Past and recent studies have focused on the effects of global change drivers such as species invasions on species extinction. However, as we enter the United Nations Decade of Ecosystem Restoration the aim must switch to understanding how invasive‐species management affects the persistence of the remaining species in a community. Focusing on plant‐pollinator interactions, we test how species persistence is affected by restoration via the removal of invasive plant species. Restoration had a clear positive effect on plant persistence, whereas there was no difference between across treatments for pollinator persistence in the early season, but a clear effect in late season, with higher persistence in unrestored sites. Network structure affected only pollinator persistence, while centrality had a strong positive effect on both plants and pollinators. Our results suggest a hidden effect of invasive plants—although they may compete with native plant species, invasive plants may provide important resources for pollinators, at least in the short term. As we enter the United Nations Decade of Ecosystem Restoration the aim must switch to understanding how invasive‐species management affects the persistence of the remaining species in a community. We found that restoration via the removal of invasive plant species has a clear positive effect on plant persistence, whereas for pollinators persistence was higher in unrestored sites in the late season. Our results highlight that network structure may be a useful tool in restoration studies to assess the impact of restoration practices on population dynamics and emphasize a hidden effect of invasive plants‐‐‐although they may compete with native plant species, invasive plants may provide important resources for pollinators.  We are currently undergoing an unprecedented biodiversity crisis  or maintained . For all network analyses, when the network was compartmentalised we only included species present in the largest component. Below, we present all the results for both the monthly data  and the seasonal data .We used y et al. . Brieflyy et al. . Thus, hP) and pollinators (A). We modelled changes in abundance over time for species i as:i as a function of their intrinsic growth rate (αi), interspecific competition with plant j (βij), intraspecific competition (βii) and mutualistic effects based on the interaction strengths with pollinator k (γik). The mutualistic benefit γik depends on the per capita effect of animal k on plant i. We assumed that intraspecific competition βii is stronger than interspecific competition βij to prevent species from outcompeting each other ; as a result, interaction frequency saturates when resource availability is high. The equation describing the dynamics of pollinators is the same as equation (1), but with the indices (P) and (A) exchanged.To study the population dynamics of species in each network, we used the dynamic model proposed by Bastolla et al. , composees i as:dSiPdt=α64 monthly networks (month‐level data), as well as for the early‐ and late‐season data . For all analyses presented in the main text, we limited the pollinator guild to invertebrate species (139 out of the 144 species) because of the order‐of‐magnitude differences in invertebrate and vertebrate longevity, and the model assumption that animals (pollinators) are completely dependent on plants for their survival, which may not be true for the five vertebrate species present in the original dataset (Supporting Information). However, results are qualitatively similar when vertebrates are included in the models   . Similarly, for the network‐level analyses, we calculated proportional persistence as the mean proportion of all species that persisted across all simulations runs.Following previous studies  and season‐level (N = 16) datasets, we characterised community structure using two common network‐level metrics: nestedness and modularity. We used the bipartite package  and season‐level (N = 16) network, we also calculated two centrality metrics as a measure of resource overlap and diet breadth: weighted closeness and specialisation (d’). Weighted closeness centrality measures the number of shortest paths between a focal species and every other species in the network—the closer a species is to all other species in the network, the more central a species is and thus, the larger the closeness centrality, resulting in greater resource overlap , and their interaction, and included by‐site random intercepts. We conducted separate analyses for the month‐level and season‐level data. To account for the fact that species richness and number of interactions are correlated with nestedness and modularity, we also included a quadratic fixed effect for the total number of species and a linear effect of the total number of interactions.103) in which a species persisted. We included restoration status, species centrality, and their interaction as fixed effects, as well as by‐site, by‐species, and by‐network random intercepts. We ran separate models for weighted closeness and specialisation (d’), and separate analyses for the month‐level and season‐level data. Below we report both results separately.Finally, to test the effect of centrality on species persistence, we fitted a linear mixed‐effects model with a binomial error distribution to the number of iterations , and this effect was stronger in late season , with plant persistence in restored sites being more than double that of unrestored sites  and in unrestored sites , with a significant effect in late season  and modularity . For plants, we found no effect of network structure on persistence . In contrast, for pollinators, increases in nestedness resulted in greater pollinator persistence  and pollinators .In addition to exploring persistence at the network‐level, we also investigated whether species that are more central in their interaction networks have greater persistence than more peripheral species, and whether there is a difference between restoration treatments. Here, we focus on the effect of weighted closeness, but we found similar results for specialisation . For the month‐level data, we found that centrality had a clear, positive effect on the persistence of both plants (unrestored sites the late season. Moreover, pollinator persistence was more closely dependent on nestedness and modularity in restored sites than in unrestored sites, suggesting the existence of a link between the consequences of network structure and restoration status. Finally, at the species level, we found that more central species—both plants and pollinators—had a higher persistence on both restored and unrestored sites and that this effect was stronger in restored sites. We expand on each of these findings in the paragraphs below.Elucidating the interplay between ecological interactions and global change drivers such as the presence of invasive species is critical for anticipating how ecosystems respond to novel environmental scenarios (Blois et al., Cinnamomum verum, is known to have long flowering seasons (from November until March; Azad et al., We expected that restoration via the removal of invasive plant species would benefit the native plants due to competition release. As expected, we found a clear positive effect of restoration status in plant persistence, especially in the late season, with plants in restored sites having greater persistence. Originally, Kaiser‐Bunbury et al.  found thAnother potential explanation for greater pollinator persistence in unrestored sites may lie in the long‐term response of native species in the restored areas. In a similar restoration experiment, Heleno et al.  found thWe also explored whether there was an effect of community structure on the persistence of plants and pollinators. For the season‐level data, we found no clear effect of network structure and persistence of either plants or pollinators. However, this is unsurprising given that analysing networks at finer temporal scales better identify nuances in network properties (CaraDonna & Waser, In addition to looking at species persistence from the perspective of the whole community structure, we also explored whether the position of specific species in their networks could be related to their persistence. In an experimental approach using centrality in restoration practices, Maia et al.  found thIn this work, we explored the effects of community structure on species persistence after restoration. Although we acknowledge that neutral‐processes play a role in the observed changes in species persistence, recent empirical work in other systems has demonstrated the importance of niche‐based processes in determining biotic interactions. In a seed‐dispersal network study in the highly invaded Oahu Island in Hawaii, Vizentin‐Bugoni et al.  showed tThe ultimate success of restoration strategies is the persistence of wild populations (Miller et al., MPG and JB designed the study. MPG collected data, performed analyses, and prepared the figures, with input from JB. MPG wrote the manuscript and JB contributed to revisions.Supporting information S1Click here for additional data file.


