IgE and not IgG is usually associated with allergy. IgE lodged on mast cells in skin or gut and basophils in the blood allows for the prolonged duration of allergy through the persistent expression of high affinity IgE receptors. However, many allergic reactions are not dependent on IgE and are generated in the absence of allergen specific and even total IgE. Instead, IgG plasma cells are involved in induction of, and for much of the pathogenesis of, allergic diseases. The pattern of IgG producing plasma cells in atopic children and the tendency for direct or further class switching to IgE are the principle factors responsible for long‐lasting sensitization of mast cells in allergic children. Indirect class switching from IgG producing plasma cells has been shown to be the predominant pathway for production of IgE while a Th2 microenvironment, genetic predisposition, and the concentration and nature of allergens together act on IgG plasma cells in the atopic tendency to undergo further immunoglobulin gene recombination. The seminal involvement of IgG in allergy is further indicated by the principal role of IgG4 in the natural resolution of allergy and as the favourable immunological response to immunotherapy. This paper will look at allergy through the role of different antibodies than IgE and give current knowledge of the nature and role of IgG antibodies in the start, maintenance and resolution of allergy. IgE and not IgG is usually associated with allergy. Allergic sensitization is conventionally thought of as the establishment of a population of IgE making plasma cells which induce the degranulation of vasoactive amines from gut, skin, or lung mast cells and blood basophils and cationic proteins from eosinophils. IgE lodged on mast cells and basophils through the prolonged expression of high affinity IgE receptors allows for the protracted duration of allergic. But the initial allergic symptoms may originate from the pathogenesis of IgG producing B cell clones to allergens. The frequency of B cells in allergic children switching from IgG to IgE production may be the critical difference in atopic children that enables priming of mast cells and basophils.However, many allergic reactions are not dependent on IgE and are generated in the absence of allergen specific and even total IgE. Instead, IgG plasma cells are involved in induction of allergy. It has been shown lately that B cells start secreting IgG but are disposed in allergic people either by an inherent genetic disposition or experience in the womb or soon after birth, resulting in a Th2 polarized immune reaction to allergenic compounds that generates class switching of initially IgG secreting B cells to produce IgE, thereby potentiating an allergic or anaphylactic reaction. Additionally, IgG may be involved in the resolution of allergy. IgG4, in particular, is produced or correlates with desensitization of allergy by immunotherapy. The structure of IgG4 enables the blockading of IgG receptors and, because IgG4 is unstable and mops up antigen in blood as a monovalent protein, there is reduced free allergen to stimulate IgE on sensitized mast cells and basophils. IgG4 also reacts with FcγIIb, the inhibitory immunoglobulin receptor present on monocytes, macrophages, and dendritic cells and reduced allergic reactions through the production of IL‐10. Thus, the induction, the pathology or the resolution of allergy entail other factors than specific IgE to allergens. Allergic reactions involve a large number of factors and the formation of allergic conditions involves IgG in the establishment of atopy, the generation of clinical symptoms of allergy and in the amelioration of the response and resolution of allergy. The pattern of IgG producing plasma cells in atopic children and the tendency for direct or further class switching to IgE are the seminal events that generate long‐lasting sensitization of mast cells in allergic children. This paper will look at allergy through the role of antibodies other than IgE and give current knowledge of the nature and role of IgG antibodies in the start, maintenance, and resolution of allergy.Immunoglobulins of all classes, but especially immunoglobulin G (IgG), are induced as part of the natural exposure to allergens daily. Peanut, milk, and other natural allergens provoke antibody responses, particularly IgG, to incidental ingestion and each person has their own distinct and variable repertoire of antibodies to their diet and environment. Antibody levels to different foods vary greatly in different children despite similar exposure or diet but levels of immunoglobulin G class or subclass antibodies can be associated with levels of allergy and Th2 cytokine responses to sensitising allergens Dermatophagoides pteronyssinus) Der p 1 is able to cleave CD23  and CD25 (IL‐2 receptor α‐chain) expressed on the surface of some leukocytes Sensitization to allergens usually starts in the early maturation of the individual immune system with the development of B cell clones producing specific antibodies of IgE class that continue to trigger reactivity on the surface of mast cells and basophils where they are docked in high affinity receptors IgM and subsequently IgG are produced predominantly in the first exposure to an allergen. The majority of people have a conventional immunoglobulin reaction to allergenic substances, mainly in the form of Immunoglobulin G antibodies of the five immunoglobulin classes Table , and onlTh2 cytokines, such as IL‐4, binding to receptors activate STAT6 , leading to phosphorylation by JAK kinases, homodimerization, and binding to the Iϵ promoter Artemisia artemisiifolia) airborne pollen concentrations as low as 6–9 grains/m3 can produce symptoms of asthma in sensitized children Classical allergic sensitization is customarily associated with elevated IgE antibodies generated by class switched B cells in bone marrow and in atopic lymph nodes. Circulating IgE from class switched plasma cells in the bone marrow and blood lodges on high affinity FcϵRI receptors on the surface of basophils and mast cells in tissues, potentiating an immediate hypersensitivity response. Then, contact with the allergen triggers specific IgE lodged on receptors to stimulate mast cell and basophil degranulation and the release of vasoactive amines and other reagents that induce the symptoms of clinical allergy. The IgE‐coated cells are sensitized to the allergen A distinct form of IgE receptor, with different affinities and expression patterns on immune cells, contributes to the longevity of clinical allergy. The low‐affinity IgE receptor  is expressed on the surface of B cells, as well as other hematopoietic cells, while the high‐affinity IgE receptor FcϵR1) is expressed on mast cells and basophils  are not dependent on IgE and are generated in the absence of allergen specific and even total IgE. Since basophils express both activating and deactivating Fcγ receptors, including FcγRI and FcγRIIb Table , as wellEvidence indicates that most atopic people start off with a normal broad distribution of food directed IgG secreting B cells but are disposed in certain situations, either by an inherent genetic disposition or experience in the womb or soon after birth to generate a Th2 polarized immune reaction to allergenic compounds, causing a class switch toward mature plasma cells producing IgE. The tendency for the plasma cells to undergo further class switching beyond IgG in atopic individuals and the nature of allergenic epitopes in inducing specific IgE reactions will be established by advances in current immunogenetics techniques in sequencing individual and clonal B cell IGH gene sequences in populations of sensitized and allergic children Finally, as regards the cycle of allergy, it is IgG4, in particular, that is produced or correlates with desensitization of allergy by oral immunotherapy or AIT. IgG4 has an unstable structure and some estimates are that the majority of antigen bound IgG4 is present as monovalent halves of antibody that detach at the intrachain disulphide bond present in the hinge region Fig. . MonovalThe problem with associating an individual immunological effector in allergy is unequivocally separating the individual actions of the many immune factors in pathogenesis. Human sera contain a mixture of antibodies of different classes and subclasses produced by B cells with a wide range of specificities and clonal sizes. B‐1a cells, resident on pleural and peritoneal surfaces in older mice, generate natural antibodies whereas B‐1b cells in the spleen marginal zone and some mucosal surfaces pick up some microbial polysaccharides, glycolipids, and a few commensal and infectious microorganism antigens B‐1 lymphocytes generate from stem cells in foetal and early neonatal immunity and tend to become localized to peritoneal and pleural cavities in adult mice. These lymphocytes are primarily induced by high molecular weight antigens with low degradability with repeating epitopes, such as bacterial capsular polysaccharides, that elicit rapid antibody responses by multivalent BCR crosslinking in the absence of major histocompatibility complex class II‐restricted T cell help IgE‐producing plasma cells may have two origins; they may originate from an immature IgM‐producing B lymphocyte transformed directly to IgE secreting plasma cells or from an IgG producing intermediate mature B cell in bone marrow or lymph nodes that has already met its cognate antigen or allergen. Immature lymphocytes triggered by allergens would initially produce weak antibodies with poor affinity in comparison to IgE‐producing cells derived via indirect switching that have undergone affinity maturation as an IgG producing clone. Evidence suggests that most IgE plasma cells are derived from previously antigen‐experienced B cells rather than naive B cells. DNA sequencing of 15,843,270 of immunoglobulin heavy gene rearrangements of B cells from allergic and normal children expressing IgE gave results consistent with indirect switching to IgE from IgG or IgA expressing B cells The class of immunoglobulin produced by B cells is determined by two signals; CD40L ligation provided by CD4 T cells and specific cytokines which activate the promotor of particular immunoglobulin isotypes. Different cytokines direct the differentiation of early B cells and the recombination of the heavy chain class genes on chromosome 22 in particular ways , and serotonin when triggered by IgE class