Signal‐enhanced MRI biomarkers enriched with stable magnetic nuclear isotopes can be used to monitor radiation effects, as demonstrated recently by the use of dynamic nuclear polarization (DNP) for biomolecular observations in vivo. In this context, nanoparticles can also be used as radiation enhancers or biomarker carriers. The radiobiology‐relevant features of high dose‐rate secondary radiation generated using high‐power lasers and the importance of noninvasive biomarkers for real‐time monitoring the biological effects of radiation early on during radiation pulse sequences are discussed.Recently developed short‐pulsed laser sources garner high dose‐rate beams such as energetic ions and electrons, x rays, and gamma rays. The biological effects of laser‐generated ion beams observed in recent studies are different from those triggered by radiation generated using classical accelerators or sources, and this difference can be used to develop new strategies for cancer radiotherapy. High‐power lasers can now deliver particles in doses of up to several Gy within nanoseconds. The fast interaction of laser‐generated particles with cells alters cell viability via distinct molecular pathways compared to traditional, prolonged radiation exposure. The emerging consensus of recent literature is that the differences are due to the timescales on which reactive molecules are generated and persist, in various forms. Suitable molecular markers have to be adopted to monitor radiation effects, addressing relevant endogenous molecules that are accessible for investigation by noninvasive procedures and enable translation to clinical imaging. High sensitivity has to be attained for imaging molecular biomarkers in cells and  Despite the progress in revealing the mechanisms underlying cellular responses to various cues — including exposure to radiation — there is a compelling need to develop methods for in vivo evaluation of biomarkers and their biochemical transformations during the chain of events leading to final products. Progress in MR sensitivity using hyperpolarizationin vivo, can be decisive for evaluating radiation efficiency on an individual basis. A better understanding of the processes involved in radiation‐induced damage signaling, upstream of the endpoints, will allow an improved monitoring of the outcome of radiotherapy based on sequences of enzyme‐controlled transformations.Using rapidly developing omics approaches, the various pathways involved in the cells’ coping with radiation‐induced damage have been studied and molecular endpoints for these pathways are often analyzed . The evaluation of cellular responses to the radiation challenge relies on the detection of a broad array of accumulating products of cellular pathways activated by irradiation. The final outcome of this network of events can be defined This radiation‐monitoring approach may allow, in the case of high dose‐rate radiation, for fine tuning of the doses and of the sequences of radiation pulses for personalized therapy, as well as for the development of cotherapies to increase treatment efficacy and to limit radiotherapy side effects.Molecular imaging techniques are used to monitor functional and metabolic biomarkers for better orienting and monitoring personalized radiotherapeutic strategies.in vivo. In terms of the minimum quantity of a tracer molecule needed for detection, MR‐based techniques using stable isotopes are less sensitive than PET. However, they are more flexible in terms of setup and can be used to image therapy effects noninvasively as often as clinically necessary after initial and subsequent radiotherapy sessions., ex vivo  and in vivo imaging of the effects of radiation can be conducted with the same approach.UV‐Vis or fluorescent spectroscopic methods for the detection of biomarkersBiomarkers can be used for improving image‐guided interventions. This raises the need to identify endogenous molecules that provide information on the effects induced by ionizing radiation in due time, that is, before toxic effects arise, help predict individualized radiation sensitivity and treatment outcome.220 photons in tens of femtoseconds to a solid target, which can, in turn, generate 1010–1011 ions with energies higher than 10 MeV/nucleon, depending on the laser acceleration mechanism.In recent years, short‐pulse high‐power lasersRadiation can also be delivered on short timescales  using classical accelerators. Such pulses have been demonstrated using a superconducting nanoscope in conjunction with TANDEM accelerators for proton irradiation.9 Gy/s. High energies can be attained with the current state of the art for laser‐driven proton acceleration  on the order of 1 Gy/10 ms, obtained with conventional particle accelerators is a good radiation strategy to spare healthy tissue while remaining effective on tumor tissue.On the side of experimental evidence using radiation from classical accelerators, recent research conducted The relationship between the persistence of the free radicals generated on ns time scales or even faster and the inflicted cell damage is to be explored, as bursts of free radicals on ns timescales were difficult to induce until recently. The molecular effects of radiation pulses delivered to cells on these timescales are anticipated to offer new therapeutic promises.Decreases in tumor radiosensitivity by transient oxygen depletion following a short‐pulse irradiation2.A.Several relevant experiments of cell radiation by pulsed beams using laser‐driven and conventionally accelerated protons are presented in Table Laser sources are expected, in the near future, to deliver proton pulses corresponding to radiation levels of Gy on timescales of hundreds of ps. High‐density protons delivered in clusters are thought to manifest increased linear energy transfer (LET) compared to isolated protons. Via computer simulations, the convergence of proton tracks was anticipated to have damaging effects similar to those of high LET radiation.Emerging studies comparing the effects of high dose‐rate laser‐driven radiation and low dose‐rate radiation showed that imaging techniques have to be further developed to address cellular responses to ionizing radiation exposure in order to help decide on the most effective strategy for applying radiation pulses.2.B.20 W/cm2 on a target consisting of an ultrathin carbon foil.in vitro to study the effect of ultra‐high dose‐rates (~109 Gy/s) prior to medical applications. Most likely, with the next generation of 10 PW‐class lasers, for example, at ELI‐NP,13 Gy/s. Results have been recently reported on biological material irradiated with laser generated electrons both in vitroin vivo.Investigations of the radiobiological effects of ions heavier than protons have been carried out since decades using conventional accelerators. It is well known that heavy ions based radiotherapy produces stronger biological effects than proton‐beam therapy. So far, radiobiology research has been carried out using low dose‐rate heavy ions radiation, but the biological effects of high dose‐rate heavy ions radiation are unknown due to the complete lack of experiments. It is noteworthy that experiments with laser‐accelerated carbon ions are ongoing in petawatt‐class facilities. Medical applications require ions with energies up to a few hundred MeV per nucleon, whereas, at the moment, laser‐accelerated ions, such as carbon‐12, can reach only tens of MeV per nucleon. About 10 years ago, researchers were able to generate carbon ions with maximum energy of 6 MeV/n using a 30 TW‐class laser at the Max Born Institute in Germany.In order to destroy tumor cells that adapt to radiation, synergy between the effects of subsequent pulses or different types of radiation is taken into consideration in complex radiotherapy‐oriented studies. For the moment, evidence of such synergy was found3in vivo monitoring.Early detection of radiation effects is needed to orient pulsed radiotherapy in real time. The formation of free radicals and reactive molecules either directly by radiolysis or as a cellular response to radiation, if promptly detected, can help in this regard. Due to the timescale on which free radicals are formed and recombine in laser‐stemming radiation Fig. , their din vivo monitoring of cancer response to radiation is especially sensitive to oxygen presence via mechanisms forming reactive species.Clinical studies have addressed the use of MRI in the radiotherapy of static organs, for example, for the treatment of brain and prostate cancers.in vivo imaging of radiation effects.Emerging MRI‐guided proton beam therapy (MRgPT) elicits increasing interest, triggered by the already‐implemented real‐time MRI‐guided x‐ray beam therapy (MRXT), as MRI guidance for proton beam therapy will offer an improvement over the conventional proton therapy in terms of toxicity outcomes. The use of MRI‐Cobalt (ViewRay™) for imaging‐oriented radiotherapy was shown to extend cancer survival by up to a factor 2.We comment herein on the potential of using noninvasive magnetic resonance methods to orient pulsed radiation therapy, when the detected concentrations of endogenous molecules are sensitive, directly or indirectly, to the levels of free radicals induced by radiation.3.A.4 using “hyperpolarization.”in‐cellin vivo can be carried out using pyruvate or other biomarkers. The DNP‐MR imaging approach has been adapted for the clinic.in vivo within hours after radiation therapy.The sensitivity of MR has been recently improved by a factor 10in vivo.A strategy for orienting radiation therapy based on hyperpolarized MRI biomarkers has been described in the literature,The advantages of this approach have been outlined by a recent work3.B.In connection with MRI, nanoparticles are tested for biomarker development and treatment delivery. On the one hand, MRI detection of biomarkers can be improved using nanoparticles. Their large specific surface and the fact that this surface can be functionalized according to the intended use make them ideal candidates for developing biomarker platforms.On the other hand, nanoparticles can also deliver targeted chemotherapeutic drugs and enhance MRI imaging of their effects. Thus, nanostructures are expected to be used as targeted theranostic nanoplatforms for both therapeutic and imaging purposes. This is an important aspect in personalized cancer medicine, given their therapeutic potential and their simultaneous ability to track a patient's response to chemotherapy at the same time.177Lu for radiation therapy. The beta decay of 177Lu significantly decreased the growth of cancerous cells, as an enhanced permeability and retention (EPR) effect at the tumor site was achieved. Gold nanoparticles can be functionalized with epidermal growth factors (EFG) and labeled with 111In.Nanoparticles are used to enhance the therapeutic effects of radiation in cancer treatment. Satterlee et al.4in vivoin cells and subsequently used in vivo based on this optimization; (b) the difference between high dose‐rate radiation and classically generated radiation resides in the formation of reactive molecular species whose dynamic transformations can be followed by DNP‐MRI; (c) short‐pulse radiation effects are detected in a timely manner. In vivo, functional effects can be sensed by biomarkers hours after treatment, well before any observable structural morphologic changes would occur in tumors — that is, anticipating tumor shrinkage. With early monitoring of its effectiveness and toxicity at hand, radiotherapy may become, in numerous cases, the first clinical approach to be considered.High‐power lasers are unique sources for radiation featuring new interactions with living matter and very promising opportunities for radiotherapy. The effects of high dose‐rate radiation on cells and organisms need to be characterized using endogenous biomarkers in order to be fully exploited for spatially and time‐controlled radiotherapy. Using DNP to enhance the sensitivity of MRI, radiation‐induced perturbations mediated by free radicals can be followed inside cells. The irradiation of free radicals with microwave frequency can also be used The pulsed nature of the laser‐generated radiation, which exerts its effect in short bursts, may redefine the way of anticipating the biological effectiveness and the toxicity of different types of particle beams. Notwithstanding the fact that the same quantity of energy is delivered per unit mass to living tissues or cells by the same particle type, the effectiveness of the dose can depend on the pulse duration, as free radicals in water are known to recombine on fast timescales. It emerges that, with the development of ultrashort radiation pulses, the inclusion of a time dimension in the description of impinging radiation is needed to anticipate the biological effect of radiation doses. Consequently, the picture describing the classical mechanisms by means of which ionizing radiation exerts biological effects can be revisited considering the ultra‐short period of radiation action, in the case of high‐power laser‐based radiation. This can have beneficial consequences for exploiting the observed mechanistic effects in radiotherapy, in terms of deleterious effects for tumors and sparing of the healthy tissue.The authors have no conflicts to disclose.