Optimized diagnostic algorithms to detect active infections are crucial to achieving HCV elimination. We evaluated the cost effectiveness and sustainability of different algorithms for HCV active infection diagnosis, in a context of a high endemic country for HCV infection.A Markov disease progression model, simulating six diagnostic algorithms in the birth cohort 1969‐1989 over a 10‐year horizon from a healthcare perspective was used. Conventionally diagnosis of active HCV infection is through detection of antibodies (HCV‐Ab) detection followed by HCV‐RNA or HCV core antigen (HCV‐Ag) confirmatory testing either on a second sample or by same sample reflex testing. The undiagnosed and unconfirmed rates were evaluated by assays false negative estimates and each algorithm patients’ drop‐off. Age, liver disease stages distribution, liver disease stage costs, treatment effectiveness and costs were used to evaluate the quality‐adjusted life‐years (QALYs) and the incremental cost‐effectiveness ratios (ICER).The reference option was Rapid HCV‐Ab followed by second sample HCV‐Ag testing which produced the lowest QALYs . The highest gains in health  was obtained by HCV‐RNA reflex testing which produced a high cost‐effective ICER (€891/QALY). Reflex testing (same sample‐single visit) vs two patients’ visits algorithms, yielded the highest QALYs and high cost‐effective ICERs , confirmed in 99.9% of the 5,000 probabilistic simulations.Our data confirm, by a cost effectiveness point of view, the EASL and WHO clinical practice guidelines recommending HCV reflex testing as most cost effective diagnostic option vs other diagnostic pathways. AbAntibodies‐AgAntigenCEACcost‐effectiveness acceptability curveDAAsDirect Acting AntiviralsDSAdeterministic sensitivity analysesFFibrosis stageHCVHepatitis C virusHCV‐AgHCV core antigenICERincremental cost‐effectiveness ratioMIN–MAXMinimum‐MaximumPSAprobabilistic sensitivity analysesQALYquality‐adjusted life‐yearsRNARibonucleic AcidSoCStandard of CareWHOWorld Health OrganizationWTPwillingness‐to‐payHepatitis C virus (HCV) is a leading cause of liver‐related morbidity and mortality worldwide. The limitation of HCV therapy is the identification of available patients to treat because chronic infection often remains asymptomatic thus undiagnosed. The data reported in this study are of importance in that they demonstrate the value for money profiles of several diagnostic algorithms used for HCV screening in the general population. In this study, the most effective diagnostic algorithm for HCV screening in terms of value for money spent was reflex testing, which is confirmatory testing of possible infection is done on the sample blood sample not requiring a second patient visit to healthcare. Based on these results, reflex testing should become the standard of care for HCV screening in each epidemiological peculiarities of HCV infection in that it can support increases in diagnosis and subsequent treatment of infected patients necessary for achieving elimination.1Chronic viral hepatitis C is a major public health problem. Achieving the WHO’s Global Health Sector Strategy (GHSS) goals for the elimination of Hepatitis C virus (HCV) by 2030 has reinvigorated public health initiatives aimed at identifying patients with HCV related disease.“Milleproroghe Decree”, through an amendment approved in March 2020, has allocated €71.5 million for the period 2020‐2022 to introduce free‐of‐charge screening for the general population born between 1969 and 1989, as well as all individuals at public specialist facilities for drug addiction and prisons. Although the screening budget has been established, optimisation along the entire patient pathway is necessary to achieve elimination by 2030.Italy is one of the countries with the greatest burden of HCV in Western Europe.The aim of this study was to evaluate the cost‐effectiveness of different diagnostic algorithms for active HCV infection including conventional two steps algorithms and same sample reflex testing (single step) combined with modelling treatment impacts and disease progression in order to provide for a complete overview of diagnostic costs and benefits.2The primary outcome measure of screening effectiveness was the number of active infections diagnosed. An adapted multicohort Markov model Figure  capturinWe compared strategies in terms of the total costs of screening according to each diagnostic algorithm and treatment costs of active HCV infection vs the disease costs of those not diagnosed over time. We considered the Italian general population birth cohort (1969‐1989) screening.The model inputs are shown in Tables 2.1Active infection is defined as the presence of markers of viral replication in chronic infection state.‘Reflex testing’ means that HCV‐RNA of HCV‐Ag is performed on the same serological specimen with a positive anti‐HCV finding. If the reflex test is positive, an active HCV infection is diagnosed and the patient will be referred for disease staging and treatment.“Undiagnosed” cases were defined as having active HCV infection but with HCV‐Ab false negative results, or false negative confirmation test following an anti‐HCV positive test result.“Unconfirmed” active infection was defined as HCV‐Ab positive without confirmation of active infection.In both undiagnosed and unconfirmed groups, individuals with active infection will not be linked to care following the first HCV‐Ab test Figure .The model starts with a decision probabilistic tree that simulates HCV testing in the general population cohort born between years 1969‐1989 with a coverage rate of 70% . This first part of the model identified, categorized and evaluated all patients with an active HCV infection that could be potentially diagnosed by each screening option. Each strategy in the decision tree considers the detection of HCV antibodies (HCV‐Ab) results and in case of positive test the confirmation of active infection through HCV‐RNA or HCV core antigen (HCV‐Ag) testing either by conventional two steps or reflex testing (single step). We have considered the following definitions:In the simulations, we considered six alternative diagnostic algorithms (1a to 3b) for diagnosis of active HCV infection. In each scenario, the initial screening is performed through an assay for HCV‐Ab, either rapid or laboratory (phlebotomy) based, followed by confirmation through HCV‐RNA or HCV‐Ag testing (laboratory based). Four of these scenarios require two visits for confirmation of active HCV infection with subsequent patient referral, while the remaining two require only one visit Figure . Based o2.2Table Disease progression depends on the linkage to care probabilitiesIndividuals with undiagnosed or unconfirmed infection were considered as not being linked to care. Therefore, these individuals were assumed to either progress according to the natural history of disease until 2030 or diagnosed because of complications of cirrhosis (1 year later for F4 fibrosis stage and 4 years later for F3 fibrosis stage that progress to cirrhosis). Unconfirmed and undiagnosed F0‐F2 fibrosis also progress according to the natural history of the disease until the year 2030. After these periods, the model assumes that all patients were diagnosed and treated. For unscreened individuals, the model assumes progression according to the natural disease history.2.3The model assumes a fibrosis distribution for the diagnosed patients through screening as it is reported in our previous studies, based on infection and disease burdens for yet to be treated patients.2.4The efficacy of second‐generation DAA regimens used in the Markov Model, was considered 98%2.5The decision tree model considers only the unit price related to the first‐line test (HCV‐Ab), the cost of administration of the first‐line test and the tariff associated with the second line tests Table .Direct healthcare costs were those associated with DAAs and the management of HCV‐related diseases. The average and range of costs (MIN–MAX) of HCV‐related liver disease were derived from the literature Table .12, 22.6Health outcomes were expressed in terms of quality‐adjusted life‐years (QALYs) incorporating mortality and morbidity associated with a particular health state. Utilities were associated with each health state and a full health condition was assumed for undiagnosed individuals. The model considers in the base‐case the same utilities previously reported and used in our modelling studies on HCV treatment Table .21QALY2.7Strategies were compared using incremental cost‐effectiveness ratios (ICERs), calculated as the additional cost divided by the additional health benefit of the alternative with lower QALYs or compared with the Standard of Care (SoC) Other direct costs Health status utilitiesWe performed deterministic sensitivity analyses (DSA) to identify parameters with the greatest impact on cost‐effectiveness. We considered one‐way variations Table  and 2 anProbabilistic Sensitivity Analysis (PSA) was performed considering a gamma distribution for costs and beta distribution for epidemiological parameters.3The screening costs for different options evaluated varied from €60.5 million to €66.2 million with higher costs in algorithms that contain HCV‐RNA test for confirmation vs the HCV‐Ag Table . An incrThe comparison of cost effectiveness results is based considering as reference the option which produce the lowest QALYs. As shown in Table All ICERs estimated are far below the WTP threshold. The lowest ICER is estimated for the HCV‐Ag reflex testing, however, in a range of cost effective options  the best option is given by the HCV‐RNA reflex testing in that it produces the highest QALYs 974,458) or the highest incremental QALYs  vs the reference (1b) option which is the least effective option. Comparing reflex vs two steps diagnostic algorithms a persistent increase in QALYs with a very low ICERs varying from €566‐635 per QALYs is estimated  compared to two step testing strategies within a 10 year time horizon (up to 2030).Importantly these results suggest that despite the highest screening cost, HCV‐RNA reflex is the most cost effective strategy. Our findings suggest that the reflex testing should become the standard of care for the diagnosis of active HCV infection in both public and private laboratories. From a public health perspective, the real‐world utility of HCV reflex testing at population level is also demonstrated in a recent cost‐effectiveness analysis on routine universal HCV screening in urban emergency departments in England.In Italy, based on WHO and EASL recommendations reflex testing is already explicitly included in the recommendations of Italian Ministry of Health free of charge screening law decree.Our study has been tailored to the Italian context but the reflex testing strategies in detecting the active infection has proven effective also in other countries.Within the two reflex testing strategies the use of HCV‐Ag assay is not widespread in Italy, however, we feel that its inclusion in our cost‐effectiveness analysis is justified for completeness, especially as our findings suggest that reflex testing with HCV‐Ag compared to conventional two step testing could prove useful for high volume screening in countries where HCV‐RNA testing is not available or affordable.In some settings HCV‐Ab point of care testing has been shown to reduce time between the initial observation and treatment administration.Health state utilities, costs of screening tests and direct medical costs had the highest impact on the ICER of reflex testing compared to the (two step) SoC. However, the highest ICER (resulting from the lowest reported utilities) was less than €800/QALY, far lower than the WTP threshold. Based on the simultaneous variations of the parameters evaluated by the PSA analysis, reflex testing although more expensive than the two steps testing, remained highly cost effective in 99.9% of the scenarios and dominant in 5%, which indicates less costs sustained and higher efficacy for reflex vs the two step SoC diagnostic algorithm.The strength of our study is that using a specifically designed Markov model of liver disease progression enables the evaluation of the relative costs of screening, treatment and overall disease costs, which change according to the proportion of undiagnosed patients assumed, based on data from real life studies.The first and main limitation of this study is the assumption for drop‐off rate for each scenario. Reports are scarce, therefore in the absence of Italian data we had to extrapolate from recent estimates reported in the literature.These screening algorithms are suggested only for general population unaware of chronic HCV infection. As the frequency of acute infection in general population without apparent risk factors is likely very low at population level in Italy and other developed countries, we did not consider diagnosis of acute infection in this evaluation. Different diagnostic algorithms should also be evaluated for marginalized populations.In conclusion, our findings suggest same sample reflex testing, using either HCV‐RNA or HCV‐Ag, is the most cost effective diagnostic algorithm for countries wanting to embark on high volume HCV testing. Our data confirm the EASL and WHO guidelines recommending reflex testing as best practice in identifying HCV active infection in general population as compared to the other screening approaches. In line with the Italian Ministry of Health HCV screening recommendation, reflex testing should be adopted by the regional Italian health authorities as standard of care for the HCV diagnostic pathway.Andrea Marcellusi has nothing to disclose; Francesco S. Mennini received advisor/speaker/research grants from Abbvie, MSD, Gilead, BMS; Maurizia R Brunetto received advisor/Speaker grants from AbbVie, Gilead, Janssen, Roche, EISAI‐MSD and is Coordinator of the control room for the application of the Resolution n.397 April 2018 of the Tuscany Government for the control of chronic hepatitis C; Loreta A. Kondili received Speaker grants from Abbvie and Gilead. Murad Ruf is an employee of Gilead. Claudio Galli is employed by and owns stocks from Abbott.The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.Supplementary MaterialClick here for additional data file.