immunoglobulin to allergens. A large range of pre‐formed immunomodulating molecules such as kinins and proteases are also released from secretory granules. Leukotrienes, prostaglandins, and PAF (platelet activated factor) are synthesized by activated mast cells from arachidonic acid. A whole raft of cytokines , chemokines  and growth factors  are synthesized de novo and released soon after activation +CD25+ allergen‐specific Tr1 (regulatory T) cells, B cells and monocytes induces and correlates with the production of IgG4 and the increase in IgG4/IgE ratio in allergen and peptide immunotherapies in allergy and autoimmune diseases Immunoglobulin triggered mast cells, through the release of histamine and prostaglandins, also induce the downregulation of IL‐12 and stimulate the production of IL‐10 by dendritic cells, resulting in a decrease in expression of IFNγ and an increase in IL‐4 by T cells Human IgG Fig.  is comprIgG1 and IgG3 antibodies activate complement and clear the majority of pathogens through opsonization and uptake by macrophages, neutrophils, basophils, and monocytes. IgG3 is the strongest complement activator, followed by IgG1 while IgG2 can only activate complement in the presence of high concentrations of antigen and IgG4 does not activate complement at all B cells mature in bone marrow, rearranging the sequences of heavy and light chain genes on chromosomes 22, 2, and 14, respectively, by recombination, splicing together V, D (heavy only), and J segments to form an antibody sequence unique to each B cell by the time it emerges into blood. Cytokines secreted by a T helper cell in antigen presentation binding to the IgD or IgM antibody docked on the surface of a naïve B cell can generate antibody class switching and proliferation of the cognate B cell in an interaction that usually occurs in secondary lymphoid tissue like lymph nodes or spleen. VDJ genes on chromosome 22 are stimulated to recombine with different C regions of the heavy chain gene sequence by switch recombination with deletion of the intervening DNA  between two IgG4 molecules, generating new IgG4 antibodies with bivalent reactivity, have been demonstrated in vivo. Van der Neut Kolfschoten et al. While immunization typically stimulates IgG1 and IgG2 antibodies, allergy immunotherapy (AIT) is often associated with the production of IgG4. An increase in blocking IgG4 antibodies has repeatedly correlated with the success of the treatment of grass pollen hayfever and the relief of asthma symptoms by immunotherapy IgG4 mediated tolerance after AIT or SLIT  may be due to its function as a blocking antibody, preventing the allergen causing degranulation of IgE‐bearing mast calls and basophils. AIT also stimulates a complex of B and T cell responses to cope with allergic symptoms: regulatory CD4‐ positive T cells (Tregs) with anti‐inflammatory functions are induced; lymphocytes, monocytes, and dendritic cells secrete anti‐inflammatory IL10 and TGFb cytokines. AIT decreases the production of proinflammatory mediators with reduced migration of mast cells in target organs, IgA antibodies in mucosal surfaces or blood IgG can lead to improvement of symptoms by inhibiting binding of allergen to IgE on mast cells and basophils Thus, three possibilities may explain the association of IgG4 with favorable AIT and natural resolution of allergy Fig. . IgG4 anDifferent effector functions of IgG4 may be involved in different forms of immunotherapy because it addresses a wide range of allergic symptoms from allergic rhinoconjunctivitis to anaphylaxis. The same mechanism cannot be expected for all systems. Anaphylaxis is a rapid process that cannot be prevented through the relatively slow process of T regulatory cell activation but depends on fast‐acting blocking antibodies. In contrast, reducing inflammation in the airways is much more likely to involve regulatory T cells. The significance of regulatory T cells in controlling allergy is highlighted by the fact that Foxp3  mutation in mice and humans leads to intense multi‐organ inflammatory responses Human sera contain a mixture of antibodies of different classes and subclasses with a wide range of specificities. Most allergens are internalized by antigen‐presenting cells, including B‐2 cells in germinal centers, macrophages, and dendritic cells, and digested to form peptide fragments expressed on surface MHC class II molecules. CD4+ Th cells differentiate when presented with a cognate antigen, secrete cytokines, and stimulate the class switching in B cells. The IgG subclass generated depends on the type of Th cell response, particularly Th1 cells producing IFNγ and class switching to IgG1 and IgG3 antibodies and Th2 cells producing IL‐4 and IL‐5 and class switching to IgG4 and IgE antibodies Self‐reactive IgG and IgE antibodies are commonly detected in both allergic and autoimmune diseases and contribute to the pathogenesis of BP, RA, SLE, and MS Evidently neither the induction, the pathology or the resolution of allergy revolves entirely around specific IgE to allergens. IgG antibodies play a role in the induction of allergic symptoms and pathology of allergy and other autoimmune diseases. IgG antibodies are involved in induction an allergic response, are formulated to bind and eliminate allergenic epitopes, are generated in oral therapy that effectively ameliorates clinical sensitisation and may also be the major means of natural resolution of allergy.IgG4 may be effective in interrupting the cyclical elaboration of atopic conditions that lead to prolongation of allergic sensitization. IgG4 does not cross‐link complement and does not bind efficiently to activatory Fcγ receptors but, due to the inhibitory action FcγIIb receptors, can interrupt the cyclical induction of Th2 cytokine polarization. IgG4 antibodies may act as blocking antibodies, preventing IgE‐dependent activation of mast cells and interfering with IgG‐allergen complex induced activation of Th2 cells, leading to reduced activation of proinflammatory cells. The IgG4 sequestration of allergen may be more dependent on the weak association of bimodal FAE antibodies as the monomeric form of IgG4 is close to the glomerular filtration threshold (70 kDa) Given that IgG4 is one of the cardinal signs of developing immune tolerance and may be one of the most effective means by which the immune system generates an escape from the cyclical production of IgE and further Th2 cytokine polarization, how can IgG4 antibodies be used therapeutically? It may be dangerous to promote IgG4 antibodies in all disease. IgG4‐related diseases can affect any organ but are most common in the pancreas, and lacrimal, submandibular, and parotid glands. Patients with an IgG4‐related disease demonstrate high levels of IgG4 in their serum and organ infiltration of IgG4‐bearing plasma cells with consequent fibrosis and sclerosis. In various forms of cancer IgG4 levels correlate positively with T regulatory cells but negatively correlate with cytotoxic T lymphocytes Nevertheless, the deficiency in triggering of many cellular effector functions makes IgG4 an attractive therapeutic monoclonal antibody format. Pembrolizumab and Nivolumab, for example, both anti‐PD‐1 (programmed death‐1) IgG4 monoclonals in the USA for treatment of melanoma since 2014, block the ligation of the immunoinhibitory PD‐1 receptor on T‐cells, but do not elicit ADCC or complement‐dependent cytotoxicity. Antibodies that target PD‐1 and CTLA‐4 in cancer therapy are thought to act directly by antagonising these inhibitory receptors, and there is no significant evidence to indicate that engagement of Fcγ receptors plays any important role in their therapeutic activity. As the principal inhibitory receptor targets of cancer immunotherapy are expressed either on T cells or on antigen presenting cells, IgG4 has been the isotype of choice in the formation of monoclonal antibody therapeutic reagents as IgG4 does not cause the depletion of cytotoxic T cells or APCs through Fc mediated mechanisms. Therefore, Nivolumab and Pembrolizumab which are in use and MDX‐1105 and BMS‐663513 which target PD‐L1 and CD137, respectively, may have longer duration in serum owing to their IgG4 isotype.Based on the observation that IgG4 antibodies exchange their Fab arms through a dynamic process that involves separation of the two heavy chains and reassembly into the full molecule, conditions were adapted to generate stable bispecific IgG1 molecules by controlled FAE Similarly, Ibalizumab and PRO140, both new IgG4 mAb undergoing evaluation as treatments for human immunodeficiency virus (HIV)‐1 infection, act directly on viral receptors on cells and owe their efficacy to interfering with virus binding without disturbing the cells’ immunological functions. Ibalizumab binds to the second extracellular domain of CD4 Instead bivalent antibodies, sometimes involving IgG4, are being formulated for a new generation of wide‐ranging therapeutics. A bivalent IgG4 antibody with arms specific to factor IXa and factor X, termed hBS23, binds and brings these two factors into juxtaposition, mimicking the cofactor function of factor VIII to alleviating bleeding in hemophilia A At least twelve bispecific mAbs are currently being evaluated in clinical studies Other mAbs have also been tested in allergic disorders, including agents Th2 and Th2‐promoting cytokines, IL‐4, IL‐5, IL‐9, IL‐13, IL‐31, and thymic stromal lymphopoietin (TSLP) No human or animal subject was involved in this study, no ethical approval was required for the manuscript.


In response to the review “Advanced airway management in hoist and longline operations in mountain HEMS - considerations in austere environments: a narrative review.” by Pietsch et al. we refer to recently published original research describing manual versus automatic ventilation of intubated patients during helicopter hoisting operations. The recently published “Advanced airway management in hoist and longline operations in mountain HEMS – considerations in austere environments: a narrative review.”  by PietsContemporaneously to the authors' review we have published an original research paper “Ventilatory choices for intubated patients during helicopter stretcher winching” . ConcentOur paper appears to be the only publication to date which has directly addressed the safety of ventilation during hoist operations. We believe that we have been able to demonstrate the advantages to both patient and team of utilising mechanical ventilation.