Patient‐derived tumour xenografts and tumour organoids have become important preclinical model systems for cancer research. Both models maintain key features from their parental tumours, such as genetic and phenotypic heterogeneity, which allows them to be used for a wide spectrum of applications. In contrast to patient‐derived xenografts, organoids can be established and expanded with high efficiency from primary patient material. On the other hand, xenografts retain tumour–stroma interactions, which are known to contribute to tumorigenesis. In this review, we discuss recent advances in patient‐derived tumour xenograft and tumour organoid model systems and compare their promises and challenges as preclinical models in cancer research. It was previously demonstrated that orthotopic transplantation can lead to local invasive growth and metastases, similar to those observed in patients , or to which the differentiation was directed (embryonic stem cell‐derived organoids)  xenografts was treated with topotecan, a topoisomerase I inhibitor, combinations of topotecan and the topoisomerase II inhibitor etoposide or alkylating agents ifosfamide or cisplatin at maximum tolerated dose , observed in a breast cancer cohort, within a tumour can be indicative of germline mutations in NTHL1  play an important role in the tumour environment. As such, Öhlund and colleagues showed that a co‐culture of murine pancreatic stellate cells (PSCs) and PDAC tumour organoids recapitulate properties of PDAC desmoplasia. They demonstrate that PSCs differentiate into two distinct subtypes of CAFs with elevated expression of αSMA and secretion of IL‐6 and additional inflammatory mediators, respectively  mouse model can be generated by transplantation of CD34‐positive human hematopoietic stem cells (HSCs) or precursor cells. These cells can be isolated from bone marrow, peripheral blood or umbilical cord blood. CD34‐positive HSC transplantation can be performed alone or in combination with transplantation of human immune tissues, such as thymic tissue  can be differentiated towards several lineages and can be used to model normal development The authors declare that they have no conflict of interest.


The management of conflicts between wildlife conservation and agricultural practices often involves the implementation of strategies aimed at reducing the cost of wildlife impacts on crops. Vital to the success of these strategies is the perception that changes in management efforts are synchronized relative to changes in impact levels, yet this expectation is never evaluated. We assess the level of synchrony between time series of population counts and management effort in the context of conflicts between agriculture and five populations of large grazing birds in northern Europe. We reveal inconsistent patterns of synchrony and asynchrony between changes in population counts and impact management effort relating to population harvesting, monetary payments, or scaring practices. This variation is likely due to differing management aims, the existence of lags between management decisions and population monitoring, and the inconsistent use of predictive models across case studies. Overall, our findings highlight the need for more adaptive and timely responses of management to changes in target species numbers so as not to unexpectedly increase social conflicts and jeopardize the status of wildlife populations. Many populations of large grazing birds have undergone exponential growth and expanding distributions in recent decades owing to an increase in protective legislation, improvements in agricultural land quality, and global climate change  and one species of crane (common crane Grus grus), all of which are known to cause damage to agricultural crops. Case studies included two island archipelagos (the isle of Islay and the Orkney archipelago in the United Kingdom), one Norwegian county , one Norwegian district (Vesterålen in northern Norway), one Swedish county , and the northern, western, and southern regions of the Jutland peninsula in Denmark . Case study area ranged from 620 km2 for Islay to 22,412 km2 for Nord‐Trøndelag, with a total area considered of 57,458 km2.We considered time series of population counts and management effort collected for six case studies in northern Europe Figure , and inv2.2For each case study, we collated time series of annual counts for the target species and relevant management effort , be it for sport, culling, or lethal scaring purposes. It was recorded as the winter hunting bag  in the case of the Svalbard pink‐footed goose in Jutland (open season from 1st September to 31st December) and Nord‐Trøndelag (10th August to 23rd December), as well as for the Greenland barnacle goose on Islay (October and March), and as the number of licenses issued to hunt resident British and migratory Icelandic greylag geese in Orkney (October to January). Monetary payments included: (1) financial compensation made to cover the cost of damage to crops after it had occurred (in Örebro), and (2) subsidies paid in advance to cover the cost of expected damage or the setting aside of grazing areas (on Islay and in Vesterålen). Last, scaring consisted of practices aimed at preventing flocks of geese or cranes from damaging unharvested crops. Although a diverse range of scaring practices is likely implemented on an ad hoc basis at many of the sites considered, effort in each case has not been quantified. We therefore used expenses relating to scaring activities as an indicator of scaring effort in Örebro and on Islay. All time series data are supplied in the Supplementary Information 2.3For each case study, we modeled separate trends for counts and management effort over time using generalized additive models  combined with a randomization procedure that shuffled values within each time series independently to test whether annual changes in count and management effort were more synchronous than expected by chance in the short term , matching an upward but nonsignificant trend in the combined counts for Svalbard pink‐footed and barnacle geese. Compensation payments and scaring subsidies associated with the management of common cranes in the Örebro county of Sweden showed nonsignificant negative  and significant positive . It is important to note that, due to strong serial autocorrelation in the time series of counts and hunting bags for both Jutland and Nord‐Trøndelag, synchrony remained high regardless of the time lag considered  than the previous year  than with any other count. Similarly, total expenses for scaring activities on Islay showed significant lags of 2  and 3  years with the combined winter counts of white‐fronted and barnacle geese. Lastly, changes in scaring subsidies in Örebro showed no evidence of short‐term synchrony or asynchrony with common crane counts (φobs = 0.599, φexp = 0.562, P = 0.381 for a time lag of 0; Figure Changes in average subsidy per application in Vesterålen were more strongly synchronized with changes in the average number of geese recorded the same year (φ4Sus scrofa; Massei et al., Our study reveals inconsistent patterns of synchrony and asynchrony between changes in impact management effort and population counts of large grazing bird species across case studies in northern Europe. In highlighting this variation, we provide valuable insights into potential indicators of social conflicts involving wildlife conservation and agricultural activities. Indeed, perceived randomness and inconsistent changes in management effort relative to wildlife impacts in the short and long terms have been shown to influence the level of trust stakeholders place on the decision‐making process (Young et al., Long‐term patterns of synchrony and asynchrony in hunting bags need to be considered within the context of specific management aims, which may vary across space and time (Madsen et al., Similarly, a time lag in management actions is to some degree inevitable and depends on the specific management process at hand. Annual hunting bags in Jutland and Nord‐Trøndelag are based on population estimates obtained the previous year and complemented with an estimation of harvest‐induced mortality as well as a forecast of the breeding output (Madsen et al., One surprising result is the absence of time lag in the synchrony between subsidies and population counts in Vesterålen, despite subsidies being allocated before geese arrive in the spring and based on previous counts (Tombre, Eythórsson, & Madsen, Lack of short‐term synchrony can be seen as both a cause and a consequence of social conflict between parties invested in agricultural activities and wildlife conservation. Observed inconsistencies may arise as a result of competing interests influencing the decision‐making process. This may result in compromises that, although conducive to the attenuation of social conflicts (Liukkonen, Mykrä, Bisi, & Kurki, The limitations of our study open up important avenues for future research. First, we make the assumption that the relationship between population count and agricultural damage is linear. However, quantitative studies linking large grazing bird numbers to incurred damage remain scarce (Fox et al., Conflicts between wildlife conservation and agricultural activities are becoming more widespread, threatening biodiversity and food security globally. As demonstrated in this study, the analysis of historical time series provides a useful evaluation of conflict management. Despite this, quantitative data on the history of management actions remain scarce and we urge managers and researchers to better document actions taken to promote transparency and evaluation. We also emphasize the importance of using models to support management decisions. A structured approach to decision‐making paired with adaptive co‐management could allow for quicker cycles of up to date population data, their subsequent translation into appropriate management actions, and the monitoring of their implementation by people on the ground. Socio‐ecological studies are required to clarify the relationship between changes in management actions and changes in stakeholder attitudes and behavior, thus enabling a sustainable process of conflict mitigation to be reached.S1 Details relating to time series of management effortClick here for additional data file.S2 Population and management effort time seriesClick here for additional data file.S3 GAM implementation and trend estimationClick here for additional data file.S4 Estimation of short‐term synchronyClick here for additional data file.S5 Autocorrelation coefficients for flyway counts of Svalbard pink‐footed geese and hunting bags in Jutland and Nord‐TrøndelagClick here for additional data file.S6 Estimated trend in the ratio of monetary payments to scaring expenses for both the Islay and Örebro case studiesClick here for additional data file.