Similar to persister bacterial cells that survive antibiotic treatments, some cancer cells can evade drug treatments. This Commentary discusses the different classes of persister cells and their implications for developing more efficient cancer treatments. Similar to persister bacterial cells that survive antibiotic treatments, small populations of cancer cells can evade drug treatments and cause recurrent disease. This Commentary discusses the different classes of persister cells and their implications for developing more efficient cancer treatments.et al, In 1944, Joseph Bigger, a lieutenant‐colonel in the British Royal Army Medical Corps, reported a peculiar population of bacteria that could survive very high concentrations of penicillin (Bigger, So why can some bacteria persist in the face of therapy? The answer largely lays in the mode of action of antimicrobial drugs. Penicillin and newer generation antibiotics target bacterial cell division. As such, if the bacteria are dormant or reside in a low metabolic state, they are unafflicted by the drug. Dormant bacteria are frequently resistant to multiple stressors and drugs making them difficult to eradicate even with a very aggressive treatment. Unsurprisingly, similar phenomena are observed in the context of chemotherapy treatments in cancer. Like antibiotics, early cancer therapies were largely based on drugs that target highly proliferative cells. Sustained proliferation in the absence of external stimuli is one of the hallmarks of cancer. Because cancer cells divide more frequently than most normal cells, they are more likely to be killed by chemotherapy treatment. As both antibiotics and chemotherapy treatments target proliferating cells, it is not surprising that cell dormancy was linked to cell persistence in both cases. “Classical” nondividing persister cells have been implicated in treatment failure both in cancer and in microbial infections and are thought to provide a reservoir for subsequent relapse events.per se but rather act on specific molecular targets associated with cancer. For example, some targeted therapies target proteins that are more abundant on the surface of cancer cells compared with that of normal cells. While slow proliferation has also been implicated in tolerance in the context of targeted therapy, multiple additional mechanisms are at play, which are not characteristic of microbial persister cells. For instance, oncogene‐targeted therapies are taking advantage of the acquired dependence of a cancer cell on the activity of a single oncogenic gene product. As many oncogenes control cell metabolism (Levine & Puzio‐Kuter, et al, et al, In the last 20 years, a new class of cancer drugs, called targeted therapies, have emerged and revolutionized patient care. Unlike chemotherapies or antibiotics, these drugs do not target proliferating cell et al, et al, in vivo may allow cancer cells to modulate the cytotoxic T cell in a way that would favor their persistence. Hence, understanding what underlies T‐cell phenotypes might as be as important as studying the cancer persister cells they are targeting.The most recent addition to the cancer‐fighting arsenal are immunotherapies designed to boost immune responses. Immune‐persisters, cells that can evade immune response, have been reported in multiple cancer types and are thought to underlie the late relapse frequently observed in patients (Shen et al, The holy grail of the persister filed is finding ways to target these drug‐tolerant cells in a manner that would prevent disease recurrence. However, given at least three classes of persisters have been already reported, and more are expected to arise as we continue to expand our therapeutic toolbox, would it even be possible to implement a single approach to eliminate them? Studies that searched for a magic bullet that could eliminate persister cells were largely based on the hope that persister cells would be less heterogenous than the drug‐naïve cell population they were derived from (Cabanos & Hata, The author declare that she has no conflict of interest.


To determine whether occlusal maintenance and reconstruction by dental intervention is associated with the prognosis of older home‐care patients.The study participants were 289 older home‐care patients  who received visiting dental treatment from dental clinics in the region between 2012 and 2018. The participants were followed up for 1000 days after receiving the necessary dental treatment in a home‐visit setting. The participants were divided into three groups: those with natural tooth occlusion, those whose molar occlusion was maintained or reconstructed by dentures, and those whose occlusion was not reconstructed. Factors associated with prognosis were determined using the Cox proportional hazard model, with occlusal status, comorbidities, the activity of daily living, and residence status as explanatory variables.In the overall population, occlusal status  and age  were identified as significant factors.In the group of participants aged <85 years, only occlusal status  was a significant factor. In the group of participants aged ≥85 years, occlusal status was not significantly associated with prognosis.Geriatr Gerontol Int 2022; 22: 976–981.The maintenance and acquisition of occlusal support achieved by dental treatment contribute to improved prognosis in older patients younger than 85 years requiring home nursing care.  Maintenance of the remaining number of teeth leads to the maintenance of occlusal support and healthy oral function.Continuous dental treatment has been shown to be effective in maintaining physical function in community‐dwelling older individuals.The objective of this study was to investigate the association of the acquisition or maintenance of occlusal support achieved by dental intervention with prognosis in older home‐care patients and to determine whether occlusal maintenance or reconstruction achieved by dental intervention contributes to improved prognosis in these patients.Figure Data on the status of occlusal support after the necessary dental treatment were used to evaluate occlusal support. For participants who had lost occlusal support before the intervention, dentures were fabricated to restore occlusion. In participants requiring tooth extraction owing to severe periodontal disease, severe caries, or other problems, tooth extraction was followed by the fabrication of dentures with the aim of restoring occlusal support. For those who used dentures that were incompatible, denture adjustment was performed or new dentures were made so that these individuals could continuously use dentures. Subsequently, visiting dental treatment was continuously provided at monthly intervals.The first day of follow‐up was the day of the first visit for participants with natural tooth occlusion, and at 3 months after the completion of denture fabrication for those who did not have natural tooth occlusion and for those for whom the fabrication of a new denture was considered necessary owing to denture incompatibility.Sex and age at the start of follow‐up were recorded. Activities of daily living (ADL) were evaluated using the Japanese Bedriddenness Rank (BR).Comorbidities were evaluated according to the Charlson Risk Index, with a score of 0 indicating low risk, a score of 1 or 2 indicating medium risk, a score of 3 or 4 indicating high risk, and a score of 5 indicating very high risk.Occlusal support zones  in the left and right premolar/molar regions were evaluated using the Eichner classification.Participants who were hospitalized or died during the follow‐up period were considered to have a poor prognosis, except for those who could not be followed because of withdrawal owing to deconditioning or admission to nursing care facilities. Participants who continued to receive dental treatment beyond the follow‐up period were considered to have a good prognosis.The sample size was calculated using G*Power 3.1.9.2 Statistical Power Analyses , with a type I error of 0.05, a type II error of 0.2, and an effect size of the medium. Assuming that 30% of patients would stop receiving dental treatment owing to hospitalization or death during 1 year (based on unpublished data), it was estimated that at least 217 patients would be required.The participants were followed up for up to 1000 days. Associations between the maintenance/restoration of occlusal support with natural teeth or dentures, each factor, and prognosis were examined using the chi‐square test and Cox proportional hazard model. Owing to an anticipated age effect, participants were divided into two age groups (<85 and ≥ 85 years) for comparison. All statistical analyses were performed using the IBM SPSS Ver. 23 for Windows.A total of 49 participants  were lost to follow‐up owing to admission to nursing care facilities during the follow‐up period, leaving 240 participants  included in the final analysis  and residential status (p = 0.024).Table p = 0.033), where the hazard ratio (HR) of those