Limosa limosa limosa), which breeds in agricultural grasslands in Western Europe, has such a disjunct nonbreeding distribution: The majority spend the nonbreeding season in West Africa, while a growing number winters north of the Sahara on the Iberian Peninsula. To test whether crossing the Sahara has an effect on breeding season phenology and reproductive parameters, we examined differences in the timing of arrival, breeding habitat quality, lay date, egg volume, and daily nest survival among godwits , individually marked in a breeding area in the Netherlands for which wintering destination was known on the basis of resightings. We also examined whether individual repeatability in arrival date differed between birds wintering north or south of the Sahara. Contrary to expectation, godwits wintering south of the Sahara arrived two days earlier and initiated their clutch six days earlier than godwits wintering north of the Sahara. Arrival date was equally repeatable for both groups, and egg volume larger in birds wintering north of the Sahara. Despite these differences, we found no association between wintering location and the quality of breeding habitat or nest survival. This suggests that the crossing of an important ecological barrier and doubling of the migration distance, twice a year, do not have clear negative reproductive consequences for some long‐distance migrants.Migrating long distances requires time and energy, and may interact with an individual's performance during breeding. These seasonal interactions in migratory animals are best described in populations with disjunct nonbreeding distributions. The black‐tailed godwit ( We thus classified an individual as wintering south of the Sahara if it was seen in West Africa at least once in the nonbreeding period (July–March) during any of the years of our study (2004–2015). Because godwits migrating to and from West Africa also use Doñana and other regions of the Iberian Peninsula as a stopover location during late summer , we systematically searched the breeding study area and surroundings daily for color‐marked godwits, from the arrival of the first adults in early March until the beginning of the laying phase in April. Resighting probability was high, with on average 3 ± 1 days between resightings  from each individual for molecular sexing  with a normal error structure. We included sex and its interaction with wintering region as factors, because males normally arrive earlier than females  with year and individual as a random effect did not converge because too few individuals changed breeding habitats between years. To overcome this problem, we used a generalized linear model (GLM) with the proportion of breeding attempts in good quality areas per individual over the years (with the function cbind). We used a binomial error structure and a logit link function.Next, we determined whether lay dates of females differed between individuals from the two wintering regions with a LMM with a normal error structure and individual and year as random terms. Godwits can lay a second clutch when the first failed  on egg volume . Models of daily nest survival were compared with the second‐order AIC (Akaike information criterion) for small samples (AICc) . Males wintering south of the Sahara arrived on average at the Dutch breeding areas on 19 March , while northerly wintering males arrived on average on 21 March . For females, the average arrival dates were 22 March  and 24 March , respectively. These differences in arrival date were significant, and males arrived significantly earlier than females  and females wintering north of the Sahara laying eggs of 41.3 cm3 .Females that wintered south of the Sahara on average initiated clutches on 20 April, which was 5 days  earlier than females wintering north of the Sahara Figure , in our On average, an individual had a 71% (67–75 95% CI) chance to be found in herb‐rich meadows, and wintering region and sex had no effect on this probability Table d. Daily 4Like several other European migrant birds (e.g., Flack et al., Previous studies of other long‐distance migratory birds with similarly disjunct populations have found a positive correlation between migration distance and the timing of spring arrival at the breeding grounds, and timing of clutch initiation (i.e., Bregnballe, Frederiksen, & Gregersen, Does earlier arrival and clutch laying in our study population suggest that wintering in West Africa is more favorable for Continental godwits than wintering in Southern Spain, for instance because of environmental related differences of the two regions? Despite arriving earlier, which would in principle give them first access to high‐quality breeding territories, godwits wintering south of the Sahara did not occupy a higher proportion of the better breeding habitat. Moreover, although previous studies on godwits have found that early lay dates are associated with higher reproductive success (Kentie et al., Repeatability in timing of migratory movements is generally high among long‐distance migrants (Conklin, Battley, & Potter, There is thus no clear evidence to suggest that the recent and rapid growth of the Iberian nonbreeding population (Márquez‐Ferrando et al., None declared.


A partnership of large health‐care purchasers created a workgroup to reduce the overuse of harmful and wasteful medical care in California.Employ a civic engagement process to identify the social values important to the public in considering different strategies to reduce overuse.Use of deliberation techniques for 3 case examples that explore possible strategies: physician oversight, physician compensation, increased patient cost‐sharing or taking no definitive action.Five themes were identified, including strong support for physicians’ leadership role to reduce overuse; nuanced enthusiasm for increasing patient cost‐sharing to discourage excessive demand; and marked disapproval of physician compensation as a motivator.Most but not all of the perspectives voiced by participants are congruent with efforts to reduce overuse that is being initiated or discussed at the state, provider and health plan level. As health‐care policymakers and leaders consider more targeted approaches to reducing overuse, these findings will inform decision‐making. Policy experts contend that up to 30% of health‐care dollars in the United States is inefficiently used, and a good proportion is linked to the overuse of unnecessary, harmful and/or wasteful medical care.Social values assessment is distinct from patient preferences. Most patient decisions concern the clinical care their physicians recommend, such as tests, treatments or procedures. The factors patients consider in deciding to accept or reject recommended individual care are an important aspect of patient‐centered research.Potential strategies to reduce overuse may threaten aspects of health‐care delivery that the public highly values, such as physician autonomy or patient choice. Physicians’ central role in the prevalence of overuseAmong efforts to reduce the frequency of overuse, the 3 largest purchasers in California—the California Department of Health Care Services , California Public Employees Retirement System  and Covered California —joined forces in 2015 to identify statewide priorities and establish processes that will help reduce unnecessary care. This public‐private partnership, called Smart Care California, involves coverage for more than 16 million Californians and aims to meaningfully reduce the level of inappropriate care over a 2‐year period.Doing What Works (DWW), using a non‐partisan, carefully structured qualitative process called public deliberation.DWW that are central to the public's views on reducing overuse of medical care and illustrates how these themes are consistent with or diverge from existing and proposed health‐care policy.Consequently, as part of this partnership, the Center for Health‐care Decisions (CHCD)—a non‐profit specializing in civic engagement in health‐care policy—developed 22.1This deliberative process asked the public to help address the problem of overuse by recognizing that they are responding as citizen decision makers providing input to policy decisions; considering the impact of overuse on society at large; and debating why various resolutions to the problem are more acceptable than others.2.2Experienced, non‐partisan facilitators led 10 DWW sessions, each lasting 4 and a half hours, in 6 communities, urban and rural, across California. Five groups consisted of Medi‐Cal members; 4 groups included individuals who purchased insurance through Covered California; and one group of individuals was insured through CalPERS. These groups were chosen because they are insured members of the project sponsors. To establish commonality among the groups, all participants would be low‐to‐moderate income individuals, those most likely to be sensitive to higher cost‐sharing or reduced coverage.Professional recruitment companies and community‐based organizations recruited the 117 participants. Inclusion criteria were limited to individuals between the ages of 30 and 60 years to capture the perspectives of those who are more likely to have had experience interacting with their health‐care system and are not on Medicare. Each participant received a $200 incentive to participate. Table 2.3The California State University, Sacramento Institutional Review Board approved this project (IRB 14‐15‐126).2.4During each session, participants completed a pre‐ and post‐survey to capture demographic data as well as assess and determine shifts in beliefs and attitudes regarding the use of evidence to inform treatment and coverage decisions pertaining to low‐value care. Pre‐ and post‐survey results can be found in the DWW Final Report.Each session commenced with a review and discussion of an educational handout describing the problem of medical care overuse; the meaning of high‐ and low‐value care; the reasons low‐value care exists and its harms; and the medical research that forms the basis for evidence‐based practice. The educational handout was developed with input from the DWW Advisory Committee, which was comprised of consumer advocates, health education experts, a patient representative and health‐care policy leaders.Participants then reviewed and discussed in turn 3 case scenarios illustrating the problem of overuse: antibiotics for adult bronchitis; Caesarean sections for low‐risk births; and Magnetic Resonance Imaging (MRI) for assessment of acute low‐back pain  there is a range of policy options to be considered from gentle to draconian; (ii) there are tensions among values ; and (iii) the topic must be easily relatable to participants, avoiding complex case examples that are difficult for the public to grasp.For each case scenario, participants considered 5 strategies or potential approaches to reducing overuse: (i) establish greater oversight and control of physicians who overuse (monitoring physicians); (ii) reduce demand by increasing patient cost‐sharing for unnecessary care; (iii) influence physicians through rewards; (iv) influence physicians through non‐payment; and (v) take no specific action, therefore continuing to leave these decisions to individual physicians and their patients.2.5Quantitatively, the number and percentage of participants who favoured the various strategies were central to assessing results. But the rationale for their choices was determined through qualitative analysis. Discussions were audio‐recorded, transcribed and analyzed using inductive, grounded theory methodology. Transcript analysis focused on the reasons, values and rationale given by participants for why certain strategies were more or less desirable than others and how the different scenarios influenced their perspective. The development of themes was theoretically guided by the constant comparison method: (i) immersion in the transcripts (reading and rereading); (ii) the development of themes and codes; (iii) coding the transcripts; and (iv) reintegrating the codes into an explanatory narrative. Two research team members (SLP and MG) independently read the transcripts and developed codes as well as themes. The 2 codebooks were compared for congruency before all transcripts were coded. Through this process, themes and principles emerged that characterized participants’ priorities.3Table 3.13.1.1if corrective action is the most effective, retrospective review is a fairer approach than pre‐approvals, and physicians were willing to judge and be judged by each other.Across all 3 scenarios, monitoring of physicians by physicians was chosen by 72% of the participants, far more often than the other strategies. The key rationale is that physicians must be in control of instituting their own corrective actions. Although participants were concerned about administrative burden, few doubted that the task of reducing overuse rested with the medical profession. Participants were willing to overlook the administrative burden 3.1.2Only 5 participants supported the option of rewarding physicians for reducing overuse (a strategy offered in 2 of the scenarios), representing 2% of the total votes. There was almost universal opposition to paying doctors more for “doing what they should be doing.”Many saw this approach as contrary to medical professionalism that purports to embrace standards of excellence and allegiance to patient well‐being and not the self‐interests of practitioners.Interestingly, with 23% of the votes, participants were more accepting of the strategy not to compensate doctors for chronic overuse. While most felt strongly that physicians’ treatment decisions should not be tied to compensation in any way, the Caesarean birth example indicated that the overuse problem in California is largely driven by physicians and hospitals and not by patients. It appears that this fact (and the cost and number of unnecessary procedures) elicited atypical enthusiasm for denying provider payments. However, the majority still preferred using strategies that relied on medical professionalism.3.1.3The option to increase patient cost‐sharing for unnecessary interventions was proposed in all 3 scenarios. While the total support for this strategy was just 26%, it was most favoured in the Caesarean birth example, where almost half of all participants supported it.Many participants regard childbirth as a health‐care domain that is distinctive from others, where a women’s right to make decisions about her own body is almost sacrosanct. In this situation, their strong belief in patient choice was balanced by their conviction that the state should not waste its resources on unnecessary care. They believed that higher patient cost‐sharing would dampen enthusiasm for the procedure while maintaining a woman's right to choose it. Contrary