Immunometabolism is a branch dealing at the interface of immune functionalities and metabolic regulations. Considered as a bidirectional trafficking, metabolic contents and their precursors bring a considerable change in immune cells signal transductions which as a result affect the metabolic organs and states as an implication. Lipid metabolic ingredients form a major chunk of daily diet and have a proven contribution in immune cells induction, which then undergo metabolic pathway shuffling inside their ownself. Lipid metabolic states activate relevant metabolic pathways inside immune cells that in turn prime appropriate responses to outside environment in various states including lipid metabolic disorders itself and cancers as an extension. Although data on Immunometabolism are still growing, but scientific community need to adjust and readjust according to recent data on given subject. This review attempts to provide current important data on Immunometabolism and consequently its metabolic ramifications. Incumbent data on various lipid metabolic deregulations like obesity, metabolic syndrome, obese asthma and atherosclerosis are analysed. Further, metabolic repercussions on cancers and its immune modalities are also analysed. Metabolism is sole source of energy for cells, which they extract from available nutrients in the microenvironment. These cells in turn utilise this energy to perform their vital functions. Interestingly, microenvironment remains virtually same for static cells but obviously keeps changing in case of more dynamic ones such as immune cells which require to circulate to ensure immune surveillance.Immunity and metabolism are critical determinants of each other as increasing evidence are suggesting the link between these two vital systems of human body.2f/f; Lyz2‐Cre mice blocked all kinds of lipid accumulation within body and reversed insulin resistance  of non‐alcoholic fatty liver disease (NAFLD) and this phenomenon coexisted with pro‐inflammatory bias in these patients.ob‐ob mice.Metabolic diseases are growing rapidly in present world food scenario. Obesity, NAFLDs, hyperlipidaemia, metabolic syndrome and diabetes are all associated with negative alteration in immune functionalities. Leptin is one of the key hormones secreted from adipose tissues and is involved in regulation energy storage and expenditure.Atherosclerosis is rather more relevant to Immunometabolism because this disease, over the course of decades, have acquired the reputation as a metabolic state as well as immune complication. It's a disease that occurs at the interface of immunity and metabolism and hence become a vital case study in this context.Another relevant example of Immunometabolism can be traced in obese asthma, which is a state characterised by infiltration of adipose tissue by activated macrophages and mast cells. Periyalil et al in one clinical study demonstrated age and sex specific macrophages activation in obese asthma patients. Study compared obese and non‐obese asthma patients through spirometry, body composition assessment by dual energy X‐ray absorptiometry and found raised levels of sCD163 in former. The study also found elevated plasma CRP and leptin levels in obese asthma adults, while serum tryptase concentrations remained unchanged across different age groups of obese individuals. Finally, it concluded the higher existence of subphenotypes of macrophages in obese asthma patients at the molecular level.Another landmark study was reported by Scott et al in which obese and non‐obese adults with asthma, and obese and non‐obese healthy controls were compared by analysing neutrophil percentage and C‐reactive protein level. Sputum neutrophil percentage and severity of neutrophilic asthma was positively found to be correlated with BMI and obesity. In conclusion, saturated and monounsaturated fatty acids were put as vital predictors of neutrophilic airway inflammation in asthma.Excellent reviews on Immunometabolism are written in current years.3+ tumour‐infiltrating lymphocytes (TILs) in TME which ultimately results in “functional exhaustion” of TILs. This hypoxic and hypoglycaemic environment are sufficient to pose a significant threat to otherwise extremely resilient cells.Current list of cancer hallmarks is extended by Hanahan et alMyeloid cells, normally having protective response, transform into their immunosuppressive counterparts due to metabolic reprogramming in TME and termed as myeloid‐derived suppressor cells (MDSC). These cells are known to curtail anti‐tumour T cell functions and shield tumours from the effects of chemotherapy and radiation therapy.Treg cells are well‐known to possess immunoregulatory activities that inhibit the anti‐tumour responses from immune cells. Wang et al summarised the immunomodulatory functions of Tregs in the TME and discussed the metabolic regulation of Tregs that can facilitate intratumoural Treg storageIt is now believed that internal metabolism of cancer cells not only helps support the malignant growth but also affects malignant cells phenotype.Cancer cachexia (CC) is a complex wasting syndrome associated to the majority of cancers, and characterised by abnormal immune cells activation and their presence in metabolic tissues. Increased immune cells presence in WAT of CC patients,4Based on the above discussion, it is plausible to conclude that molecular metabolic contents play a vital role in priming surrounding immune cells to given conditions by affecting their metabolic pathways. Immune cells metabolic changes, in turn, often lead to metabolic deregulation outside, which culminates into metabolic diseases. Furthermore, tumourigenesis has inflammatory traits that can ultimately lead to metabolic deregulation to worsen the deadly disease known as cancer. Future directions can be traced on the existing gaps in the incumbent data which include but not restricted to (a) knowing the exact mode of actions of immunometabolic states and observing the relevant signal transduction; (b) finding important drug therapy targets within the immunometabolic axis that can be prospectively used to treat metabolic diseases; (c) exploring the natural means to switch or shuffle the immunometabolic pathways in a specific direction in favour of patients.The authors confirm that there are no conflicts of interest.


Establishing patient safety priorities in psychiatry has received less international attention than in other areas of health care. This study aimed to identify safety issues as described by people in the United Kingdom identifying as mental health service users, carers and professionals.YCFF) which categorizes factors that contribute to patient safety incidents in general hospital settings. Service user and carer responses were described separately from professional responses using descriptive statistics.A cross‐sectional online survey was distributed via social media. Identified safety issues were mapped onto the Yorkshire Contributory Factors Framework  which included competence and listening skills; “Service process” that contained concerns about waiting times; “Management of staff and staffing levels” dominated by staffing levels; and “External policy context” which included the overall resourcing of services. Professionals identified staffing levels and inadequate community provision more frequently than service users and carers, who in turn identified crisis care more frequently.One hundred and eighty‐five responses from 95 service users and carers and 90 professionals were analysed. Seventy different safety issues were identified. These were mapped onto the 17 existing categories of the YCFF was successfully modified to describe these issues and areas for further coproduced research are suggested.This study updates knowledge on stakeholder perceived safety issues across mental health care. It shows a far broader range of issues relating to safety than has previously been described. The  Research into patient safety in mental health care has been dominated by the process of individual risk assessment with a focus on the prevention of suicide and homicide,In the past decade, UK mental health services have continued to change at a rapid pace; detentions under the Mental Health Act have increased,This study aimed to identify current safety issues in UK mental health care as described by service users, carers and professionals.2This was a cross‐sectional semi‐structured survey accessed by a web address distributed across the United Kingdom via social media (twitter). Twitter was selected as the primary method for distribution due to its ability for social reach into specific communities of interest, in this case mental health professionals, service users and carers. Using social media has been shown to be a cost‐effective and rapid way in which to recruit people into research, particular those from potentially stigmatised groups, and the peer network structures of platforms such as twitter mean that users can recruit other users.2.1https://doi.org/10.6084/m9.figshare.6300800.v1.The electronic survey was created by the authors using the Bristol Online Survey platform which collates responses into a database and records IP addresses to prevent multiple responses from any one internet connection. The study was open between September and December 2016. The survey consisted of 18 questions specifically designed for this study. The questions about safety issues were consciously open and exploratory due to the broad range of potential safety issues identified both in the literature and during initial consultations with stakeholders. Participants were routed in one of three different ways depending on whether they primarily identified as a service user, carer or professional. The survey asked about demographic characteristics , and asked for free‐text responses to the question: “Please tell me what you think are the things that affect safety in mental health care?” The full survey is published at Approval for the study was granted by the University of Leeds, School of Healthcare Research Ethics Committee (ref. HREC15‐059). Information was provided about both the survey and sources of support at the beginning and consent was implied by completion and submission of the survey.2.2All the individual safety issues identified by participants were read and then coded by two researchers (KB and JB). Initial codes were generated, for example: “poor crisis support” or “alcohol on wards” resulting in 70 codes that accounted for all responses. These codes were then mapped onto the Yorkshire Contributory Factors Framework (YCFF) to aid interpretation. The decision to use the YCCF was made as it is theoretically based, there was no similar framework specific to mental health care available and it was not possible to develop one in the same way as there is not the primary research to draw upon. The framework consists of latent external factors (government policy), organisational factors (scheduling and bed management), local working conditions (staff workload), situational factors  and active failures (mistakes), along with two cross‐cutting themes of communication and safety culture. The mapping of codes onto the YCCF was initially carried out by KB and JB and discrepancies discussed with RL , before amendments were made (described below) and consensus gained. The free‐text responses were coded using the modified YCCF (supported by Microsoft Excel) to provide illustration of