with occlusal disintegration versus those with natural tooth occlusion was 2.12 . A significant association was also found for age group, with an HR of 2.28 .Table p = 0.032), with the HR of those with occlusal disintegration versus those with natural tooth occlusion being 3.41 . In contrast, no significant effect of occlusal status was observed in the denture maintenance and restoration group .Among those aged <85 years, 31 participants had poor prognosis. A Cox proportional hazard model analysis showed a significant association for occlusal status (Among those aged ≥85 years, 65 had poor prognosis. A Cox proportional hazard model analysis showed no significant association between the occlusal status and prognosis.This study is the first to demonstrate that the maintenance and reconstruction of occlusal support achieved by dental intervention are associated with prognosis in older patients requiring home nursing care. The results of this study revealed that the maintenance of occlusal support affects the prognosis of older patients in need of nursing care. Especially in patients younger than 85 years, the maintenance and restoration of occlusal support with dentures achieved by prosthodontic treatment had a positive effect on prognosis.et al. showed a significant difference in survival prognosis between those without occlusal support who did not use dentures and those who did use dentures.et al. examined the effect on survival prognosis of not only the number of remaining teeth, but also the number of functional teeth, including prostheses and implants, and found that the survival prognosis improved with an increasing number of teeth.Denture fabrication is performed to restore occlusal support in patients with collapsed occlusal support. If the area of occlusal support including dentures is associated with the prognosis of older home‐care patients, it will be possible to emphasize the effectiveness of prosthodontic treatment and regular oral management provided in a home‐visit setting. Only a few studies have evaluated and demonstrated the association between the reconstruction of occlusal support with dentures and survival prognosis. Among studies involving community‐dwelling older adults, a follow‐up study of randomly selected community‐dwelling older individuals conducted by Yoshida et al. reported that prosthodontic treatments can improve nutritional status in institutionalized older people.The results of the present study demonstrated that the presence of occlusal support and the maintenance/acquisition of occlusion achieved by visiting dental treatment had a positive effect on prognosis. The maintenance of occlusal support is known to be important for the preservation of swallowing function.et al. demonstrated that among older patients requiring nursing care, the presence of occlusal support was associated with prognosis in those with relatively preserved ADL, while nutritional status was associated with prognosis in those with impaired ADL.The present study showed differences in some results between participants aged <85 years and those aged ≥85 years. Suzuki et al. found that cognitive decline affected patients' ability to use dentures.This study has several limitations. First, it remains unclear how occlusal support and the acquisition of occlusion achieved by denture use affected prognosis. A significant association has been demonstrated between denture use and independence in oral hygiene behavior.The maintenance and acquisition of occlusal support achieved by dental treatment are associated with prognosis in older patients requiring home nursing care. Dental treatment provided in a home‐visit setting contributes to improved prognosis in older patients younger than 85 years requiring nursing care.Takeshi Kikutani, Noriaki Takahashi, Takashi Tohara, Hiroyasu Furuya, Kumi Tanaka, Kimiko Hobo, Tomoko Isoda and Tomoko Fukui were involved in study design and data interpretation. Takeshi Kikutani and Kumi Tanaka were involved in the data analysis. All authors critically revised the report, commented on drafts of the manuscript, and approved the final report.The authors have no conflicts of interest to declare.The data are not publicly available due to privacy or ethical restrictions.


Azadirachta, Callophyllum, Madhuca, Moringa, Pongamia, Ricinus, and Simarouba, which are not being used for eating but are otherwise high yielding (ranging from 1.5 to 20 tons per hectare) with seeds having a high oil content (40–60%). Additionally, understanding the toxin biosynthesis in Ricinus and Simarouba would be useful in developing toxin‐free oil plants. Realization of the importance of cell cultures as “oil factories” is not too far into the future and would soon be a commercially viable option for producing oils in vitro, round the clock.There are three pathways for triacylglycerol (TAG) biosynthesis: De novo TAG biosynthesis, phosphatidylcholine‐derived biosynthesis, and cytosolic TAG biosynthesis. Variability in fatty acid composition is mainly associated with phosphatidylcholine‐derived TAG pathway. Mobilization of TAG‐formed through cytosolic pathway into lipid droplets is yet unknown. There are multiple regulatory checkpoints starting from acetyl‐CoA carboxylase to the lipid droplet biogenesis in TAG biosynthesis. Although a primary metabolism, only a few species synthesize oil in seeds for storage, and less than 10 species are commercially exploited. To meet out the growing demand for oil, diversifying into newer sources is the only choice left. The present review highlights the potential strategies targeting species like  Newer alternative sources like cell cultures and high yielding (nonedible) species with high oil content are commercially viable targets to engineer in producing edible‐grade oil using the omics tool. ACCaseacetyl‐CoA carboxylaseDGATdiacylglycerol acyltransferaseLDlipid dropletPCphosphatidylcholineWRIwrinkled1Seeds are sink tissues containing nutritional reserves such as carbohydrates (as starch or hemicellulose), proteins, and fats or oils (in different proportions). They are utilized during the germination process for initial establishment and growth of a plant. Of the three types of reserves, carbon density of fats and oils are nearly double when compared with carbohydrates Lüttge, . Due to Plant oils or vegetable oils are energy‐rich long chain hydrocarbons and provide maximal calorie equivalents compared with carbohydrates or proteins. There is an upsurge in the demand for vegetable oils due to their both edible and nonedible applications including biofuel and other industrial applications that have caused increase in prices of vegetable oils . Their oils contribute to 60–80% of the seeds' dry weight  and PC‐derived (acyl‐CoA‐independent), both accomplishing in the plastid and the ER, a third route (acyl‐CoA‐dependent) in the cytosol is reported  to FA, and also in the steps between FA and TAG formation  for the conversion of DAG to TAG , Leafy cotyledon (LEC1 and 2), abscisic acid insensitive (ABI3) are known to regulate TAG biosynthesis  the de novo TAG biosynthesis. However, when regulated through ACCase , stearic (18:0), oleic (18:1), linoleic (18:2), and linolenic (18:3) are the most common ones constituting more than 90% of the acyl chains found in the TAG and membrane lipids , Sterculiaceae , Bignoniaceae (Cuspidaria pterocarpa), Malvaceae (Hybiscus syriacus), Santalaceae (Acanthosyris spinescens), and Sapindaceae (Euphoria longans) are reported to contain odd number of carbon atoms (C13 to C31) in the FAs  is one of the promising nonedible oilseed crops with nearly 50% oil content by weight of the seed  is another promising source for oil with 60–70% oil content  if we could succeed in modifying the desired plant using genetic engineering technologies. Reports indicate the possibility of overcoming the post‐translational regulation issues through using a set of key TAG biosynthetic genes than a single desired gene , different set of strategies are required.There are more than 20 species available as the sources for edible oilseeds Table . HoweverAlthough a few of the toxins present in the seeds do not get extracted along with the oil during the extraction process, they will still be present in the seed meal in higher concentrations (30–60% depending on the oil content). This requires scientific interventions to develop methods that would neutralize or detoxify the toxic components for further utilization. To overcome, the available and affordable breeding or biotechnological tools could potentially be used to develop plants that are free from toxicity  in the cytosol, for the cytosol derived TAG, require scientific insights.Understanding the gene regulatory networks in plants that produce oil in the endosperm (Reynolds et al., The authors declare no conflict of interest associated with the work described in this manuscript.Table S1. Genes and transcription factors of TAG biosynthesis identified in plant species.Click here for additional data file.