to research,3.1.4Although each case scenario emphasized medical harms , participants tended to focus almost exclusively on the waste of communal resources as a motivator for action. These low‐to‐moderate income Californians seemed acutely aware of increased health‐care costs and the impact this has on the services they receive. While many were aware of and alarmed by the problem of antibiotic resistance and its impact on society at large, the statistics associated with the individual harms of unnecessary Caesarean births and MRIs did not resonate with participants.Their concern about wasting societal resources, however, was not limited to overuse, per se. The strategies that are intrusions into independent doctor‐patient decision‐making must be justified by evidence that these strategies are, in fact, effective in reducing waste.3.1.5Participants made it clear that their views reflected the role they were asked to assume as follows: that of policymaker, not of patient. Many stated, “ if I am responding as a patient, I would take no action and continue to leave it to the doctor and patient to decide.” Conversely, they acknowledged that as a citizen decision maker, they were responsible to many more people and most endorsed actions that might, in fact, hamper the doctor‐patient autonomy that they, as patients, preferred.There was considerable discussion on the need for more education to help both patients and the general public fully understand the problems of overuse. Educating patients in the context of their own medical care must be matched by a broader societal emphasis on financial and medical harm.44.1DWW results and themes that emerged, health‐care leaders were especially interested in how the findings are congruent with and/or depart from existing strategies to reduce overuse. As Smart Care California develops and implements approaches to reducing overuse, the DWW findings can help inform their activities and decision‐making. The following describes some of the overuse strategies now being used.In reviewing the 4.1.1As noted earlier, participants regard these clinical decisions as ones “belonging to the profession” and thus, it is the profession that must remedy problems among its members.®, a national programme sponsored by the American Board of Internal Medicine Foundation in partnership with more than 75 national medical societies.This perspective is consistent with and widely endorsed by state and national initiatives.Hospitals in California have initiated programmes that focus on physicians working with their colleagues to improve practices.In an effort to broaden CW initiatives, 2 medical groups, a physician organization and a consumer group collaborated to integrate CW recommendations into clinical practice. These medical groups began tracking and reporting site‐level change to clinicians over time on imaging for uncomplicated headache to provide comparative performance feedback.4.1.2DWW participants only marginally supported reducing compensation for physicians who consistently prescribe low‐value care, but were more inclined to do so for unnecessary C‐sections.In California, hospitals are experimenting with the use of monetary disincentives with notable success. To remove financial incentives for Caesarean births, 3 hospitals negotiated a blended case rate for deliveries—one flat rate regardless of delivery method . These hospitals concurrently implemented processes for data and measurement of physician‐level Caesarean rates and a quality improvement programme. Using this three‐pronged approach—payment reform, quality improvement and physician feedback—the average number of Nulliparous, Term, Singleton, Vertex (NTSV) Caesarean births was reduced by 20% in less than 1 year.4.1.3DWW participants with only 2% of participants supporting this option.Of all the strategies proposed, this one elicited the strongest opposition from Ironically, California has been a long‐standing leader in Pay‐for‐Performance (“P4P”) programmes that acknowledge and reward physician groups showing improvement in quality of care measures.Within the P4P programme in California, Hill Physicians Medical Group, a very large Northern California Independent Practice Association, has—for more than 15 years—been using financial incentives that now amount to over 30% of primary care physicians’ compensation. Of the dozen quality measures most recently in its primary care incentive programme, one focused explicitly on overuse. This measure, avoiding overuse of antibiotics for acute bronchitis, showed a solid 8.5% improvement in 2016 compared to 2015. The quality incentive programme has proven effective in moving from volume to value, it pays for both attainments against external benchmarks as well as improvement towards those benchmarks. The jury may still be out on whether physician practices can be meaningfully influenced through professionalism alone or whether financial motivation—sticks or carrots—is needed.4.1.4DWW. Those who supported it did so because it retained patient authority, even over ineffective and harmful medical treatment. Patient choice is a long‐standing, well‐engrained value in American health care.With 26% of the votes, this strategy was not a dominant one in California policymakers have indicated interest in ways to reduce patient demand for unnecessary care4.1.5Participants conveyed their strong support for disseminating more information to patients and to consumers in general about the harms and costs of unnecessary care.There is a growing volume of patient materials about the harms associated with the use of unnecessary medical care. Although CW has included some information in its patient‐facing materials about wasting resources,Individual patients are not likely to respond positively to discussions of financial harm or resource stewardship. However, when people learn about the impact of the financial harms of overuse on the health‐care system outside their interactions with their health‐care providers, they are more likely to view the problem from a purchaser, co‐payer or citizen role.4.1.6DWW participants embraced this role, even while acknowledging that it may conflict with their views as patients.If my doctor and I agree on the best treatment for my problem, my health plan should pay for it no matter what the research shows), 65% of participants agreed with that statement. But when the question was asked indirectly , only 27% agreed.This contrast between the perspectives of the patient and those of the informed citizen is also evident in survey research.DWW suggest value in including another stakeholder group: the informed citizen. Just as purchasers and providers have different priorities and perspectives, DWW illustrates that citizens approach the problem of overuse from distinct vantage points.Health‐care policymaking typically involves 4 major groups: purchasers, health plans, regulators/legislators and providers. The findings from 4.2The sample size of 117 lower‐to‐moderate income California residents does not necessarily represent the views and values of the state's population at large. The overrepresentation of females does not reflect the population, but it is common and often expected in social research studies.”5DWW participants are congruent with efforts to reduce overuse that are being initiated at the state, provider and health plan level. The public's disapproval of programmes that reward doctors for good quality care suggests that consumer‐facing communications should focus on recognition of excellence rather than monetary rewards. Increasing patient cost‐sharing to maintain patient choice without jeopardizing shared resources is appealing to many but not feasible to implement in Medicaid. The lay public also shares the concern of many medical professionals on the ethics of prescribing unneeded, potentially harmful care, regardless of who is paying.Most of the perspectives voiced by the Civic deliberation of complex health‐care topics is not a common practice in the US. Yet, as long as health‐care reform continues to focus on cost containment policies, the public voice will play an important role in balancing the tension between cost and benefit. Harmonization of evidence‐based practices, responsible use of resources and patient preference is not easily achieved. Future research on public values might explore more closely how to best reconcile these often‐conflicting values.None declared. Click here for additional data file. Click here for additional data file.


Registered nurses at primary health care centres in Sweden receive about 20 million telephone calls annually. Questions related to sick leave occur regularly. Previous studies conclude that those calls often are perceived as problematic. The aim of this study was to explore factors associated with problems regarding sick leave questions in telephone nursing.n = 185) working with telephone nursing in 26 Swedish primary health care centres, of whom 114 (61.6%) responded. Based on the results of a Spearman correlation analysis a logistic regression analysis was performed of significant exposure variables on outcome (perceived problems).A questionnaire was distributed to all registered nurses (Significant exposure variables were: experience of telephone nursing, age, being educated in social insurance medicine, and frequency of telephone calls with sick leave questions. Young age was associated with more problems than old age. Those having education in social insurance medicine reported fewer problems than those who had not, and so did those having few telephone calls with sick leave questions as compared with those who had many.Young age, lack of education in insurance medicine, and high frequency of sick leave questions increased the perceived problem level in telephone nursing. Registered nurses working at Swedish primary health care centres receive about 20 million telephone calls annually  during tThe handling of telephone calls with sick leave questions has been described in two previous Swedish studies ,7 as proThe underlying factors causing the registered nurses to assess sick leave questions as problematic or not problematic are so far unknown. The aim of this study was to explore possible underlying factors associated with registered nurses experiencing problems with sick leave questions in telephone nursing.n = 185). The primary health care centres provided a contact person who was informed about the study and in turn informed the registered nurses about design of the study, checked informed consent, and distributed the questionnaire.All registered nurses working with telephone nursing at 26 primary health care centres in mid-Sweden were invited to participate. Of the 26 primary health care centres, 20 agreed to participate in the study and to contact their registered nurses , ‘a few times a year’ (n = 2), ‘a few times a month’ (n = 32), ‘1–5 times a week’ (n = 61), ‘6–10 times a week’ (n = 14), and ‘more than 10 times a week’ (n = 0). The variable was dichotomized into ‘less than once a week’ (problem = 0) and ‘once a week or more often’ (problem = 1).The outcome variable was the response to the question ‘How often do you find it problematic to handle sick leave questions?’ The possible responses were ‘never’  as the dependent variable and the significant exposure variables as independent variables. To check the results of the correlation analysis a logistic regression was also performed with all the 14 exposure variables, with backward elimination and with stepwise inclusion of exposure variables. The results of all these analyses yielded almost identical results.First, a univariate analysis of differences between groups was performed with Student’s n = 34), ‘1–5 times a week’ (n = 61), and ‘6 times a week or more often’ (n = 14). Data for P value of less than 0.05 was regarded as statistically significant.A sensitivity analysis was performed with the outcome variable trichotomized into ‘less than weekly’ (P < 0.0005), had a longer experience of telephone nursing (P < 0.005), had more education in social insurance medicine (P < 0.05), and had less frequent telephone calls with problematic sick leave questions (P < 0.001). A sensitivity analysis was performed with the outcome classified into three groups , and the highest level among the youngest with the highest frequency of sick leave questions (75.8%) . The corSignificant factors affecting experienced problems with sick leave questions in telephone nursing were age, education in social insurance medicine, and frequency of telephone calls with sick leave questions. Young registered nurses experienced more problems than the older nurses did. Registered nurses educated in social insurance medicine reported fewer problems than those without such education, as did the registered nurses having fewer telephone calls with sick leave questions. Of the three significantly associated factors, frequency of sick leave questions had the largest impact on experiencing problems, followed by age and education in social insurance medicine.The finding that the registered nurses’ age was associated with fewer experienced problematic sick leave questions is most probably linked to the fact that skills and knowledge increase with age . SimilarHypothetically, encountered problems might be reduced by intervention towards the underlying factors. Of these, education in social insurance medicine is a possible way of developing more competence and thereby reducing the perceived problem level. A reduction of registered nurses’ experienced problem levels by education was previously proposed in two interview studies with registered nurses ,8 and isThe strengths of the study were that the sample included a fairly large population, although a substantial proportion of the registered nurses declined the invitation to the study. It is possible that there is a selection bias among the participating registered nurses in terms of being more positive towards the subject and therefore responding positively to the invitation. The use of contact persons informing participants about the study could have affected the rate of participation depending on the engagement of the contact person. The analysis model was robust in the sense that classification of the outcome into two or three groups yielded similar results.As described before it was not possible to carry out a non-participant analysis due to not having data on the participants declining. How the participants interpreted the questions is—as in all surveys—unknown, especially concerning concepts connected to a topic where the participants express a large lack of knowledge.In conclusion, young age, lack of education in insurance medicine, and high frequency of sick leave questions from calling patients increased the perceived problem level in telephone nursing.


