the mutant could be safely used as a vaccine candidate are not adequately supported; additional safety & toxicity assessments would be needed to support such claims. This issue calls into question the reliability of the following statements:The corresponding author agreed that additional safety and toxicity assessment studies are needed for further development of the mutant strain as an auxotrophic vaccine. He clarified that this particular study was carried out with the idea of providing a proof of concept and exploring a potential vaccine candidate, to be worked upon further if it showed promise.M. tuberculosis incapable of causing pathology in guinea pigs at 10 weeks post inoculation”.The following subtitle in the Results section overstates what can be drawn from the reported data, and is misleading in light of pathology results reported for the 4 week timepoint: “Deletion of phosphatase genes renders mms exhibited a more sustainable and superior protection as compared to BCG.” Similarly, the conclusions state that the MtbΔmms mutant “imparted an enhanced protection against pulmonary TB” [mms vs. BCG groups was observed according to results reported in Figs 7 and 9. At the 12 week timepoint, a significant difference in pulmonary bacillary load was observed for MtbΔmms vs. saline control groups but not for BCG vs. saline control groups. This suggests that MtbΔmms may provide a more sustained protective response than BCG against pulmonary TB infection, but further studies are needed to explore this hypothesis.The Results paragraph discussing the Fig 7D experiment include the statement, “These observations demonstrated that MtbΔnary TB” ; the impPLOS ONE Editors concluded that the results in Figs 3, 4 and 7 support the article’s main claims about the MtbΔmms mutant’s attenuated growth in macrophages and guinea pigs and ability to impart protection against pulmonary TB in guinea pigs. However, the article’s claims about organ pathology, the safety of MtbΔmms for use as a possible vaccine candidate, and enhanced protection by MtbΔmms (vs. BCG) are not adequately supported by the reported experiments and data.Based on the outcome of our post-publication assessment, the The conclusions are hereby updated as follows:Original: “The MtbΔmms was not only significantly attenuated for growth in macrophages and guinea pigs, it also imparted an enhanced protection against pulmonary TB.” [ary TB.” Revised: “The MtbΔmms mutant was significantly attenuated for growth in macrophages and guinea pigs, and appeared to impart protection against pulmonary TB infection as evidenced by bacillary load data and whole organ assessments in a guinea pig model. However, spleen data from the in vivo model indicated that the MtbΔmms mutant is less effective than BCG at controlling hematogenous spread. Further studies are needed to (a) explore the safety and effectiveness of Mtb mutants as potential vaccine candidates, using additional histopathological analyses, toxicity assessments, and disease readouts, and (b) identify and investigate potential candidates that provide clinical advantages over BCG considering whole animal outcomes with regard to infection, pathology, safety and toxicity, and disease progression.”PLOS ONE Editors issue this Expression of Concern to notify readers of the above issues and the revised Conclusions.The S1 File(ZIP)Click here for additional data file.