A 9‐week‐old male intact Cavalier King Charles Spaniel was presented for evaluation of acute onset dyspnea caused by left‐sided pneumothorax. Thoracic computed tomography (CT) identified multiple pulmonary bullae and blebs in multiple lung lobes. Rupture of ≥1 pulmonary blebs or bullae, precipitated by low impact trauma, was the suspected cause of pneumothorax. A volume of 7.5 mL/kg of fresh whole blood was collected from a type‐matched donor dog and administered into the left pleural space using a thoracostomy tube. The pneumothorax was successfully resolved and no adverse effects of blood patch pleurodesis were noted. The dog was clinically normal 12 months later. CTcomputed tomographyELISAenzyme‐linked immunosorbent assayRIreference intervalSpO2peripheral capillary oxygen saturation1A 9‐week‐old male intact Cavalier King Charles Spaniel was presented to University College Dublin Veterinary Hospital for evaluation and management of acute onset of dyspnea. The dog had been in the owner's possession for 2 weeks and had no previous relevant medical history except for a fall from a chair 2 days before presentation. On physical examination, the dog was tachypneic, with a respiratory rate of 56 breaths per minute, and had a restrictive breathing pattern. Auscultation of the left hemithorax identified decreased lung sounds dorsally and increased bronchovesicular lung sounds ventrally. Auscultation of the right hemithorax and heart were normal. Body condition score was 4/9. The remainder of the physical examination was unremarkable.2, 53 mm Hg; [RI] 30‐43). Peripheral capillary oxygen saturation (SpO2) was 93%. Complete blood count and serum biochemistry indicated no clinically relevant abnormalities. Serum  and fecal tests (modified Baermann) were negative for Angiostrongylus vasorum.Thoracic‐focused assessment by ultrasonography identified absence of a glide sign in the left hemithorax, consistent with free gas in the pleural space. A volume of 120 mL of air was aspirated from the left pleural space by ultrasound‐guided thoracocentesis, confirming the presence of a left‐sided pneumothorax. Venous blood gas analysis identified a mild respiratory acidosis attributed to hypoventilation  of the thorax was performed under sedation . A moderate amount of pleural free air was seen in the dorsal left hemithorax, and a smaller amount was present in the right cranial hemithorax extending medially and mimicking pneumomediastinum. Several well‐defined structures of irregular shape and central gas attenuation consistent with pulmonary bullae were scattered throughout the mid‐caudal lung fields bilaterally. Dimensions of the bullae ranged from 2 to 6.5 mm; the largest bullae were located ventral to the caudal vena cava. Many of the smallest gas‐attenuating foci were located peripherally in a subpleural position, suggestive of pulmonary blebs. All of the bullae had well‐defined surrounding rims of soft tissue attenuation. At least 3 of the bullae in the ventral left caudal lung lobe were surrounded by areas of pulmonary parenchyma with increased attenuation consistent with focal alveolar infiltrate, suggestive of either consolidation or contusion. Similar lesions also were seen in other sections of both the left and right lung lobes  was placed in the 8th intercostal space in the left dorsal hemithorax. A single dorsoventral thoracic radiograph confirmed appropriate thoracostomy tube placement Figure . Repeat 2We describe the occurrence of pneumothorax in a young dog with multiple pulmonary bullae and blebs. Pulmonary blebs are defined as accumulations of air within the layers of the visceral pleura, whereas pulmonary bullae are air‐filled spaces within the lung parenchyma that can result from destruction, dilatation and confluence of adjacent alveoli.Angiostrongylus vasorum infection.Angiostrongylus vasorum were negative in this dog, the possibility of occult angiostrongylosis cannot be excluded.Blastomyces dermatidis,Paragnonimus spp.,Dirofilaria immitis.Bulla or bleb rupture, and subsequent leakage of air from the alveoli into the pleural space, is the most commonly identified cause of spontaneous pneumothorax in dogsIn human medicine, spontaneous pneumothorax associated with rupture of pulmonary blebs and bullae is reported rarely in children, with an increased incidence in males compared to females (4 : 1) and in individuals with low body mass index and in those with aesthenic features.Treatment options for management of pneumothorax associated with ruptured bullae or blebs include conservative management with placement of a thoracostomy tube and repeated thoracocentesis or continuous suction, blood patch pleurodesis, or surgical thoracotomy for identification and removal of the lung lobe from which air leakage has occurred.Blood patch pleurodesis for management of pneumothorax is believed to work by the mechanical action of coagulated blood adhering to the site of air leakage. In addition, the inflammation and fibrinous pleuritis that results from the presence of coagulated blood in the pleural space promotes the formation of adhesions and, eventually, pleurodesis.Authors declare no conflict of interest.Authors declare no off‐label use of antimicrobials.Authors declare no IACUC or other approval was needed.Authors declare human ethics approval was not needed for this study.


All five studies found that reduced muscle mass determined by computed tomography, dual‐energy X‐ray absorptiometry, and bioelectrical impedance analysis was associated with increased mortality in men. Of these, two studies identified a corresponding relationship in women; reduced muscle mass defined by computed tomography was associated with increased mortality , while increasing muscle mass by bioelectrical impedance analysis likewise conferred a survival benefit . Only one study assessed the relationship of muscle function with sex‐stratified mortality , concluding that reduced muscle function predicted mortality in both men and women . Reduced muscle mass in cirrhosis is consistently associated with mortality in men, but lack of sex‐stratification of mortality analyses limits the ability to make strong conclusions about the impact of sarcopenia specifically in women, with even fewer data available for analysing muscle function. Improved understanding of the sex‐specific impacts of sarcopenia may help address patient deterioration and mortality while awaiting liver transplantation and allow for early intervention to mitigate mortality risk. Large, multicentre studies with adequate female participation and sex‐stratified mortality analyses are warranted.Sarcopenia is an increasingly recognized complication of cirrhosis that is associated with morbidity and mortality. Differences in the prevalence and prognosis of sarcopenia between men and women have been reported in other patient groups, but there is insufficient understanding of how sex impacts the prognostic value of sarcopenia in cirrhosis. A search of MEDLINE and Embase was conducted from earliest entries to April 2021. Studies were included if they examined sex‐stratified mortality impact of reduced muscle function or mass in outpatient populations with cirrhosis. We identified 700 studies of which 6 were deemed relevant for inclusion in this narrative review. Studies of interest were heterogeneous, precluding pooling of data and making interpretation of the literature challenging. Muscle mass was assessed in five studies ( Cirrhosis is a global disease with significant morbidity and mortality. Over 1.3 million deaths resulted from cirrhosis in 2017, accounting for 2.4% of deaths worldwide.Expert consensus from the European Working Group on Sarcopenia in Older People currently requires evidence of impaired muscle function to make a presumptive diagnosis of sarcopenia before confirming either low muscle mass or low muscle quality.While sarcopenia has been validated as a prognostic marker in cirrhosis, few studies directly address the influence that sex may have on muscle parameters beyond the intermittent use of sex‐specific definitions of reduced muscle function, mass, or quality. Studies are almost invariably performed in male‐dominated cohorts, which is problematic as results cannot be generalized because muscle homeostasis is known to be under the control of multiple factors, some of which are sex specific.This review examines the current literature to understand the relationship between sex and the prognostic significance of sarcopenia in cirrhosis.AppendixA comprehensive MEDLINE and Embase electronic database search was performed from earliest entries to April 2021 using the search terms including ‘cirrhosis’, ‘liver fibrosis’, and ‘liver failure’ with ‘frailty’, ‘sarcopenia’, and ‘muscular atrophy’, as well as ‘mortality’, ‘prognosis’, ‘survival’, and ‘death’. Medical Subject Headings, Boolean operators, and truncations were also utilized throughout the strategy  based on title and abstract highlighted 45 citations that remained of interest. Ten papers were excluded following a review of full text, leaving 35 studies that used a sex‐stratified diagnosis of sarcopenia. A further 29 were excluded due to lack of sex‐specific mortality analyses; thus, 6 studies of interest were included in this review  of whom were men and 1414 (36%) of whom were women. Most studies were conducted in North America, which also contributed the largest patient cohort. Patients awaiting transplantation predominated the populations of included studies. Liver disease aetiology differed with sex and location of the study. Time to follow‐up across the studies ranged from 8.8 months to 3.2 years.n = 2566, 1730 men, 836 women) that took a sex‐stratified approach to mortality assessment  assessed the impact of muscle function on mortality in both sexes  score is the most widely applied prognostic tool in hepatology. Despite its utility, evidence suggests that the MELD score may disadvantage women during prioritization.Despite varying diagnostic definitions of sarcopenia appearing in the literature, sarcopenia has been repeatedly associated with mortality in patients with cirrhosis. This review examined the sex‐specific impact of sarcopenia on mortality and found that although reduced muscle mass is invariably associated with increased mortality in men, results for women are conflicting. Reduced muscle function appears to be more prevalent in women than reduced muscle mass alone and may be a better marker of mortality risk. However, the failure to stratify mortality associations by sex in the majority of studies in this field means that it is impossible to draw strong conclusions regarding the prognostic implications of sarcopenia in women as compared with men. Given the known differences in muscle mass and function between men and women and the clear prognostic impact of sarcopenia in cirrhosis, there is an urgent need for large‐scale studies with adequate female participation and sex‐stratified analyses to better understand the diagnosis and impact of sarcopenia in both men and women with cirrhosis to improve prognostication and aid clinical management.None.None of the authors have competing interests to disclose.Appendix S1. Search StrategyClick here for additional data file.