We discuss here the prospects for biotechnology of extreme thermophilic microorganisms. On top of that, consider working with microorganisms that do not grow at ambient temperatures or on solid media. Yet another challenge – these microorganisms inhabit extreme thermal environments that can be dangerous and expensive to access Fig. . These wMethanococus, Archaeoglobus and Methanobacterium), with those of the most thermophilic bacteria determined shortly thereafter (Thermotoga and Aquifex). Their genomes were typically smaller (~2 Mb) than those of the model mesophilic bacteria (3–4 Mb), and their sequences provided insights into how these microbes from odd places fit into the evolutionary scheme of life. They also enabled the expression of numerous genes from these organisms in microbial models, such as Escherichia coli, opening up the window on studies of protein stability and enzyme catalysis at temperatures even above 100°C. Genome sequences enabled global transcriptional studies that, coupled with biochemical analyses, provided many novel physiological and metabolic details of extreme thermophily, although general rules of life at extreme temperature remained elusive and still do to this day. Stabilizing a protein above the boiling point involves rather minor changes relative to its mesophilic counterpart, and the mechanisms involved are generally unique to a particular protein. Moreover, even with genome sequence information in hand, biotechnological opportunities at extreme temperatures were restricted to single‐step biocatalysis using recombinant enzymes.In the mid‐1990s, the enormous interest in these extremely thermophilic microbes, and also in the archaeal domain of life, is well illustrated by the fact that three of the first dozen genomes to be sequenced were from thermophilic archaea  over a decade ago through the pioneering work of Imanaka and Atomi , the first for a microbe to grow at or above the boiling point of water , was recently reported: a recombinant strain of this organism was optimized for the conversion of carbon monoxide produced from processing steel into hydrogen gas at very high efficiency . In fact, in a process based on metabolically engineered T. onnurineus, production of hydrogen gas at 85°C from CO generated in steel mills has no sterilization requirements, no cooling needs, uses waste heat from the plant site, and uses sea water to make up water losses (T. onnurineus of a marine organism).Bioprocessing at temperature near and above 80°C can have important advantages over near‐ambient operations. Highly genetically modified microorganisms usually have a fitness disadvantage and can be easily overtaken in culture when contaminating microbes are present. The high growth temperature of extreme thermophiles precludes growth or survival of virtually any contaminating organism. This reduces operating costs associated with reactor sterilization and maintaining a sterile facility. In addition, at industrial scales, heat production from microbial metabolic activity vastly outweighs heat loss through bioreactor walls such that cooling is required. Extreme thermophiles have the advantage that non‐refrigerated cooling water can be used if needed, and heating requirements can be met with low‐grade steam typically in excess capacity on plant sites. In fact, in the process in which the metabolically engineered Thermococcus and Pyrococcus species. All are heterotrophs and include the aerobe Thermus, the acidophilic aerobe Sulfolobus, and the anaerobes Thermoanerobacterium and Caldicellulosiruptor. Of these, Caldicellulosiruptor species probably have the most potential in the biotechnological field because of their ability to break down and grow on the carbohydrate polymers cellulose and hemicellulose (xylan), the primary components of plant biomass. Indeed, these organisms can degrade wood and grasses without any thermochemical pre‐treatment (Kataeva et al., et al., et al., Genetic systems are also available for four genera of microbes that grow optimally in the 70 – 80°C range see Fig. , and theSo, a renaissance of sorts is at hand in the field of extreme thermophily that offers engineering these organisms for biotechnological processes. One can anticipate that this field will soon take advantage of the latest developments in genetic manipulations, such as Tnseq and CRISPR, as well as the full spectrum of tools in systems biology. The future looks bright for these remarkable organisms that thrive at the upper temperature limits of life.


Clinical diagnosis of occlusal dysesthesia (OD), also referred to as phantom bite syndrome, is currently based on the absence of objective occlusal discrepancy despite the persistent complaint of uncomfortable bite sensation. We previously demonstrated that the subjective feeling of occlusal discomfort generated by artificial occlusal interference can be objectively evaluated using prefrontal hemodynamic activity in young healthy individuals. The aim of this study was to investigate whether dental patients with and without OD show distinct prefrontal activity during grinding behavior with an occlusal interference. Six dental patients with OD (OD group) and eight patients without OD (control group) grinded piled occlusal strips placed between their first molars and reported their perception and discomfort thresholds during continuous monitoring of prefrontal hemodynamic activity with a portable functional near‐infrared spectroscopy. Although patients without OD showed the typical hemodynamic pattern of increased oxyhemoglobin and reduced deoxyhemoglobin (HHb) concentration, those with OD showed persistent incremental increases of HHb concentration that began at the loading of occlusal strips on their molars before they executed grinding. The intensities of the task‐related HHb activities showed statistically significant differences between OD and control groups, particularly at channel 3, arranged over the left frontal pole cortex. When the discrimination criterion was set using the intensity values of channel 3 from both groups, the overall accuracy of the OD discrimination was 92.9%. Although physiological interpretation has yet to be elucidated, the task‐related response of an increase in HHb may be a useful neuronal signature to characterize dental patients with OD. Occlusal dysesthesia (OD)  and eight age‐matched dental patients without OD  participated in the experiment. Mean patient age and gender distribution conformed to those in a previous report of 37 cases  , and discomfort thresholds were 79.5 ± 9.6 and 76.0 ± 19.5 µm in control and OD groups, respectively (P = 0.865). There were no statistically significant differences in mean discrimination and discomfort thresholds between participant groups.Control and OD groups showed comparable occlusal vertical dimensions at perception and discomfort thresholds. Discrimination thresholds were 40.5 ± 6.0 and 32.0 ± 8.0 µm in control and OD groups (HRF(t) was defined from the loading of occlusal strips  and 4  and deoxyhemoglobin (HHb) concentration change responses in conditions without bite rise, with occlusal vertical dimension at perception, and with that at discomfort threshold were shown in Figure We calculated threshold values to discriminate the occurrence of OD using the regression coefficient values of channel 3, showing the highest statistical significance in group comparison. After determining the threshold value in each test and training data sets in the leave‐one‐out cross‐validation, the mean classification accuracy was 92.9%. The overall sensitivity, specificity, positive predictive value, and negative predictive values were 83.3%, 100%, 100%, and 88.9%, respectively.We measured prefrontal hemodynamic responses during grinding behavior with slight occlusal interference in dental patients with and without OD. Patients with OD showed a task‐related increase in HHb; however, those without OD showed a task‐related reduction in HHb. This suggests that prefrontal hemodynamic responses may be a potential marker for detecting patients with OD. In addition to high discrimination accuracy of OD patients in the regression analysis of HHb responses, this examination requires minimal stress to the patient, because the thickness of the occlusal interference does not exceed the individual discomfort threshold and the portable fNIRS system enables the patient to remain in the dental chair during examination. In addition to the previous studies  suggesting that this response is associated with top‐down cognitive control, preparing for the upcoming examination of occlusal vertical dimension, as opposed to bottom‐up perception processing based on ongoing motor/proprioceptive afferent information. The potential contamination of the motion artifact and the autonomic change in the cutaneous blood flow can be excluded because cortical HbO and HHb behaved differently, and the time course of the cutaneous blood flow response differed from those of the cortical. Alongside the fact that the HHb responses are less affected by systemic responses, such as breathing cycles and blood pressure changes (Kirilina et al., We observed a distinct pattern of HbO and HHb responses during the grinding task between patients with and without OD. Corresponding to our previous fNIRS study applying a similar bite rise paradigm to healthy young adult volunteers (Ono et al., The time course of the hemodynamic responses at discomfort threshold tended to show larger amplitudes compared with those in the other conditions in both participant groups, although the peak amplitudes were not statistically different among the conditions Fig. . The disIn addition to the averaged hemodynamic responses obtained through all bite rise conditions, we also examined discrimination accuracy using regression coefficient values from hemodynamic responses in the individual trial at no bite rise, discrimination threshold, and discomfort threshold. The best discrimination accuracy was obtained when we utilized the averaged hemodynamic responses. This suggests that averaging responses may be useful to suppress artifacts that are not time‐locked with the grinding task.There were several limitations to the current study. First, the sample size was small because of the relatively rare occurrence of OD. Accumulating more cases could help determine the general diagnostic criteria of OD via intensity of task‐dependent HHb responses. Second, measured cortical areas were limited to the anterior prefrontal region. The portable fNIRS system utilizes light‐emitting diodes as a light source, and therefore, we were unable to detect signals from cortical areas covered with hair, such as somatosensory cortices and DLPFCs, because of the absorption of near‐infrared light by black hair and hair roots in the Asian participants. Whole‐head fNIRS imaging using a system equipped with high‐power laser diodes as a light source should be utilized to investigate whether the increased HHb response in the FPC is associated with reallocation of blood flow. However, the FPC activity well characterized dental patients with and without OD and is therefore potentially useful for OD diagnosis. The comparable perception and discomfort thresholds between patients with and without OD found in the current study support a previous report (Baba et al., In conclusion, we propose a regression analysis of fNIRS signals during grinding behavior to diagnose OD. Our results suggest that HHb response coefficients from the left FPC are significantly different between patients with and without OD and are therefore potentially useful to discriminate the occurrence of OD.None declared.