individual issues.The survey findings were numerically coded for analysis using SPSS 22,2.3Mental health service user and carer representatives and other stakeholders  were involved throughout this study. The research aims arose from social media discussions with a range of people, including (ex)service users, family members, carers and professionals in a range of roles about improving and understanding key safety issues in mental health services. The subsequent survey was developed following discussions with (ex)service users about patient safety in mental health settings. A number of active social media campaigners, including (ex)service users, were contacted about the specific design and content of the survey. They provided feedback on the questions and participant information resulting in adaptations being made to the wording of the survey, and this continued when the survey was launched after feedback from respondents, for example the additional of an employment category. These individuals assisted with maximising response rates using their substantial networks to actively promote the distribution of the survey. Author MB is mental health design researcher, writer and consultant. MB has direct lived experience of mental health difficulty and 12 years of experience in developing and delivering mental health projects with a strong participatory element. He has been involved for the duration of the study having been part of the initial application for funding, codesigned the survey, led the distribution through social media and subsequently provided input into the analysis and reporting of this study.3The survey received 188 responses from across the United Kingdom although three were excluded from the analysis as they were less than 50% complete. The analysed sample of 185 consisted of 90 professionals (48.6%), 77 service users (41.6%) and 18 carers (9.7%). For the purpose of analysis service, users’ and carers’ views were combined and presented separately from professionals. The demographic characteristics of the respondents are shown in Table There were more women than men in both groups and the majority of respondents described themselves as White British. The largest percentage of service users and carers (33%) had been in contact with services for five years or less with most of their contact over the previous two years with Community Mental Health Teams (CMHT) (48%), although 40% had experienced compulsory treatment in the past. Registered nurses were the largest professional group , 17 respondents described themselves as managerial (18%) rather than by professional orientation. Service users and carers were asked to describe their mental health problem in their own words; many provided diagnoses but others used non‐diagnostic terms such as “severe and enduring” (21%). Nearly half said they experienced depression and anxiety ; 17% PTSD, 16% personality disorder, 10% schizophrenia and psychosis and 9% bipolar disorder.3.1There were 796 individual responses identifying safety issues which after coding resulted in 70 first‐level categories. The majority of these codes fitted well within the YCCF but 20% did not. Following scrutiny of these codes by the author team, a decision was made to add two new categories. These were termed “Social environment” which took into account concerns about the social aspects of the service environment, for example other patients’ behaviour on mental health wards; and “Service process” which took into account both gaining access to and discharge from services, for example, not being able to access crisis care or being discharged from hospital before feeling suitably recovered. These were factors that the original YCCF did not address as it was derived exclusively from general hospital studies“Individual (staff) factors” was the most frequently cited YCCF‐MH category of both service user and carers and professionals. The second YCCF‐MH categories differed between groups with service users describing “Service process” followed by “External policy context.” Professionals cited “Management of staff and staffing levels” as the second with “Service process” coming third.Professional #159Lack of skills, confidence, and knowledge of staff to deal with challenging behaviour and risk. Within the “Individual (staff) factors” category, both groups most frequently referred to staff competence followed by poor attitudes. Staff competence was often illustrated by respondents describing specific issues such as staff not being able to respond to service user distress:P < .05, see Table Service user #36Truly listening to service user/carers views rather than [saying] ‘well that's your perspective’. Significantly more service users than professionals thought staff not listening was a safety issue .There were differences between the safety issues identified by staff depending on whether they worked in community or inpatient services. Significantly fewer inpatient staff gave responses related to individual staff characteristics as a safety issue .A larger proportion of service users and carers with recent experience of community‐based services had identified issues relating to service process as a safety issue . Correspondingly, a greater proportion of professionals currently employed in inpatient services also reported staffing levels to be a safety issue when compared with those working in the community .The service users and carers with recent experience of inpatient services were more likely to have identified short staffing as a safety issue  The category “External policy context” was dominated by concern about the safety implications of overall resourcing of mental health services. Both groups most frequently described this in terms of government cuts affecting mental health funding at local levels:Service user #124…the risks are more caused by people/human error  than broken equipment. Overall, the defining feature of the majority of the safety issues raised by participants was their reference to staff characteristics:4This paper reports mental health service users’, carers’ and professionals’ views of current safety issues in UK mental health services, across both inpatient and community settings. The safety focus in mental health has been confined to risk, homicide, suicide and deaths. Broader research which considers systemic safety issues does not appear to have been as prolific as in other areas of health care in the last ten years.The data we present update the issues and demonstrate there is a far broader range of safety issues identified in mental health care services than the threat to self and others that underlies the dominant risk‐management approach within mental health services. These issues range from the distal such as under‐resourcing of NHS services, to the proximal such as interaction with the individual practitioner. Previous research reporting safety issues in mental health services has referred to only a small number of concerns, whereas we identified 70 different issues. The majority of those previously reported in a safety context locate the risk within the service user, for example, self‐harm, suicide and violence.These data identify that patients feel their safety is at greater risk from service failures such as poor interaction with staff and the impact of short staffing than they are from self‐harm or suicide. This might reflect service users’ perceived lack of influence over the care they receive, of the power imbalance between service providers and those who want or need to use them.The inadequacy of community services as a safety issue was highlighted with service users reporting particular difficulties accessing crisis services and professionals perceiving all community provision as lacking, for example access to CMHTs, specialist teams and day services. There was a clearly perceived threat from the broader climate of reduced public spending that has led to cuts in overall mental health service provision, benefit entitlement and valued community services.Mapping the responses onto the YCCF clarifies these priorities showing both groups concerns about individual staff factors, staffing levels and the related problems with service process. The amendments made to broaden the scope of the YCFF to include community services and take account of the importance of social as well as physical environment in mental health care provide a framework within which further research and interventions can be developed. One way in which it is feasible to involve patients in safety improvements is by encouraging them to provide feedback on the safety of the care they are receiving. One such tool that uses the YCFF as an underpinning framework is the Patient Measure of Safety now validated for use amongst all general hospital patients.4.1This survey identified a wide range of concerns held by service users and professionals but they mostly fell into three categories: individual staff characteristics, service process and staffing levels, and there is a fundamental tension between them. Understaffed services will inevitably struggle to respond to service users’ needs due to constraints on professionals’ time and personal resources. This is not to say that all professionals have skills to deliver care in a compassionate and considerate manner, but that many that do are likely to be hampered by the circumstances in which they are working. That these individual staff characteristics were identified as safety issues is not something that has featured in the literature previously. Not being listened to, believed or feeling able to trust staff can make service users feel unsafe. This suggests these are important aspects of positive relationships and highlights the importance of professionals being able to develop them with service users and carers, but crucially that services are adequately resourced to make this possible. To make improvements to practice, it is recommended that direct collaboration takes place with service users to address the safety needs they have identified.4.2There are limitations to using an opt‐in survey although it was widely publicised using twitter and resulted in a large number of respondents reporting experiences and perspectives. As with all surveys, there was little potential for verifying responses, particularly in a novel area such as this where there are no other data sets that might have been used for comparison. Using twitter as a recruitment mechanism runs the risk of reaching people with the same interests and views, an “echo chamber” effect which has been found to occur with political affiliations.4.3Future coproduced research should aim to explore these numerous safety issues in greater depth. Qualitative data would illuminate many of the issues and in turn inform the development of interventions to address systemic safety issues such as optimum staffing levels as well as individual staff factors such as burnout.5This study updates knowledge on patient safety issues in mental health care for the first time in over a decade. It shows that service users, carers and professionals have considerable concerns about the manner in which staff interact with service users, access to support and inadequate staffing levels. Future research should focus on coproducing interventions with service users and carers to improve safety in mental health carer services by focusing on these areas of concern.The authors declare they have no competing interests.