The lack of racial/ethnic diversity in research potentially limits the generalizability of findings to a broader population, highlighting the need for greater diversity and inclusion in clinical research. Qualitative research  was conducted to identify (i) the potential motivators and barriers to study participation across different races and ethnicities; (ii) preferred delivery of education and information to support healthcare decision‐making and the role of the community.Patient focus groups were conducted with 26 participants from the sponsor's Patient Engagement Research Councils selected through subjective sampling. Recruitment prioritized adequate representation across different race/ethnic groups. Participation was voluntary and participants underwent a confidential interview process before selection. Narrative analysis was used to identify themes and draw insights from interactions. Experienced research specialists identified emerging concepts, and these were tested against new observations. The frequency of each concept was examined to understand its importance.Based on self‐selected race/ethnicity, participants were divided into five focus groups  and were asked to share their experiences/opinions regarding the stated objectives. Barriers to study participation included: limited awareness of opportunities to participate in research, fears about changes in standard therapy, breaking cultural norms/stigma, religion‐related concerns and mistrust of clinical research. Participants identified the importance of transparency by pharmaceutical companies and other entities to build trust and partnership and cited key roles that communities can play. The perceptions of the African American group regarding diversity/inclusion in research studies appeared to be different from other groups; a lack of trust in healthcare providers, concerns about historical instances of research abuse and the importance of prayer were cited.This study provided insights into barriers to study participation, and also highlighted the need for pharmaceutical companies and other entities to authentically engage in strategies that build trust within communities to enhance recruitment among diverse populations.The data collected in the present study was provided by the participants in the focus groups. Participants were recruited through outreach to patient advocacy organizations, online advertising websites, social media, and physician referrals. Recruitment targeted ‘everyday’ participants with a variety of healthcare experiences; some participants were very involved in healthcare decision‐making, others less. Participants were not exclusively experts or advocates in their disease area. The screening and recruitment process for this study allowed participants to self‐identify race and ethnicity, and these identifiers were taken into account when designing and analyzing research. Subjective sampling was used, and demographics such as race/ethnicity were often prioritized in the recruitment process to ensure adequate representation. Individuals were subjected to a confidential and thorough screening and interview process before selection by a series of questions, assessing prior participation in any research study, self‐identification in terms of race/ethnicity, and the highest level of education received. Of patients who expressed interest, on average, approximately 64% were interviewed; 57% were eligible to participate and 42% were invited to become PERC participants. Council members were compensated for their time participating in research activities and each research opportunity was voluntary.At the time of this study, the PERC program consisted of 108 participants, 30% of which self‐identified as African American/Black, 8% as Hispanic/Latino and 7% as Asian American.2.2Research questions were developed to address the key study objectives before conducting the focus groups. The questions were formulated by a research specialist who possessed experience in culturally appropriate research methods and patient literacy and were structured around validated health behaviour principles that were used by the research team across similar studies. A discussion guide was developed by a research specialist with additional review by senior researchers and sponsor representatives. Participants involved in these sessions had one of the following self‐reported disease conditions: peripheral arterial disease, venous thromboembolism, cardiovascular disease, inflammatory bowel disease, ankylosing spondylitis, psoriatic arthritis, prostate cancer, multiple sclerosis or pulmonary arterial hypertension. Information from five focus groups was gathered and analysed; each discussion was conducted for 90 min on different dates.n = 11 (42.3%); females: n = 15 (57.7%)] engaged in this study. Participants were grouped by self‐identified race/ethnicity to facilitate open discussion; these included two African American/Black groups [n = 11 (42.3%)], one Hispanic/Latino group [n = 5 (19.2%)], one Asian American group [n = 4 (15.4%)] and one white group [n = 6 (23.1%)] ‐compliant practices. All data were deidentified; thus, no ethics board review was required. The purpose of this study was to collect personal perspectives and qualitative insights from the participants. The study was also conducted in accordance with the Helsinki Declaration of 1964 and its later amendments. All sessions were conducted virtually, and participants joined from their homes.For each focus group, participants were first introduced to the types of clinical research to provide the foundation for discussion and the basic role of the participant Figure . Partici2.3All discussions lasted 2 h each and were audio‐recorded and transcribed. Following the sessions, recordings for transcription were submitted through a transcription firm experienced in transcribing medical market research.33.1Motivators to study participation cited during the discussions included access to novel treatments for participants who were ‘out of options’ for their diseases, altruism, better or free medical coverage, compensation, curiosity to learn more about their disease and improved medical attention. A few felt a responsibility to represent an under‐represented group, be it their gender identity , sexual orientation (LGBTQ+), race (African American/Black) or even geographic location . In particular, African American/Black participants suggested that medications are not typically designed with them in mind, so involvement in research studies was perceived as a positive change to this pattern of underrepresentation. Each group identified better or free coverage as an advantage, especially among those who struggled to afford expensive care/treatment. A few participants expressed willingness to enroll in research studies simply on the strength of their healthcare professional's (HCP's) recommendation  due to untested medications; potential loss of standard of care (SOC) or other treatment disruptions; violating cultural norms, including defying family members; stigma; their data being tracked ; misinformation; not being able to comprehend the salient points of a trial and/or research study because of health literacy or language barriers; and being subject to abuse based on historical events see Box . While aBox 3:When it comes to taking something that's not on the market or FDA approved, you're obviously going to be fearful.–African American/BlackMisinformation…especially when it comes to minority populations…and I've seen clinical trial teams and coordinators be very stigmatizing towards low/moderate income communities.–African American/BlackAnything that changes my medication routine now would be an obstacle for me…also the language barrier and complexity of health care [for Latino immigrants].–Hispanic/LatinoIt becomes a balance of the inconvenience versus the possible benefit…I'd want to make sure I was doing something that wouldn't have a permanent [negative] impact, like if I was given the placebo.–whitePeople in my Orthodox community are very hesitant to be involved…whenever people in my community find out that I am in a study, they think I am absolutely insane…because a lot of medical treatment was done on Jews during the Holocaust…so you never want to do anything first…only if the general American public accepts it first.–whiteI need a dictionary to understand the consent forms in order to get the information!–African American/BlackAdditional barriers identified included a lack of trust in the overall study process and in pharmaceutical companies. While some participants were willing to acknowledge the contribution of pharmaceutical companies in advancing diversity and equity in research, they displayed hesitation in considering them a trusted source. Affiliation with an advocacy organization, or an endorsement by a member of their identified community, however, was perceived to be an effective way to enhance the trustworthiness of a pharmaceutical company. Overall, there was reluctance to trust any entity or institution with a financial stake in the outcome of the study.3.3Participants were less likely to consult primary care physicians about disease‐specific questions and tend to address these issues with their specialists instead. Although many viewed their relationship with their doctors as a partnership, they also liked to self‐educate about their specific health condition(s) and elicit medical opinions on information obtained rather than relying exclusively on their doctor as a source. Preferred sources for educating oneself included: Internet searches, literature reviews, eliciting opinions from educated friends/family and exposure to experiences of other participants. WebMD was considered too elementary to be viewed as a credible source of information; websites with extensive scientific content, such as NIH, Mayo Clinic, Johns Hopkins and PubMed were the preferred choices.Trust in social media for medical guidance was roughly predicated on the age of the participant, and to a lesser extent, the platform. In general, younger participants  trusted social media. Twitter and Reddit/sub Reddits were cited specifically, and Facebook appears to be the least trusted of all platforms. Few participants also preferred utilizing Google searches, YouTube and other social media platforms. Connecting with peers living with the same condition appeared to be extremely important, especially among younger participants.Religion was found to play an important part in medical decisions; however, its role appeared to vary for different ethnic groups. Association with religious groups was the strongest among African American/Black and orthodox Jewish white respondents. African American/Black participants cited ‘prayer’ as important, after arming themselves with as much knowledge as possible regarding a potential research study. For other ethnic groups, the religious social group was a more significant influencer of medical decisions than the religious beliefs themselves. For example, an Asian American respondent stated they consulted the medical professionals from their church community on medical decisions. A few selected quotes from participants on the preferred delivery of education and information to support healthcare decision‐making and the role of the community are available in Box Box 4:My GP is great, but I would not let them make decisions about my VTE…And I find my female doctors are more focused on my particular needs.