The Synthetic Yeast Genome Project will give scientists a tool for understanding the biological intricacies of eukaryotes and for synthetic biology. Wine researchers will greatly benefit from this project to build new wine yeast strains. More than 7,000 years ago, when grapes and yeast joined forces for the first time to lift the spirit of humankind, the ancients imbibed with joy, unknowingly celebrating the beginnings of one of the world's oldest biotechnological processes. The first “magical” juice came from spontaneously fermented grapes cultivated in the Zagros Mountains of Ancient Persia and the Caucasus Mountain Range between the Black and Caspian Seas. The “mystical art” through which sugary, bland‐tasting grape juice is turned into flavoursome wine with hedonic and preservative properties, quickly spilled over into neighbouring regions of Mesopotamia, Anatolia, Egypt, Phoenicia, Greece and the Mediterranean Basin As European seafarers set sail to discover and explore far‐off continents, their ships carried both the “fermenting knowledge” of winemaking and the “geminating seeds” of yeast biotechnology.Following colonisation by the Greeks, Phoenicians and Romans, winemaking spread throughout Europe and became embedded in the diet and cultural activities of both the aristocracy and proletariat. Roman potters developed large earthenware pots for storage and transport. The Gauls taught the Romans how to fashion barrels from wood, and oak barrels became the vessel of choice for yeast cells to ferment grape must into wine—a skill that survived the Roman Empire and the Dark Ages of economic and cultural decay.With the dawn of the Age of Enlightenment, geographic exploration was accompanied by a search for scientific knowledge. As European seafarers set sail to discover and explore far‐off continents, their ships carried both the “fermenting knowledge” of winemaking and the “geminating seeds” of yeast biotechnology. A century before the French biochemist, Louis Pasteur, zoomed in to the bubbling and frothing content of oak barrels and discovered that tiny yeast cells were responsible for the fermentation of grape juice into wine, the Berkshire cartographer, John Spilsbury, zoomed out to reveal the “Big Picture” of the British Empire in 1767 through the invention of a “dissected map”. Spilsbury pasted maps onto wood, cut them into small pieces and reconstituted a jigsaw puzzle of the world. Ever since, the jigsaw puzzle evolved into a problem‐solving recreational pastime and educational toy.Oddly, Pasteur and Spilsbury have much in common. In their indomitable quest to solve challenging problems, both were interested in uncovering every bit of detail of the “problem” and in piecing the “Big Picture” together. Their approach of seeking to understand the “fundamentals” in the context of potential application served us well through many centuries of scientific endeavour and remains the most powerful dynamo of technological and societal progress today. This statement also applies to the emerging science of synthetic biology.There is no doubt that synthetic biology technologies will be crucial to solve the puzzling challenges of a world with dwindling finite resources and a rapidly growing and ageing global population. Maximising the bioeconomy—that is, the economic activity derived from scientific advances and innovations in biotechnology and, in particular, the engineering of biology and biomanufacturing—will be one key strategy. However, assessing current bioeconomical trends and finding solutions for the grand challenges are like trying to solve a complex jigsaw puzzle without all the pieces in the box Fig . The besThere is no doubt that synthetic biology technologies will be crucial to solve the puzzling challenges of a world with dwindling finite resources and a rapidly growing and ageing global population.Once the frame of the puzzle is pieced together, the middle pieces can be sorted by colour and a more complete picture emerges. These pieces include: prediction and prevention of diseases; affordable healthcare; adequate access to clean water and safe, nutritious foods; energy‐rich molecules for renewable biofuels and novel bioenergy resources; bioremediation of polluted environments and improved land use; biodegradable pesticides and sustainable, environmentally friendly industrial chemicals; and continuous workforce training in biodesign and biomanufacturing for the new bioeconomy The emerging discipline of biodesign—synthetic biology—builds on the rich legacies of several branches of biology—including genetics, molecular biology and systems biology—biomolecular platforms, chemical and physical sciences, mathematical and computational sciences, data science and bioinformatics, as well as engineering and information technology Saccharomyces cerevisiae, has become a legacy eukaryotic “chassis” for synthetic biology , devices (gene networks) and modules (biosynthetic pathways) to (re)design biological systems (cells and organisms) Saccharomyces cerevisiae has a long history as a model organism for fundamental academic research as well as being a workhorse for a wide range of industrial applications. Based on this track record, it is now the preferred “cell factory” of semi‐synthetic products, such as artemisinic acid, a precursor of the potent anti‐malarial artemisinin, as well as food ingredients, including vanillin, resveratrol, saffron, stevia and nootkatone S. cerevisiae to produce these commercial products has moved synthetic biology from the “laboratory” to the “field”, thereby changing the term “genetically modified organism” (GMO) to “semi‐synthetic organism” (SSO) In this context, the well‐studied, food‐grade yeast, logy Fig . In syntS. cerevisiae so that we can better understand the biological intricacies of eukaryotic SSOs and be able to more accurately predict and control the practical outcomes of genome engineering—as opposed to individual gene‐based genetic engineering. This is the primary purpose of the international Synthetic Yeast Genome Project, known as Yeast 2.0 or Sc2.0. This ambitious collaborative project is guided by an agreed and legally binding policy statement on key issues, such as social benefits, intellectual property, safety and governance Recent commercial advances with semi‐synthetic yeast cell factories have tossed a fresh pile of jigsaw pieces of a highly complex puzzle on the discussion tables of scientists, industry practitioners, policymakers, regulators, governments, consumers and society at large. One approach to help solve this puzzle is to create a fully man‐made genome for S. cerevisiaeS. cerevisiae genome puzzle in order to, for the first time, completely rebuilt a eukaryote's genome. Each piece of the puzzle is essential if a complete picture is to be produced, and the Sc2.0 team is working to have it in place by 2018.The laboratory benches of a dozen Sc2.0 research groups around the world  are strewn with pieces of a complex 6,000‐piece  jigsaw puzzle comprising the genetic make‐up of As the Sc2.0 project is progressing, genome engineering technologies are being advanced at a rapid pace while important fundamental biological intricacies of yeast cells are being figured out.S. cerevisiae. The ~12 Mb (non‐redundant) to ~14 Mb  genome sequence carries approximately 6,000 genes of which about 5,000 are individually non‐essential. The 6,000 genes are distributed along 16 linear chromosomes of varying length . The first step towards designing and building the S. cerevisiae's genome was taken in 2011 with the synthesis of the two arms of Chromosome 3—the third smallest S. cerevisiae chromosome S. cerevisiae chromosomes have been published  of This consolidated Sc2.0 genome was designed from the start to be fully customisable so that researchers will be able to ask otherwise intractable questions about the fundamentals of chromosome structure, organisation, function and evolution, as well as gene content, function of RNA splicing and the role of small RNAs in yeast biology Wine yeast researchers expect to gain much knowledge by borrowing some of the Sc2.0 puzzle pieces to build their favourite wine yeast strains.loxPsym sites for future genome scrambling; all TAG stop codons are recoded to TAA; all repetitive and dispensable sequences, such as Ty transposons, introns, subtelomeric regions and silent mating‐type loci (HML and HMR located on Chromosome 3) are omitted from the design; and all tRNA genes are relocated to a novel neochromosome The final Sc2.0 genome is therefore designed, curated, streamlined and reorganised to encode a slightly modified genetic code History was made with the recent successful development of the world's first semi‐synthetic wine yeast as a “demonstrator” project.th mini‐neochromosome will disadvantage the genetic processes and protein synthesis machinery of the redesigned haploid S288c laboratory strain of S. cerevisiae. These are just a few examples of the puzzling questions that are being answered as the Sc2.0 picture emerges.As the Sc2.0 project is progressing, genome engineering technologies are being advanced at a rapid pace while important fundamental biological intricacies of yeast cells are being figured out. By the end of this project, it would be known, for example, whether removing all introns and transposable elements will affect cell fitness and whether the relocation of all tRNA genes to a 17From a wine scientist's viewpoint, another perplexing question is whether some of fundamental insights from the Sc2.0 yeast strain can be extrapolated to robust industrial wine yeast strains Not all yeast strains are equally able to catalyse rapid, complete and efficient conversion of grape sugars to ethanol, carbon dioxide and other minor, but important metabolites—acids, alcohols, carbonyls, esters, terpenes, thiols and so on without the development of off‐flavours  hybridisation (mating or cross‐breeding), mutagenesis  and adaptive evolution (crossing and back‐crossing of selected mutants) Non‐genetic modification techniques include Such broad‐based acceptance by producers and consumers is, however, not the case for strains generated by genetic engineering. More than 10 years ago, the first two GM wine yeast strains, ML01 and ECMo01, which met all regulatory requirements, were commercialised in the USA, Canada and Moldova By solving fundamental yeast jigsaw puzzles over a glass of wine, we might well acquire the ability to design the ultimate wine yeast genome model…While the wine industry is caught up in the scientific and cultural maelstrom of the “wonders and terrors” of GMOs and SSOs, researchers continue to mine DNA sequencing data for the responsible design, synthesis and/or editing of wine yeast genomes with huge potential benefits for producers and consumers alike. On one hand, anti‐GMO/SSO campaigners and uninformed traditionalists might dismiss such research as an “unwanted reality” that will eventually vanish into thin air. However, future‐focussed innovators, on the other hand, are highly supportive of these research efforts because they recognise that it generates invaluable insights into the molecular intricacies of wine yeast cells. Akin to what research into the Higgs boson elementary particle is revealing about the “Standard Model” of particle physics, synthetic genomic experimentation is illuminating the biomolecular mysteries of wine yeast cells. Factually correct information and knowledge gained from such fundamental research and evidence‐based data are the only way to counteract ideologically driven doomsday prophecies, exaggerated fantasies, empty promises and guesswork about the future of SSOs.p‐coumaric acid in heterologous bacterial and yeast