Hum Brain Mapp, 40:2052–2054, 2019. © 2017 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.This technical report revisits the analysis of family‐wise error rates in statistical parametric mapping—using random field theory—reported in (Eklund et al. : arXiv 1 Parametric approaches are more efficient than their nonparametric counterpart by the Neyman–Pearson lemma. This follows because the most efficient test is based on the odds ratio inherent in parametric tests. This means that any nonparametric test can only be as efficient as a parametric test or less efficient.P‐values based on samples of the null distribution used in nonparametric tests.Parametric approaches are reproducible. In other words, one obtains the same result when repeating the analysis, unlike the Parametric approaches eschew the problem of complying with the exchangeability criteria of nonparametric procedures. These criteria make it difficult to apply nonparametric tests to data that have serial correlations or when using hierarchical models.Parametric approaches are computationally more efficient because they use distributional assumptions to eschew computationally intensive sampling from a null distribution.Random field theory has been at the heart of statistical parametric mapping in neuroimaging—and its various implementations in academic software—for over two decades. With technical advances in data acquisition, its validity has been revisited every few years to ensure it is fit for purpose [Bennett et al., These advantages rest on distributional assumptions that, if violated, render parametric tests inexact. In these instances, one could consider using nonparametric tests. It is, therefore, important to ensure that parametric tests and random field theory are robust to any violations. The analyses reported by [Eklund et al., t‐tests.Eklund et al.  assess tIn brief, they show that parametric inference based on peak height is well‐behaved and provides acceptable family‐wise error control. In contrast, parametric inference based on spatial extent is not valid when, and only when, a low cluster forming threshold is employed. This failure is well known and is consistent with random field theory: the null distribution for spatial extent is based on the Nosko conjecture that provides a distributional form for the spatial extent of a cluster [Friston et al., The effects of smoothing reported in [Eklund et al., t‐tests is slightly more difficult to interpret. This is because the authors used the same regressor for all subjects. Arguably, this was a mistake because any systematic fluctuation in resting state timeseries—that correlates with the regressor—will lead to significant one‐sample t‐tests against the null hypothesis of zero . This effect is particularly marked for a regressor  that represents a fast and inefficiently estimated event‐related response every few seconds. Crucially, the nonparametric false positive rates are beyond the 95% confidence intervals. This means that this effect is actually expressed in the data over subjects and, therefore, fails as a model of the null behaviour.The effect of one versus two‐sample t‐test. In this instance, inferences based on spatial extent fall to acceptable family‐wise error rates. We confirmed this by reproducing the analysis (using the same data and regressors) reported in [Eklund et al., This failure is finessed when comparing parameter estimates between two groups using a two‐sample P = 0.001 (uncorrected). More generally, the simulations reported in Eklund et al speak to the importance of revisiting the robustness of statistical tests as the nature of imaging data evolves and new researchers—who are not familiar with these foundational issues—enter the field.In summary, we have taken the opportunity to comment on the relative utility of nonparametric and parametric procedures in classical inference: despite the simplicity and robustness of nonparametric tests, there are principled reasons for the predominance of parametric procedures. Having said this, nonparametric tests are extremely useful when validating parametric assumptions—and establishing robustness to their violations. This use of nonparametric tests was exemplified in a recent paper entitled “Cluster failure: Why fMRI inferences for spatial extent have inflated false‐positive rates” [Eklund et al.,


To investigate the expression of long noncoding RNA (lncRNA) LINC00426 (long intergenic nonprotein coding RNA 426) in non‐small cell lung cancer (NSCLC) patients and its correlation with their prognosis.The expression of long noncoding RNA LINC00426 of non‐small cell lung cancer (NSCLC) in The Cancer Genome Atlas (TCGA) database was screened. According to the expression level of LINC00426 in tumor tissue of NSCLC patients, the patients were divided into high and low LINC00426 expression groups. The correlation between LINC00426 expression group and the prognosis of the patient was analyzed by log‐rank test. A total of 72 NSCLC patients who had undergone surgery were retrospectively included in this study. LINC00426 relative expression of tumor and normal lung tissue of the included 72 NSCLC patients were examined by real‐time quantitative PCR assay. The correlation between LINC00426 expression and the patients’ clinical characteristics were also evaluated.P > 0.05) of NSCLC patients in the TCGA database. The amplification and deep deletion mutation of LINC00426 gene was found in 0.5% of NSCLC patients. The overall survival (OS) of the LINC00426 high expression group was significantly higher than that of the low expression group , while there was no significant difference between the high and low expression group  for disease‐free survival (DFS). LINC0042646 expression level was elevated in 46 cases in normal lung tissue compared to the tumor tissue of the 72 NSCLC patients. LINC0042646 expression level was significantly correlated with the clinical stage (P < 0.05).LINC00426 relative expression was not statistically different between cancer and normal tissue (Long noncoding RNA LINC00426 was downregulated in the tumor tissue of NSCLC patients and correlated with poor prognosis. Lung cancer is the most diagnosed malignant carcinoma of the respiratory system.P < 0.05.The expression of LINC00426 in the TCGA database was screened with the limitation of human beings. LINC00426 gene relative expression between lung cancer tissues and normal lung tissues in NSCLC patients was compared in the condition of the LINC00426 gene relative expression difference more than twice (| Log2FC | > 1), The patients were divided into LINC00426 high and low expression groups according to the expression level of LINC00426 in the tumor tissue of NSCLC patients. A Kaplan‐Meier survival curve was drawn. The correlation between the LINC00426 expression and the patients’ prognosis was analyzed by log‐rank test.A total of 72 NSCLC patients who had undergone surgery were included in this retrospective study. All patients provided their written informed consent. The study was approved by the Medical Ethics Committee of Tianjin Union Medical Center. The research related to human use complied with all the relevant national regulations, institutional policies and was carried out in accordance with the tenets of the Helsinki Declaration, and approved by the Tianjin Union Medical Center Hospital's institutional review board. Tumor tissue and corresponding normal lung tissue of the 72 patients with lung cancer were lysed by Trizol. Total RNA was extracted via reverse transcription into cDNA. The relative expression of long noncoding RNA LINC00426 was detected by real‐time fluorescence quantitative PCR assay.(http://www.stata.com), the measurement data were expressed with x¯±s and comparison between groups was made based on the t‐test of the sample mean. The enumeration data were expressed with a relative number, and the comparison between groups was made based on the χ2 test. P < 0.05 was considered statistically different.The statistical analysis was performed using STATA11.0 statistical software P > 0.05). LINC00426 expression level in lung squamous cell carcinoma was lower than that of tumor tissue  , acute myeloid leukemia (AML), and thymoma (THYM) Fig a. For lussue Fig b; howeve.05) Fig c.The mutation of LINC00426 gene was analyzed from the TCGA database. Amplification and deep deletion mutation of LINC00426 gene was found in 0.5% of NSCLC patients , while there was no significant difference between the high and low expression groups  for disease‐free survival (DFS). Subgroup analysis showed that the overall survival of lung adenocarcinoma patients in the LINC00426 high expression group was significantly better than that of the low expression group . However, LINC00426 expression was not correlated with the DFS and OS for lung squamous cell carcinoma  of LINC00426 high expression group was significantly higher than that of the low expression group . However, LINC0042646 expression level was not correlated with age, gender, tumor diameter, pathology type and tumor differentiation  refers to noncoding RNA with more than 200 nucleotides.The expression level of lncRNA is significantly different in different tissues. Generally, the expression level of lncRNA is low in normal compared to tumor tissue. Some studies have shown that lncRAN had obvious tissue‐specific expression.LncRNAs with high expression and known biological functions in lung cancer have been previously described and include MALAT1,LINC00426 is a newly discovered long noncoding RNA located in chromosome 13: 30 340 267‐30 377 145 reverse strand with 12 transcripts in human beings. The biological function of LINC00426 is not as yet clear. In our study, we investigated LINC00426 expression in tumor tissue and corresponding normal lung tissue of NSCLC patients to determine its correlation with a patient's prognosis. We found that LINC00426 was downregulated in tumor tissue compared to normal lung tissue of the non‐small cell lung cancer patients and correlated with poor prognosis. Therefore, LINC00426 may be a potential biomarker for lung cancer prognosis. However, the biological function and relevant pathway of LINC00426 was not elucidated in our study and needs further investigation.This work was supported by Tianjin Health Bureau Science and Technology Fund Project (2014 KY26). Tianjin Science and technology program (18PTLCSY00080).None.


Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society.We examined the feasibility of radiostereometric analysis (RSA) in the assessment of the initial stability of internally fixed femoral neck fractures. The study included 16 patients (mean age 73 years). During surgery, multiple RSA‐beads were inserted on both sides of the fracture. Radiographs for RSA were taken in the supine position within the first 3 days and 6, 12, 24, and 52 weeks after surgery. To detect any inducible motion at the fracture‐site, radiographs for RSA were taken with the patient resting or applying a load through the fracture. Fracture loading was achieved by the patient pressing the ipsilateral foot as much as tolerated on a force plate while providing a counterforce through both hands. Micromotion exceeding the precision values of RSA (≥0.3 mm for the translation vector and/or ≥1.2 degrees for the rotation vector) was considered significant. Permanent three‐dimensional fracture‐site displacement was also recorded. Voluntary loading induced fracture‐site micromotion, which exhibited a dichotomous distribution. In patients with uncomplicated fracture union, inducible micromotion was detectable only at baseline—if at all. Conversely, fractures that developed a nonunion were characterized by the continuation of inducible micromotion beyond baseline. Permanent fracture‐site displacement was, on average, nearly an order of magnitude greater than the inducible micromotion. Fracture unions were characterized by the cessation of permanent fracture‐site displacement by 12 weeks. Nonunions presented as outliers in permanent fracture‐site displacement. Large‐scale studies are warranted to evaluate whether the detection of inducible micromotion beyond baseline could serve as an indicator of insufficient fixation stability. © 2018 The Authors.  Fractures of the femoral neck are associated with a substantial risk of incomplete recoveryThe importance of stable fixation in the treatment of femoral neck fractures has been emphasized, but some uncertainty remains regarding the optimal fixation method, warranting further studies.Radiostereometric analysis (RSA) could help solve some of these issues in RCTs of hip fracture patients. RSA is applicable for the three‐dimensional (3D) measurement of the displacement in femoral neck fractures.This exploratory study evaluated the feasibility of DL‐RSA in the assessment of the fracture‐site stability of internally fixed femoral neck fractures. RSA was used to measure both the degree of inducible micromotion and the permanent displacement of the fracture site.The study protocol was approved by the local institutional review board and Ethical Committee of the Hospital District of Southwest Finland, Turku, Finland  and was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent. This study was a prospective cohort study (Diagnostic Level II).The study population consisted of a cohort of eligible patients at a single center. A power analysis was not possible due to the exploratory nature of the study. The inclusion criteria included ambulatory men and women ≥50 years of age who presented with an isolated fracture of the femoral neck .During the recruitment period between September 2010 and June 2011, 321 patients were admitted for a femoral neck fracture  were inserted on both sides of the fracture into the femoral head and greater trochanter Fig.  using anRSA was performed within 1–3 days after surgery (baseline) and repeated at 6, 12, 24, and 52 weeks. The patients were imaged in the supine position on the examination table .Image analyses were performed using UmRSA version 6.0.3.7 software . The RSA measurement process is semiautomatic, thus minimizing subjective bias. The median number of analyzed markers was three (range 3–4) in the femoral head and four (range 3–5) in the lateral trochanteric region. The RSA markers on both sides of the fracture formed two distinct segments. At each time point, the position of the femoral head segment relative to the trochanteric segment was compared with the original position at baseline as a measure of permanent fracture‐site displacement. Unloaded and loaded images were compared in order to detect inducible 3‐D micromotion at the fracture‐site at each time point. Both permanent displacement and inducible micromotion were analyzed as linear and angular movements on three orthogonal axes  Fig. . Left‐siThe stability and adequate distribution of the RSA markers were assessed by calculating the mean error of rigid body fitting (ME) and condition number (CN), respectively.Anteroposterior (AP) and lateral plane hip radiographs were taken after surgery and at each follow‐up visit. The quality of the fracture reduction was assessed based on the Garden alignment criteria.As a reference for RSA‐based measurements of permanent fracture‐site displacement, femoral neck shortening (FNS) was measured from the AP radiographs, as described previously,The bone mineral density of the contralateral hip and lumbar spine was measured postoperatively with dual‐energy X‐ray absorptiometry  Table . The resStatistical analysis was performed using SPSS version 25 . The normality of the data was assessed using the Shapiro–Wilk test. The cut‐off value for the presence of inducible micromotion was chosen based on measurement error: Inducible micromotion was considered significant when it matched or exceeded precision values of 0.3 mm for the translation vector or 1.2 degrees for the rotation vector. Analyses of mean inducible micromotion and permanent displacement were performed using repeated‐measures ANOVA. Linear regression analyses were used to identify any associations between inducible micromotion and permanent displacement as well as between the plain radiograph analysis and RSA.Voluntary loading of the operated limb Figure  induced z‐axis) (Table S‐1), and translation along the y‐axis was minimal. Inducible rotation of the femoral head occurred mainly around the y‐axis at baseline (Table S‐1).At baseline, inducible translation occurred mainly in the sagittal plane  at baseline to 181 N  at 6 weeks and 186 N  at 12 weeks. Five patients at baseline and four patients at 6 weeks experienced moderate local pain during loading.p = 0.029, Fisher's exact test) incidence of inducible micromotion. Patients with fracture unions were characterized by no inducible micromotion or inducible micromotion only at baseline. Patients with complications, including a patient with fracture union with malrotation , while rotation mainly occurred around the z‐axis (adduction/varus) (Table S‐2). Fracture unions were characterized by the cessation of interfragmentary displacement by 12 weeks . Osteonecrosis developed in two patients. Of those patients with a nonunion or osteonecrosis  was moderate (5‐10 mm) in four cases and severe (>10 mm) in one case. Femoral length reduction (denoted by the y‐axis) was moderate (5–10 mm) in two cases and severe (>10 mm) in seven cases. The FNS vector along the axis of the femoral neck shaft (denoted by the z‐axis) was 9.2 mm .Based on the 52‐week AP radiographs of 14 patients (excluding the two patients who required an early hip replacement), the shortening of the abductor moment arm  with the FNS vector measured from plain radiographs. RSA‐measured translations along the x‐axis and the y‐axis also had high coefficients of determination  with the decrease in the abductor moment arm and femoral length, respectively.The RSA‐measured 3‐D fracture‐site displacement correlated with the two‐dimensional radiographic measurements of postfracture femoral neck deformity. The RSA‐measured translation vector had a high coefficient of determination .As a limitation, the cannulated screws permitted the implantation of only three RSA markers into the femoral head, which is the minimum requirement for this method. As demonstrated in a model of tibial plateau fractures,SF gathered data, performed the plain radiograph analysis and helped write the manuscript. NM contributed to the design of the study, performed the RSA and aided in the plain radiograph analysis. NS helped with the clinical execution of the study. JJA helped with data collection and writing the manuscript. HA designed the study, executed the clinical trial, analyzed data and prepared the manuscript. All authors have read and approved the final submitted manuscript.Additional supporting information may be found online in the Supporting Information section at the end of the article.Supporting Table S1.Click here for additional data file.Supporting Table S2.Click here for additional data file.


Proton‐coupled electron transfer (PCET) events play a key role in countless chemical transformations, but they come in many physical variants which are hard to distinguish experimentally. While present theoretical approaches to treat these events are mostly based on physical rate coefficient models of various complexity, it is now argued that it is both feasible and fruitful to directly analyze the electronic N‐electron wavefunctions of these processes along their intrinsic reaction coordinate (IRC). In particular, for model systems of lipoxygenase and the high‐valent oxoiron(IV) intermediate TauD‐J it is shown that by invoking the intrinsic bond orbital (IBO) representation of the wavefunction, the common boundary cases of hydrogen atom transfer (HAT) and concerted PCET (cPCET) can be directly and unambiguously distinguished in a straightforward manner. The transfer of a net hydrogen atom as part of a chemical reaction can proceed in many different ways. Depending on the circumstances, viewing this process as the coupled but distinct transfer of a proton and an electron can be more appropriate than viewing it as transfer of an actual hydrogen atom. An umbrella term covering reactions of this type is proton‐coupled electron transfer (PCET).The most fundamental scenarios to be distinguished are stepwise processes in which electron and proton transfer occur in individual steps, and concerted PCET (cPCET), where the proton and the electron are transferred simultaneously. Reactions in which electron and proton travel together as a true hydrogen atom will be called hydrogen atom transfer (HAT); the more general term cPCET will be used only when proton and electron are transferred in concert, but do not travel together, a definition similar to the one used by Shaik and co‐workers.Identifying which of the outlined mechanistic scenarios is operational can be challenging, as all scenarios involve the same net transfer of one electron and one proton and therefore cannot be distinguished by knowledge of properties of the reactants and products alone. Consequently, the concrete nature of the process effecting this transfer is a frequent matter of debate. Mechanistic insight is primarily gained by indirect inference, based on various physical models of the imagined sub‐processes of electron transfer (ET) and proton transfer (PT) and their coupling.3)−H activation reactions.III−OH complex with TEMPOHNevertheless, if we only pose the question of how the various PCET processes can be distinguished , and which chemical bond transformations they are accompanied and influenced by, then the construction of such quantitative rate models may not be the most direct way to obtain this information. With modern software and computers it is absolutely possible to determine approximate but qualitatively correct (Kohn–Sham) electronic wave functions for most of the involved species and, based on those, also determine all likely intrinsic reaction paths for possible PCET events and compare their barriers. Once the most favorable reaction path has been determined, it should be possible to simply analyze the obtained trajectory of the ground state N‐electron wave function directly to clarify the concrete nature of the process. After all, the N‐electron wave function contains all information about the N‐electron system which is physically observable. Additionally, recently introduced analytic methods, such as the intrinsic bond orbital (IBO)3)−H bond oxidation occurs either via cPCET, following the above definition, or a HAT mechanism. For the cPCET case, we selected the well‐studied reaction of lipoxygenase,III−OH active site which breaks one of the C(sp3)−H bonds of arachidonic acid, and for HAT we selected the C(sp3)−H oxidation event from the oxoiron(IV) intermediate in taurine dioxygenase (TauD‐J),3)−H bond of taurine. Structural depictions for the active sites and transition states for C−H bond activation are shown in Figure We initiated our studies by analyzing two reactions from the field of bioinorganic chemistryBased on these two reactions we will demonstrate that it is indeed possible to differentiate between cPCET and HAT in a straightforward and chemically intuitive way using IBOs. Our approach therefore provides a tool for unambiguous mechanism assignment with the potential for very broad applicability.S=5/2) FeIII−OH unit ligated by three imidazoles mimicking histidine residues, a carboxylate residue mimicking an isoleucine, and an amide mimicking an asparagine residue. The substrate was mimicked as a 1,4‐diene with a simple hydrocarbon framework  FeIV=O unit ligated by two imidazoles and one acetate mimicking a 2‐His‐1‐carboxylate facial triadS=2 spin state which has been judged to be energetically most favorable in the present case by Ye and Neese.For the HAT reaction of the high‐valent oxoiron(IV) intermediate TauD‐J, we selected a model system studied previously by Ye and Neese.We first computed the transition states for the C−H bond breaking events at the B3LYPIII−OH intermediate is formed, which is antiferromagnetically coupled to the radical on the substrate.3)−H bond and one electron from the FeIV=O unit. This does indeed happen and the O‐centered σ‐lone pair, which provides the β electron is shown in Figure We begin by demonstrating how IBOs can be used to identify HAT in the case of TauD‐J, which may be regarded as the simpler case. We begin our analysis by producing IBOs for the α and β spin manifold; next, we identify the localized orbitals of the C−H σ‐bond, and then follow the changes that they undergo along the IRC. In Figure 3)−H activation processes,−) gives immediate insight into which IBOs are participating in bond making and bond breaking along the reaction path. IBOs not involved in this process do not undergo significant changes and in principle do not require inspection −H bond along the IRC −H bonds to demonstrate that the electron flow of open shell reactions can be readily studied using IBOs. This simple and straightforward tool is apparently capable of differentiating electronic mechanisms even in challenging scenarios, such as occurring in HAT and cPCET reactions. We therefore believe this approach may shed light into many other challenging transformations.In summary, we have used two prototypical model systems that cleave C should be addressed to the authors.SupplementaryClick here for additional data file.