–whiteShowing up authentically is the most vitally important thing…and the main component is building trust…build partnerships within the communities…the community rapport is what you have to build on.–African American/BlackThe role of social media and whatever health community you are a part of is really crucial…a lot of physicians have taken an active role in their community –not so much Facebook, but definitely Twitter…I think it's a very big part of where a lot patients get their information from.–whiteI have a great community of other patients I met over the years at various psoriasis conferences…they are my go‐to for emotional support…and there's always quite a bit of information running around that group.–Asian AmericanI like to talk to other community members—a social media community that I built around IBD…plus a lot of Google searches, YouTube…and emailing back and forth with my doctor.–Hispanic/LatinoMy community consists of my  medical team. And a group called Black Health Matters…they help you understand the risk versus the benefit [of trial participation].–African America/BlackI would identify my community as the LGBTQ+ community…and the chronic illness/disabled community. I am very active on Twitter, so I have connected with others even if we don't share a diagnosis.–Hispanic/LatinoMy community is my Reddit group—Peeps with UC and Crohn's. I definitely trust their opinions.–African American/BlackI'm part of 2 communities, being in the healthcare field. But being part of the PH community is huge…My healthcare side helps me to investigate what I hear in the PH community.–Asian AmericanOverall, participants desired transparency and engagement to build trust and continued partnership to enhance healthcare decision‐making. Participants felt ‘showing up authentically’ and building relationships at the community level—in both real‐world and virtual settings—are important considerations for researchers. While a few participants decided by themselves, others preferred to consult individuals they trust; seeking information from communities they relate to, such as LGBTQ+ and disease‐specific support groups.4This study underscores the importance of engaging with patients directly to understand their individual perspectives and experiences to enhance participation in research studies. The findings highlight important motivators and barriers for research study participation among underrepresented racial and ethnic groups, and the significance of social identity, trusted sources and community engagement in healthcare decision‐making. It is critical for pharmaceutical companies and other entities conducting research studies to build trust and continued partnerships with participants through transparency and direct engagement with patients in their own communities.Our study detected several racial and ethnic differences. Perceptions among the African American/Black groups in our study regarding healthcare and research participation differed from other groups, especially displaying increased trust for HCPs who share their race/ethnicities. This insight should steer research sponsors to increase the involvement of HCPs across racial and ethnic groups in research and to partner with religious/cultural community groups to enhance trust among prospective study participants. An example from the literature highlights the usefulness of CBPR, through which community‐level engagements are carried out to improve diversity and inclusion in clinical research.Our findings on motivators and barriers align with those of previously published studies reporting factors that contribute to the lack of racial/ethnic diversity in study participation.Significantly, when discussing fears and barriers to participating in clinical research, participants shared the importance of self‐identification beyond race/ethnicity. For example, participants shared that gender identity or sexual preference, and religious affiliation could influence their willingness to participate in a research study. This complexity signals the importance of considering an individual's influencing ‘ecosystem’ and the concept of ‘intersectionality’ when attempting to engage populations in research. It is important to realize self‐identity not only as belonging to a race but also multiple other traits . This complexity should be acknowledged and accounted for in research.Mistrust towards clinical research and the pharmaceutical industry is a challenge; it is attributed to historical experiences, education levels, language and ethnic backgrounds,This study provides valuable insights for increasing diversity and inclusion in research. While qualitative research is a critical tool to gather the patient voice, inherent limitations exist. There is a tendency for the emergence of socially acceptable opinions and bias development within the group due to the dominance effect and groupthink. Small sample sizes cause the research to be mainly exploratory in nature, as the number of participants in each group and the duration of focus group discussions do not allow testing of the data saturation point.5Our study generated significant qualitative patient perspectives regarding potential barriers to participation in research studies, highlighting racial and ethnic differences, and the role of engaging with communities to help overcome these barriers to achieve diversity and inclusion in studies. These focus groups highlight the importance of programs that foster bidirectional collaboration between pharmaceutical or other entity sponsors and community members. The findings and recommendations presented in this study could be further integrated into the research study recruitment framework and processes to support an engagement strategy, with an enhanced focus on the intersectionality of the ‘whole patient’ to build trust and partnership with patients and their communities.All authors contributed to data analysis, drafting or revising the article, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.L. S., J. P., and G. G. are employees of Janssen Scientific Affairs, LLC. V. P., C. K., and W. P. are employees of CorEvitas, LLC, which derives its profits from interactions with pharmaceutical sponsors.


Limited data exists on Pacific Islander (PI) health, but a growing body of literature reports the existence of racial discrimination and inequities and mistrust of the healthcare system, leading to poor health outcomes. When COVID‐19 restricted health services, such inequities and mistrust due to historical trauma were magnified. This report describes one federally qualified health center's dental department's response utilizing culture‐based approaches, community relationships, and the social determinants of health (SDOH) to dispel the stigma of COVID and restrictions on in‐person care in order to lower barriers to accessing care. When the dental department transitioned to emergency‐only care, staff were redeployed to address significant inequities facing the PI community. Redeployment activities included building relationships with the most vulnerable patients, delivering healthy foods, supplies, oral hygiene kits to households, and canvasing neighborhood businesses with public health education. The mobile dental clinic, a trusted symbol in the community, also brought public health education to community testing events and food distributions. From March 2020 to July 2020, staff conducted over 800 outreach calls for health and food security, delivered over 2000 care packages and oral hygiene kits. Also, frequent community outreach by the mobile dental clinic led to a 10‐fold increase in COVID testing. Investing in relationship building can maintain access to health care and build trust in the health care system for PI communities. This approach may be relevant to others serving other communities experiencing racism. Pacific Island immigrants (PI) are a rapidly growing ethnic group in Hawaiʻi and also the continental United States (US). In addition to those from Polynesia (and Melanesia to some extent), many PIs in Hawaiʻi and the US come from the Federated States of Micronesia, one of the three nations with Compacts of Free Association (COFA) with the US. These compacts were a result of the United States' involvement in Micronesia during the post‐World War II period and allows COFA citizens free ability to enter and work in the US, and access education and health services.Limited data on the general and oral health of PIs suggests high levels of chronic diseases and low utilization of preventive health services.Studies have suggested that PIs experience racism on all levels—personally mediated, internalized, and institutional—and that it leads to increasing stress and mistrust, leading to decreased access to services.Due to the significant lack of state‐level prevention and public health infrastructure in Hawaiʻi to address health disparities that disproportionately affect PIs, the initiatives developed thus far have been led by community organizations such as non‐profits, churches, and social service providers.Unlike other US states, Hawaiʻi has only one centralized Department of Health with satellite district health offices and no department focused on oral health. Hawai'iʻs state Dental Health Division was eliminated in the late 2000s along with the state dental director position, ending school‐based screenings and any system for routine assessment of residents' oral health. There are currently no state‐wide oral health programs. In 2009 the state's Medicaid program also moved from comprehensive care to emergency‐only care for adults and has since remained at this level. Moreover, there is no community water fluoridation in Hawaiʻi except on military bases, with only 8.8% of the Hawaiʻi population served by community water systems receiving fluoridated water.Kōkua Kalihi Valley Comprehensive Family Services (KKV) is a federally qualified health center (FQHC) in Honolulu, Hawaiʻi that serves the Kalihi Valley area. KKV was founded by community leaders in 1972, in response to inadequate healthcare services for Kalihi's population of primarily Asian and PIs , new‐immigrant and low‐income residents. Many are non‐English or limited English speakers and most live in the two largest public housing complexes in Hawaiʻi. There is a strong focus on KKV's motto, “neighbors being neighborly to neighbors,” with the organizational approach to clinical services centering around patient–provider relationships by implementing the social determinants of health (SODH) and culture‐based approaches. Since its founding, KKV has leveraged several strategies to develop culturally competent clinical