strains. Yet, the high cost of p‐coumaric acid as a substrate and the trace amounts of raspberry ketone obtained in these GM strains prevented commercial production of this phenylpropanoid as a food‐grade flavouring agent. The missing puzzle pieces in this work are the ability to eliminate the requirement for supplementing the culture medium with expensive p‐coumaric acid and to increase the yield of 4‐[4‐hydroxyphenyl]‐butan‐2‐one History was made with the recent successful development of the world's first semi‐synthetic wine yeast as a “demonstrator” project. A cassette of four synthetic genes encoding the production of a highly desirable fragrant raspberry ketone—4‐[4‐hydroxyphenyl]‐butan‐2‐one—was embedded into the genetic blueprint of a wine yeast strain Fig  10. Thisp‐coumaric acid via cinnamate or directly from tyrosine to p‐coumaric acid. Conversion of p‐coumaric acid to raspberry ketone requires three additional enzymatic steps including a condensation reaction between coumaroyl‐CoA and malonyl‐CoA. To design a biosynthetic pathway for the de novo production of 4‐[4‐hydroxyphenyl]‐butan‐2‐one in a wine yeast, the following codon‐optimised genes were chemically synthesised and integrated into the HO locus of a wine yeast strain (AWRI1631): the phenylalanine ammonia lyase from an oleaginous yeast, Rhodosporidium toruloides; the cinnamate‐4‐hydroxylase from Arabidopsis thaliana; and the coumarate CoA ligase 2 gene from parsley, Petroselinum crispum, fused by a rigid linker to the benzalacetone synthase from rhubarb, Rheum palmatum. This semi‐synthetic organism was equipped to produce raspberry ketone at concentrations almost two orders of magnitude above its predicted sensory threshold in Chardonnay grape juice under standard wine fermentation conditions, while retaining the ability to ferment the grape must to dryness Solving such a scientific puzzle starts with the unravelling of the phenylpropanoid biosynthetic pathway. This pathway commences with the conversion of phenylalanine to The primary goal of this research project was not to produce raspberry‐tasting Chardonnay at a commercial scale. The objective was to hone our synthetic biology skills and to expand our toolkit with which we can advance fundamental understanding and provide solutions to the many riddling questions of flavour‐active wine yeast puzzles. By solving fundamental yeast jigsaw puzzles over a glass of wine, we might well acquire the ability to design the ultimate wine yeast genome model, thereby paving the way for further improvement of wine quality and consumer acceptance while minimising resource inputs, production costs and environmental impact.The author declares that he has no conflict of interest.


The aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options  on nurses' decision making about a deteriorating patient.An online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no‐form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures.P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments . There was no difference between the UFTO and no‐form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups.Reported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no‐form groups (The presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no‐form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care. In the United Kingdom (UK) cardiopulmonary resuscitation (CPR) is attempted for a quarter of the 285 000 patients who die in an acute hospital setting each year This last point is particularly relevant for the ‘deteriorating patient’: in the hours leading to cardiac arrest, 84% of patients show signs of physiological instability P < 0.001) in harm events  in those patients whom a DNACPR decision had been made One potential solution to ensure timely plans are in place about CPR and other medical decisions has been the introduction of overall treatment plans Although a number of studies have determined the isolated effects of the DNACPR order An online survey was developed through an iterative process with advice from an expert group consisting of a medical consultant and four specialist nurses. A case scenario was created of a 75‐year‐old lady with a newly diagnosed cancer with good functional status who developed severe sepsis. Key points in a deterioration pathway where the nurse is responsible or can influence outcome were identified Escalating Concern. Actions directed towards informing senior support of the patient's deterioration.Increasing Monitoring. Aimed at monitoring the patient's condition.Initiating Treatments. Aimed at stopping or reversing the presenting problem, sign or symptom.Comfort Measures. Actions directed at minimising discomfort from symptoms without direct attention to the underlying disease The statements addressed the following areas:The survey was pilot tested on 15 eligible nurses who were subsequently removed from the population frame. Positive feedback was received regarding readability, relevance of content and layout while several changes were made to improve clarity and language including removing two items. The time to complete the survey was reported to be approximately 10 minutes.The primary outcome measure was the sum of the nurse's believed agreement of initiating interventions. Strength of agreement was coded on an ordinal scale ranging from ‘strongly agree’ (1) to ‘strongly disagree’ (4). Approximately a quarter of the statements were worded in the negative and subsequently reversed for analysis. The secondary outcome was the sum of the nurse's 1–4 scale responses for each of the four subcategories between groups: Escalating Concerns (11 items), Increasing Monitoring (9 items), Initiating Treatments (14 items) and Comfort Measures (9 items). The variables were approximately normally distributed.post‐hoc analysis was performed to make the three possible pairwise comparisons between group means, where the variances could be assumed to be equal; Games‐Howell was used where they could not. Statistical significance was set at P < 0.05.Analysis using one‐way ANOVA was carried out to test for differences in group means where the assumption of homogeneity was met using Levene's test; Welch's adjusted F‐test was used where it was not. If a significant difference was found in group means, Tukey's honestly significant difference The responses to 41 individual statements were measured using a 1–4 category Likert Scale. The 4‐point Likert scale was combined into two scales (disagree/strongly disagree and agree/strongly agree) for ease of presentation and interpretation, and the answers presented as percentages. Demographic questions were placed at the beginning of the questionnaire.www.fluidsurvey.com).Three versions of the survey were simultaneously created: one with a DNACPR order, one with UFTO and one with no form. The UFTO Fig.  and DNACData were analysed using SPSS v21.0 . A total of 231 eligible questionnaires were received. Twenty nine missed fewer than 50% of questions; the mode of answers from other participants was used for the missing questions. A confirmatory analysis including only the 202 with complete answers was also carried out.Demographic characteristics were similar among the three groups Table . Most reEthics approval was obtained from the University of East Anglia Research Ethics Committee. Research Governance was obtained from each participating organisation.G‐Power analysis Eligible participants were band 5 and 6 nurses who had attended the Resuscitation Council (UK) Immediate Life Support course in the previous 12 months. Participants across 10 NHS Trusts were included to ensure a range of hospitals across England and Wales. The surveys were distributed via the local hospital resuscitation officer to maintain confidentiality and optimise response rate. A letter of invitation was emailed along with a link to the survey; participants were informed that the study was evaluating the effect of clinical judgement on the nursing care of a patient. No specific mention of resuscitation was mentioned to minimise response bias. Consent to participate was implicit by completion of a returned survey. The survey was completed anonymously.The resuscitation officers sent 2167 emails with links to questionnaires; we subsequently discovered many of these were not accessible to the recipients because of hospital firewalls. Because of this, it was not possible to determine an accurate response rate to the email. Four hundred forty‐six people clicked on the survey; 202 answered all questions (45% completion rate).P < 0.001). The Games‐Howell test showed the DNACPR group scores were significantly higher than the no‐form group and the UFTO group  (Table P = 0.201) between groups. Post hoc tests showed the DNACPR group was significantly different to the no‐form (P < 0.001) and the UFTO (P = 0.001) groups in the Escalating Concern and Increasing Monitoring categories. In the Initiating Treatments sub‐category, the DNACPR group was significantly different to the no‐form (P < 0.001) and the UFTO (P = 0.024) group. There were no differences observed between the UFTO and no‐form in these three subcategories aimed towards cure. Results were similar for the 202 fully completed questionnaires alone, except that the pairwise comparison of DNACPR versus UFTO was no longer significant for initiating treatment (P = 0.058) and increasing observations (P = 0.053).There were significant differences between the groups in the subcategories relating to intensity – Escalating Concern, Initiating Treatment and Increasing Monitoring  Table . In the want to start chest compressions if the patient became pulseless: over a third (38%) of the no‐form group would not want to start chest compressions when no CPR decision had been made. This rose to 58% in the UFTO group and 82% in the DNACPR group. Finally, 17% of the DNACPR group, 49% of the UFTO group and 75% of the no‐form group agreed the patient should be defibrillated if they went into a shockable cardiac arrest rhythm.The four additional items relating to CPR practices were presented separately Table . Nurses In this deteriorating patient vignette study, nurses initiated fewer interventions beyond CPR in those patients with a DNACPR order than in those with no‐form and the UFTO; these differences were not observed between the UFTO and no‐form groups. The results of this study are encouraging in that the UFTO appears to have succeeded in ensuring that the ‘do not resuscitate’ decision did not undermine other treatment decisions: the patients with UFTO were treated similarly to those with no order. The UFTO may improve the way nurses modulate their behaviours towards critically ill DNACPR patients, and more centres should consider adopting an approach where the resuscitation decisions is contextualised within overall goals of care.because they had a DNACPR order. Although DNACPR status is not intended to alter patients care in any way beyond withholding CPR, it was being interpreted to mean that other care should also be withheld. It was in part because of these studies that the UFTO was developed: to ensure a delineation between the resuscitation decision and the overall goals of care, allowing clinicians to document that a patient was for other active treatments while not being for resuscitation in the event of a cardiac arrest.Previous clinical studies had demonstrated that those with DNACPR orders received fewer interventions The experimental vignette design removes all confounders and thus provides valuable insight into the isolated effect of the UFTO compared with a DNACPR order on nurse‐led or nurse‐initiated interventions. The results show significant differences between nurses in the DNACPR group