Immune checkpoint inhibitors (ICIs), which target the programmed cell death receptor‐1 and cytotoxic T lymphocyte‐associated antigen‐4 signaling pathways, represent remarkable breakthroughs in cancer treatment and have improved survival among patients with a variety of malignancies. However, the wide use of ICIs is associated with a spectrum of immune‐related adverse events (irAEs) that can affect any organ system, and may sometimes be life threatening. Rheumatic irAEs are not an infrequent type of irAE. In this systematic review, we consider the clinical characteristics of rheumatic irAEs, including patients with pre‐existing rheumatic diseases, and focus on the management of rheumatic irAEs. Immune checkpoint inhibitors (ICIs) have recently been responsible for remarkable breakthroughs in cancer treatment. ICIs can induce T cell activation by blocking negative costimulation of T cells resulting in enhanced anti‐tumor effects, and can ultimately improve survival among patients with a variety of malignancies.The major underlying mechanism of classical rheumatic autoimmune diseases involves abnormal activation of the immune system, leading to autoantibody formation or enhanced inflammatory responses. PD‐1 expression is increased in synovial tissues in patients with rheumatoid arthritis (RA), but the PD‐1 pathway is downregulated during RA disease progression, suggesting that this pathway might be involved in the development of RA.Rheumatic irAEs are not uncommon irAEs and can generally be classified into two subgroups: new‐onset musculoskeletal symptoms or connective tissue disease, and disease flares in patients with pre‐existing rheumatic conditions. In a large prospective French study of 524 patients who received ICIs,Polymyalgia rheumatica (PMR) is an inflammatory disease commonly seen in individuals older than 50 years. It is characterized by shoulder and/or pelvic girdle muscle myalgia and stiffness, with increased acute phase reactants and negative rheumatoid factors or anti‐citrullinated protein antibody (ACPA). This disorder always responds well to low‐dose glucocorticoids. Giant cell arthritis (GCA) is a type of systemic vasculitis that is relatively rare in Chinese patients, but which has a very close relationship with PMR. GCA is characterized by large‐vessel involvement with inflammation of the arterial wall, and involvement of the internal elastic lamina and multinucleated giant cell infiltration.The median period from ICI exposure to PMR occurrence varies from 10 days to one year, with similar clinical and radiological manifestations compared with classical PMR. However, patients with ICI‐induced PMR do not always have increased acute phase reactants and may not respond well to low‐dose glucocorticoids.ICI‐induced inflammatory arthritis is one of the most common rheumatic irAEs and has been previously reported in several studies. The median period from ICI treatment to inflammatory arthritis onset ranges from two months to two years. Moreover, ICI‐related inflammatory arthritis varies in severity from mild disease, which responds well to nonsteroidal anti‐inflammatory drugs (NSAIDs) or low‐dose glucocorticoids, to severe cases that may require tumor necrosis factor (TNF) inhibitors or interleukin‐6 (IL‐6) receptor antibodies to ameliorate the symptoms.ICI‐induced inflammatory myopathy is relatively less common than inflammatory arthritis and always occurs in the first two months after ICI treatment, with sudden onset. Inflammatory myopathy is characterized by myalgia, muscle weakness, and elevated serum creatinine kinase (CK) levels. Severe cases may include rhabdomyolysis, respiratory muscle weakness, or myocardial involvement, and the condition can sometimes be life‐threatening. Muscle biopsies show focal necrotizing myopathy with extensive macrophage and T lymphocyte infiltration. Perifascicular atrophy of muscle fibers, which is a classic pathological finding of dermatomyositis, has not been found in ICI‐induced inflammatory myopathy. ICI‐related inflammatory myopathy also rarely presents with a classical dermatomyositis‐related rash, and patients are seronegative for myositis‐specific antibodies and may also have involvement of the axial part of the facial muscle.et al., a patient with melanoma treated with pembrolizumab developed typical Sjögren syndrome with subacute ataxic sensory neuropathy with only a partial response to glucocorticoids, but demonstrated remarkable improvement after treatment with intravenous immunoglobulins and rituximab.New‐onset connective tissue disease after ICI treatment is rare. A study at Johns Hopkins Hospital of patients with solid tumors who received ipilimumab and/or nivolumab treatment from 2012 to 2016 included four patients who developed sicca syndrome with relatively abrupt onset of severe dry mouth symptoms, one patient with bilateral parotid gland enlargement, and two with other irAEs. None of these patients had anti‐Ro/SSA antibody.et al. reported on two patients with melanoma and newly developed systemic sclerosis after pembrolizumab treatment.Barbosa et alThere is limited information about flares of pre‐existing rheumatic diseases in patients treated with ICIs because such patients have tended to be excluded from clinical trials. However, we managed a patient with gastric cancer who was also diagnosed with connective tissue disease associated interstitial lung disease. They received three cycles of nivulomab therapy and had a high fever and rapid progression of interstitial lung disease, which failed to respond to medium‐dose glucocorticoids but was well‐controlled by high‐dose glucocorticoids and tacrolimus. A retrospective study conducted at Massachusetts General Hospital reported six patients with rheumatic disease flares after ICI treatment,It is important for rheumatologists to collaborate with oncologists to manage patients with rheumatic irAEs, including the decision on whether or not to continue ICI treatment. Considering that patients with rheumatic irAEs tended to have better cancer‐treatment outcomes,et al. recently reported that the prophylactic use of TNF inhibitors concomitant with combined anti‐CTLA‐4 and anti‐PD‐1 therapy in mouse models ameliorated irAEs and also improved anti‐tumor efficacy.NSAIDs are the first line of therapy in patients with inflammatory arthritis with mild symptoms, and low‐dose glucocorticoids  can be considered, while NSAIDs are less effective. For patients with moderately severe inflammatory arthritis, prednisone >20 mg/day or equivalent dose plus disease‐modifying anti‐rheumatic drug (DMARDs) therapy is recommended, while the dose of glucocorticoids can be further increased in cases of severe inflammatory arthritis, and biological agents such as TNF inhibitors can also be used in glucocorticoid‐dependent patients.et al. recently reported a case in which the CTLA‐4 agonist abatacept was successfully used to treat severe and glucocorticoid‐refractory ICI‐induced myocarditis, offering a new approach for the treatment of patients with severe ICI‐induced myocarditis.ICI treatment can be continued in patients with mild myalgia, while serum CK levels should be monitored closely and NSAIDs can be used to control the myalgia. Serum CK levels usually decrease gradually after cessation of immunotherapy in patients with mild to moderate elevation of serum CK levels, but without myalgia or muscle weakness. However, in patients with moderate to severe myositis, electromyograms, muscle magnetic resonance imaging, myositis‐specific autoantibody testing, and muscle biopsy should be performed to differentiate between irAE and classical myositis. Glucocorticoids are the first‐line therapy for ICI‐induced myositis, with an initial dose of 0.5–1.0 mg/kg/day prednisone according to the severity of muscle involvement. Intravenous methylprednisolone pulse therapy should be considered and possibly combined with intravenous immunoglobulins in patients with myocardial involvement or life‐threatening conditions, and DAMRDs should be used in glucocorticoid‐dependent patients.ICI should be stopped in patients with pre‐existing rheumatic diseases who experience flare‐ups after ICI treatment. Subsequent treatment should then follow the management recommendations for classical rheumatic diseases which usually base the glucocorticoid and immunosuppressant doses on the type and severity of organ involvement.ICIs represent a new era in the treatment of malignancies, although the concomitant irAEs, including rheumatic irAEs, also bring new challenges and research areas for clinicians. Rheumatologists must engage more in the management and basic research of irAEs.The authors have no potential conflicts of interest to disclose.