compared with nurses in the UFTO and no‐form groups: nurses carried out fewer interventions on a patient with a DNACPR order than on those patients with no‐form in the Initiate Treatments, Escalate Concern and Increase Monitoring subcategories; the UFTO group was treated analogously to the no‐form group. It would have been appropriate for this patient to be treated in compliance with the Surviving Sepsis resuscitation protocol The reasons for the differences between the DNACPR and other groups need further exploration; it is possible that DNACPR was interpreted as an indication that the patient was approaching end‐of‐life and excessive monitoring and therapies could cause excessive discomfort. In fact, around 50% of patients with DNACPR orders are discharged home, and over a third are alive at a year General nurses are an important and often neglected group when it comes to understanding patients with DNACPR status; this survey across 10 Trusts gives considerable insight into how they interpret intensity of care in a patient with DNACPR status using different forms. The participating nurses had considerable experience with DNACPR status patients, yet there was still significant misunderstanding about what the order means and how to manage deteriorating patients with such orders. Hennemen and Beach's studies were carried out 10 years ago, and it is disheartening to see so little change in attitudes, particularly because vignette studies are likely to over‐estimate what nurses would do in real life.The split results regarding the course of management for the decreasing respiratory rate in the scenario reveals uncertainty in how to actively manage deterioration in a patient with DNACPR status. The UK guidelines state ‘A DNACPR decision does not override clinical judgement in the unlikely event of a reversible cause of the person's respiratory or cardiac arrest that does not match the circumstances envisaged when that decision was made and recorded’The final set of questions – on practices closely related to, or part of CPR – did not address any of our initial aims. We included it in order to reveal misunderstandings about which elements of practice are included in ‘CPR’. Interpretation of this section has its own limitations; however, we feel it important to point out that more elements of resuscitation were carried out in the UFTO than the DNACPR group. Forty five per cent of the UFTO group said they would start chest compressions, and almost half agreed the patient should be defibrillated if the patient went into a shockable rhythm, while just under a fifth of the DNACPR order group agreed to start CPR and defibrillate the patient in the event of a cardiac arrest. These are interesting findings in light of the NCEPOD report Limitations of our study include the accuracy in determining the response rate; some hospitals had firewall protection preventing nurses accessing the questionnaire at work and several resuscitation officers reported emails had been returned. Future studies should take account of this problem when targeting NHS staff, and consider a response rate of those surveys opened, rather than all emails sent. The difficulties with vignette studies in general are the lack of further instruction and information is processed less carefully and efficiently than under real conditions The DNACPR order is still misunderstood and could be associated with nurses initiating fewer interventions. This is despite attempts over the years to address this problem, not least with lengthening the acronym from DNR (do not attempt resuscitation) to DNAR (do not attempt resuscitation) to DNACPR to improve the clarity of the instruction  Attempts at education do not seem to have had long‐term effects We, the authors, state that we do not have any financial and/or personal relationships with other people or organisations that could inappropriately influence (bias) our work.Clinical setting and history.Supporting info itemClick here for additional data file.


Functional diversity is intimately linked with community assembly processes, but its large‐scale patterns of variation are often not well understood. Here, we investigated the spatiotemporal changes in multiple trait dimensions (“trait space”) along vertical intertidal environmental stress gradients and across a landscape scale. We predicted that the range of the trait space covered by local assemblages  and the dispersion in trait abundances  should increase from high‐ to low‐intertidal elevations, due to the decreasing influence of environmental filtering. The abundance of macrobenthic algae and invertebrates was estimated at four rocky shores spanning ca. 200 km of the coast over a 36‐month period. Functional richness and dispersion were contrasted against matrix‐swap models to remove any confounding effect of species richness on functional diversity. Random‐slope models showed that functional richness and dispersion significantly increased from high‐ to low‐intertidal heights, demonstrating that under harsh environmental conditions, the assemblages comprised similar abundances of functionally similar species , while that under milder conditions, the assemblages encompassed differing abundances of functionally dissimilar species . According to the Akaike information criteria, the relationship between local environmental stress and functional richness was persistent across sites and sampling times, while functional dispersion varied significantly. Environmental filtering therefore has persistent effects on the range of trait space covered by these assemblages, but context‐dependent effects on the abundances of trait combinations within such range. Our results further suggest that natural and/or anthropogenic factors might have significant effects on the relative abundance of functional traits, despite that no trait addition or extinction is detected. We further assessed the persistence of local patterns of functional richness and dispersion over multiple sites (covering ca. 200 km) and times  in a region showing a mesoscale structure in ecological subsidies such as chlorophyll‐22.1a concentration, related to freshwater inputs and apparently to runoff from forestry and agricultural activities  were analyzed to characterize the environmental conditions in the four sampling sites. Satellite‐derived MODIS data were downloaded from http://oceancolor.gsfc.nasa.gov/. Air temperature data would have been desirable to better characterize the environmental conditions to which intertidal organisms are exposed. However, air temperature data for southeastern Pacific shores are available at too coarse resolution (1°), which would have not fitted to our study.Monthly data (2003–2014) of sea surface temperature and chlorophyll‐Jehlius cirratus and Notochthamalus scabrosus , the purple mussel Perumytilus purpuratus and the red corticated algae Mazzaella laminarioides , and large brown kelps such as Lessonia spicata, Durvillaea antarctica, and Macrocystis pyrifera . Plots were haphazardly positioned along each elevation zone, but positions were restricted to flat and gently sloping surfaces lacking deep crevices and tide pools.At each site and sampling time, we estimated species abundances on ten 0.25 m2), respectively. This same protocol has been used in several studies of benthic diversity along Chile and elsewhere  occurring on each plot were identified in situ. Organisms were classified to the lowest possible taxonomic level . For each plot, we used a 50 × 50 cm frame, divided into 25 equal fields with monofilament line, to estimate species abundances. Sessile and mobile species abundances were estimated as percentage covers (1% resolution) and densities  and FDis  according to Mason et al.  and Maso2.3Separate random‐slope mixed models were fitted to SESFRic and SESFDis in order to test our prediction. In these models, intertidal height  was included as fixed factor, and sampling site and time (nested in site) were included as random factors. In addition, the autocorrelation of errors, due to repeated measurements over time of each site, was specified as an autoregressive structure (AR1). Model diagnostics were checked by visually inspecting autocorrelation of residuals and fitted‐versus‐residual plots. We compared the second‐order Akaike information criterion corrected for small sample sizes (AICc) in order to select the more parsimonious model that accounted for the variation in SESFRic and SESFDis  to determine the trait combinations that accounted for most of the differences between intertidal heights, sites, and times. SIMPER was based on a Bray‐Curtis dissimilarity matrix. Environmental SST and Chl‐3Our sampling protocol provided representative estimations of the number of unique trait combinations  and taxonomic units . This result agrees with previously published analyses showing higher Chl‐a concentrations to the north of the region  and over more than 200 km and 36 months when the range of trait space covered by the local assemblages  was analyzed. When the relative abundances of individuals within trait combinations were incorporated in the analyses , the slopes between functional diversity and decreasing environmental stress significantly varied between sampling sites and times. Importantly, these effects were independent of the spatiotemporal variation in species richness. Suspension‐feeding planktonic developers and encrusting and foliose autotrophs were the functional traits that accounted for most of the spatiotemporal variation in abundances. Therefore, local environmental stress gradients might have persistent effects on the range of trait space covered by the local communities, but context‐dependent effects on the trait combination abundance distribution. Our results stress the relevance of analyzing multiple facets of functional diversity to understand the response of community assembly mechanisms to the environmental variability.In this study, we showed that different facets of functional diversity had differing patterns of spatiotemporal variation. A significant increase in functional diversity along the vertical intertidal stress gradient was consistent across varying environmental conditions  indicated that high‐intertidal assemblages encompassed functionally similar organisms, which were characterized by small body sizes. In general, trait convergence has been usually explained as the result of environmental filters that allow a subset of organisms with similar trait combinations to colonize and survive in patchy environments  showed significant variations between sites and between seasonal samplings. This spatiotemporal variation in functional dispersion would be the result of changing environmental conditions strong enough to influence species abundances, but not enough to produce local or temporal extinctions. The higher Chl‐Acanthina monodon; Moreno, Pyropia orbicularis, and low‐intertidal kelps, such as D. antarctica and L. spicata, are also under severe harvesting  and temporal variation in the patterns of functional dispersion along the vertical intertidal environmental gradient. Future work on this issue could help to disentangle the impact of human disturbances on the functional structure of aquatic and terrestrial communities worldwide. For instance, a trait‐based approach would allow us to assess anthropogenic impacts across biogeographic regions with different levels of taxonomic and phylogenetic diversity. The integrated analysis of different facets of functional diversity can provide useful information about the variation and potential for local extinction of functional traits that ultimately influence ecosystem functioning.None declared. Click here for additional data file.