Teleogryllus oceanicus, and quantify the contribution of this paternal effect to the inheritance of this important fitness trait. We used castrated males within a full‐sib half‐sib experimental design to show that seminal fluid donors were responsible for variation in the survival of developing embryos to hatching, and in their subsequent survival to adulthood. Increased expression of two seminal fluid protein genes, previously found to be positively associated with sperm quality, was found to be negatively associated with embryo survival. These nongenetic paternal effects hold important implications for the evolution of adaptive maternal responses to sperm competition, and more broadly for the interpretation of sire effects from classic quantitative genetic breeding designs.Mounting evidence suggests that nongenetic paternal effects on offspring may be widespread among animal taxa, but the mechanisms underlying this form of nongenetic inheritance are not yet fully understood. Here, we show that seminal fluids underlie paternal effects on early offspring survival in an insect, the cricket  The resemblance of offspring to their parents is generally attributed to the contribution of genes packaged in sperm and eggs. However, there is increasing evidence that the environment experienced by parents can also influence the behavior, morphology, and physiology of their offspring. The mechanisms underlying these nongenetic effects are slowly being uncovered. In this study, we asked whether the seminal fluid in ejaculates could affect the survival and performance of offspring. We allowed female crickets to mate with both a normal sperm donating male and a castrated male that transferred only seminal fluid. We found that seminal fluid donors had a strong and significant effect on the survival of offspring but not on adult offspring size or reproductive capacity. The nongenetic paternal effect of seminal fluid donors on offspring survival was sufficient to account for previous estimates of genetic variance in this important fitness trait. Paternal effects have important implications for our understanding of evolutionary processes. Our findings cast doubt on traditional breeding designs aimed at estimating the genetic effects of fathers on offspring, and challenge our views on the nature of inheritance.Although the adaptive significance of maternal effects have been the subject of considerable research effort  in our breeding design received seminal fluid from a castrated outbred male seminal fluid donor (sfd) and a complete ejaculate  from a highly inbred isofemale line genetic sire. Any variation in offspring phenotypes due to sfds can be ascribed to nongenetic seminal fluid effects because these donors did not transfer sperm. Any variation due to dams would include maternal and paternal genetic and environmental effects. The maternal and paternal genetic effects were minimized in our breeding design by using dams and sires from a single highly inbred isofemale line.Seminal fluid donors used in these experiments were the first generation offspring of females collected from a tropical fruit plantation in Carnarvon, Western Australia. Crickets were reared en masse until the final nymphal instar at which time they were isolated into individual containers (7 cm × 7 cm × 5 cm) and supplied with cat chow and water ad libitum. Crickets were checked daily for adult emergence.On the day of adult emergence, the males were castrated. Crickets were housed at 4°C for 30 minutes and then at –20°C for 2 minutes after which each cricket was placed under a dissecting microscope. With the wings held aside with dissection pins, an incision was made in the dorsal cuticle between the second and third abdominal segments using fine scissors. Each testis was removed with forceps and the wound closed with ethyl cyanoacrylate  on a microscope slide. A coverslip was placed on to the slide and the contents viewed under a microscope to ascertain whether any sperm were present. The majority of spermatophores were found to be azoospermic. However, on the rare occasion where sperm were detected, these males were discarded. A total of 74 azoospermic males were used as seminal fluid donors.To minimize genetic variation among females and fertile males, we created a single isofemale line following a full‐sib mating protocol. One newly emerged adult male and one newly emerged virgin female were taken from the stock culture and housed in a 5‐L container provided with egg carton for substrate, and cat chow and water ad libitum. A moist pad of cotton wool was provided as an oviposition substrate. Eggs were collected after 7 days and nymphs collected as they began to hatch, 14 days after eggs were laid. Full siblings were reared en masse in a 50‐L container, provided with egg carton for substrate, and cat chow and water ad libitum. When crickets started to emerge as adults, a single brother–sister pair was isolated in a 5‐L container and left to mate and lay eggs. The offspring from this pair were reared en masse as per the previous generation. The isofemale line was thus bred via single brother–sister pairing for a total of seven generations, after which the intensity of inbreeding was relaxed. From generation 8 onward, when adult crickets emerged they were left to interact en masse in their 50‐L container and eggs were collected from the group to source subsequent generations.Crickets for this experiment were sourced from generation 15 of the isofemale line. Male and female crickets were taken at the final nymphal stage. Males were housed in individual containers (7 cm × 7 cm × 5 cm) supplied with cat chow and water ad libitum. Females were housed in groups of 20–30 in 5‐L containers. The day before males were to be used in experiments, they were provided with a virgin female sourced from the stock to ensure they were capable of mating. Crickets were used in experiments 14 days after adult emergence.Seventy‐four castrated seminal fluid donors (sfd) were each assigned two females from the isofemale line and allowed to mate with both females twice. All matings were observed to ensure the spermatophores remained attached for 60 minutes, the time required for complete transfer of the ejaculate  and females were housed either individually or if there were more than five on any given day, collectively in a 5‐L container with ad libitum food and water.2) using fine forceps. The sample was mixed thoroughly before taking a 5 µL sample and mixing it with an equal volume of 1:50 diluted 1 mM SYBR‐14 on a clean slide. The sample was left in the dark for 10 minutes before adding 2 µL of 2.4 mM of propidium iodide. Following a further 10‐minute incubation period, sperm were scored under a fluorescence microscope at 20× magnification. Sperm viability was estimated as the number of live sperm divided by the total number of sperm counted that was set at 500. Males were then frozen and later body weight and pronotum width were recorded. When females were 14 days post adult emergence, they were frozen and later dissected to record ovary weight. Ovary weight is a strong predictor of fecundity, and so provides a measure of expected female reproductive performance  which stains live sperm green and dead sperm red. Competitive fertilization success is determined largely by sperm viability, which provides an estimate of expected male reproductive performance . RNA was then extracted from the entire accessory gland using the PureLink RNA mini kit (Life Technologies) following the manufacturer's instructions. Disruption of the tissue was achieved using a micropestle (Interpath) and column homogenizer (Life Technologies). An on‐column PureLink DNase treatment was used to remove DNA from the sample and the RNA was quantified using a Qubit fluorometer v2.0 (Life Technologies). RNA yield varied from 355 to 1193 ng/µL in a 100 µL elution volume. A total of 2 µg of RNA from each sample was then converted to cDNA using the high‐capacity RNA‐to‐cDNA kit (Life Technologies) following the manufacturer's instructions. The cDNA was diluted to 10 ng/µL using previous data on standard curves to determine input cDNA amount (Simmons and Lovegrove ToSfp001 (isotig1262), ToSfp011 (isotig1709), and ToSfp017 (isotig5129)  proportion of eggs that hatched varied considerably across dams (range 0–0.63) with a mean (±SE) of 0.18 ± 0.02. We analyzed each individual offspring's egg‐to‐hatch survival in a generalized linear mixed‐effects model using the lme4 package in the R statistical framework  and to a lesser extent ToSfp011  but was not associated with the expression of ToSfp017 .We next calculated a mean embryo survival for each sfd across the dams with whom he had mated, and used multiple regression analysis to look for associations between embryo survival and seminal fluid gene expression in the accessory glands of sfds . We used a generalized linear model with a binomial distribution and probit link function to model the effect of seminal fluid gene expression in the accessory glands of sfds on hatchling‐adult offspring survival. Neither ToSfp001 (isotig1262) expression  nor ToSfp011 (isotig1709) expression  influenced the probability that hatched offspring survived to adulthood. We note, however, that the expression of ToSfp017 (isotig5129) had a nonsignificant negative effect on survival to adulthood with confidence intervals that were highly asymmetric around zero .Although our experiment was not designed to examine hatchling‐adult survival, given the high mortality observed among dam families, we modeled the effect of sfd on the probability of obtaining any adult offspring from the females with whom they had mated. There was a significant effect of sfd on the probability that their females produced surviving adult offspring  suggesting that seminal fluid‐derived proteins are incorporated directly into developing eggs, rather than affecting maternal allocation (Simmons T. oceanicus ejaculates (Simmons and Beveridge It can be difficult to establish whether a parental effect is a maternal effect, a paternal effect, or an interaction between maternal and paternal effects (Crean and Bonduriansky  Simmons . Althoug Simmons . Third,  Simmons . SeminalSeminal fluid donors had the capacity to increase and decrease the survival of embryos relative to that expected for the isofemale line males used in this study. This finding replicates that of Garcia‐Gonzalez & Simmons  who founToSfp011 in the accessory glands is associated with the viability of sperm in whole ejaculates. Thus, male T. oceanicus exposed to the calling songs of rivals show an increased expression of ToSfp011, of ToSfp001, and several other seminal fluid genes that have positive effects on sperm viability (Simmons and Lovegrove We found that the expression of two seminal fluid protein genes in the accessory glands of sfds was negatively associated with the viability of embryos produced by females with whom they mated. Gene expression is indicative of protein production, not its allocation to ejaculates. Nevertheless, previous studies have found that the levels of gene expression are correlated with the amount of protein contained in whole ejaculates (Simmons et al. Our finding of seminal fluid‐mediated paternal effects holds important implications for quantitative genetic analyses. Half‐sibling breeding designs are widely used for estimating levels of additive genetic variance in behavioral, morphological, and life‐history traits (Falconer and Mackay Genetic models for the evolution and maintenance of female mate choice rely on indirect genetic benefits accruing to offspring. However, genetic variation in fitness traits should be eroded by female choice leading to the paradox of the lek (Kirkpatrick and Ryan In conclusion, we show that seminal fluids are responsible for a nongenetic paternal effect on the survival of offspring. Nongenetic inheritance holds important implications for our interpretation of quantitative genetic designs that seek to establish the levels of additive genetic variation in phenotypic traits. Nongenetic paternal effects can generate novel and complex evolutionary dynamics. The negative effects on offspring survival of seminal fluid proteins that contribute to a male's competitive fertilization success may hold important implications for female fitness, and the evolution of adaptive maternal responses in the face of sperm competition.Associate Editor: R. Snook