services. These strategies include: collecting expertise from community members and empowering them as health educators and advocates, utilizing patient navigators and community health workers, and training KKV employees in cultural competence. That direct involvement of community members continues today. There has also been an intentional effort to hire individuals who live in the community and grow the organization's patient navigator and community health worker program. The latter has been considered one of the most successful strategies for improving healthcare access for patients of color and narrowing racial health disparities. Cultural competence is woven into various trainings for clinical and administrative staff and there are regular cross‐department meetings. Cultural immersion has also been an effective form of cultural competence training. Many of KKV's dental staff have engaged in cultural activities at the organization's 100‐acre nature preserve, Hoʻoulu ʻĀina, that provides land‐based and PI cultural programming. Staff have shared the experience improved their understanding of the community and their relationships with cultural workers at the organization.Other culturally competent strategies have included extensive language accessibility through all communications materials for the main dialects of the community, including 26 different languages for all patient interactions (from front desk to provider), and increasing access through mobile clinics and school‐based programming. Previous studies have suggested that cultural competence trainings and programming have proven effective not only in strengthening patient relationships, but also in reducing racial and ethnic health disparities and improving overall quality of care.Dental care was the first service provided by KKV, primarily because community members went door‐to‐door asking Kalihi residents about their most significant health needs. Today the dental department has grown from used military trailers to a 12‐operatory main clinic that includes dental residency programsThe COVID‐19 pandemic highlighted the inequities in the PI community in Kalihi.Dental staff joined other health center employees to focus on patients who were seniors, had mental or physical disabilities, or had comorbidities that qualified them as “high‐risk” for COVID‐19 symptoms. Staff called these patients to check‐in with them and screen for health status factors, emergency needs for food, medication, health care, socialization, and other supports for maintaining health and quality of life. These calls were opportunities to listen deeply to patients and an opportunity to build relationships, rather than cycling through a list of questions. This method of data collection is more familiar to the PI community and builds trust, rather than feeling extracted from—a common feeling from generations of mistrust of western health systems. Based on their status, dental staff made deliveries to the homes of patients and asked how they were feeling, while adhering to strict PPE protocol. Deliveries included oral hygiene supplies, medications, fresh produce, prepared healthy meals from KKV's cafe, technology support,Recognizing that many of the local mom and pop shops were frequent stops for the community, the dental staff also visited local businesses to check‐in with them and distribute public health messaging on COVID‐19. The Dental Bus, which is normally used for the school‐sealant program, was repurposed to distribute COVID‐19 kits and information at local public housing, and health center‐led COVID‐19 testing events. The familiarity of the Dental Bus in the community helped to attract community members to get tested, since there was great fear of being tested and the subsequent ramifications should they test positive . At the main clinic, dental staff continued to provide emergency‐only dental care and patients were given a survey asking if they considered going to the emergency departments to stop the pain in their mouth or face if the dental clinic were not open.conducted over 800 outreach calls for health and food security,delivered over 2000 care packages and oral hygiene kits,visited 14 local businesses to support KKV's public health messaging campaign,community outreach increased COVID‐testing by 10‐fold,796 unduplicated patients received emergency dental care, andof the 796 patients who received emergency care, over 47% of patients reported that if not seen, they considered going to the Emergency Room to stop the pain in their mouth or face.The entire FQHC achieved the following results from March 2020 to July 2020:The pandemic allowed the dental department to expand beyond its traditional methods of providing culturally competent care to the PI community and enhance its SODH approach through more community engagement. The department also learned methods for data collection to better serve the needs of the community. More importantly, the dental department learned about the role it plays in potentially diverting costly dental‐related emergency room visits, as reflected by the 47% of patients who reported considering going to the emergency room to stop the pain in their mouth or face if not seen at KKV. The dental department conducted seven tele‐dentistry visits and learned that such visits are difficult without specialized intraoral camera equipment. However, tele‐dentistry may be useful for some post‐op visits and possibly preventive motivational interviewing check‐ins.The community's responsiveness to KKV's COVID education and outreach efforts may reflect its value on social connections and strong relationships, a core value in PI culture,Future work for the dental department includes identifying opportunities to incorporate these lessons in its school‐based sealant program, coordination with other KKV programs, oral health education and prevention, and data collection and evaluation regarding community oral health disparities. This includes identifying opportunities to check‐in with patients since this pandemic outreach program has revealed the need for social connections, a core value in many PI cultures. For example, screening questions for COVID‐19 can be transformed to ask about the general well‐being of individuals in ways that deepen the dentist‐patient relationship and build trust which could increase patient adherence and loyalty, and lead to better therapeutic results and anxiety management.


Additional mechanisms, such as molecular motors binding to nuclear pore complexes or microtubules connecting to emerin and other nuclear envelope proteins, may further contribute to nucleo‐cytoskeletal coupling. Due to this physical coupling, cytoskeletal forces exerted on the nuclear lamina can severely deform the nuclear envelope and trigger the reversible formation of heterochromatin, epigenetic changes (H3K9me3 methylation) or chromatin unpacking.Nuclear deformability and changes in mechanical properties of cells are a hallmark of important physiological and pathological situations, such as the migration of immune cells that must navigate through narrow interstitial spaces of few microns or tumoral cancer cells that migrate in confined microenvironments when invading tissues and intra‐ or extravasating blood vessels to metastasize to distant tissues.To this aim, lab‐on‐a‐chip microsystems based on protein micropatterns,The field of cell mechanobiology and the focus on nuclear mechanics is emerging into a period that has rich potential for clinical translation. The ability to interrogate biophysical markers of disease, which in some instances may present earlier and be more specific than biological signs of disease, can drastically enhance the accuracy of disease diagnoses and inform disease management from a patient‐centric perspective. The possibility to implement alone or in conjunction with gold‐standard assays like flow cytometry gives lab‐on‐a‐chip microsystems substantial promise to be transformative technologies in the clinic. There are many encouragements for the translation of innovative works from diverse sources ranging from academic institutions, government agencies and private investors. Academics have therefore the opportunity to contribute to translational research in multiple ways and the possibilities for cell mechanobiology to impact society through a translation to the clinics are impressive.The authors declare no conflict of interest.


S)‐selective transaminase from Halomonas elongata (HEwT), inversion of the enantiopreference was observed at increasing substrate loadings. In addition, the enantiopreference could be altered by variation of the ionic strength, or of the co‐solvent content in the reaction mixture. For example, using otherwise identical reaction conditions, the presence of 2 M sodium chloride gave (R)‐THF‐amine (14 % ee), while the addition of 2.2 M isopropyl alcohol gave the (S)‐enantiomer in 30 % ee. While the underlying cause is not currently understood, it appears likely that subtle changes in the structure of the enzyme cause the shift in enantiopreference and are worth exploring further.Enzymatic enantiopreference is one of the key advantages of biocatalysis. While exploring the synthesis of small cyclic  such as 3‐aminotetrahydrofuran (THF‐amine), using the ‐selective, while at high ionic strength the enzyme became (R)‐selective. The mechanism for this effect is not yet clear. Curiously, the ee values decreased with two of the four tested substrates when employing the (S)‐selective transaminase from Halomonas elongata (HEwT) in flow rather than in batch conditions.Enzymes are often highly enantioselective, which makes them attractive catalysts in organic synthesis, in particular for the pharmaceutical industry where high enantiopurity is required.1, 2 Fee values were obtained at the different substrate concentrations, as seen in Table S) to (R) at the highest concentration.While exploring the intensification of this reaction using HEwT  as the amine donor), different ee through thermodynamic vs kinetic control;i. e. the racemate  was used. Highest ee values were expected at the shortest reaction times and with the lowest enzyme concentration and should decrease as either time or enzyme concentration increases. As can be seen in Figure ee values obtained under those conditions were approx. 16 % (S), and thus it seemed unlikely that this effect alone was strong enough to explain the range of ee values previously observed. Indeed, this effect would also not explain the concentration‐dependent switching behaviour that is also observed with the purified enzyme ‐selective, with slight variation. However, when IPA was varied from 50 to 1500 mM (THF‐ketone fixed at 100 mM), the same switching behaviour was observed as when both were varied proportionally R)‐THF‐amine. However, other effects pertinent to the enzyme are also possible, e. g. the increasing organic content (decreasing water content) or increasing ionic strength might result in structural changes of the enzyme that favour the production of the (R)‐enantiomer.Previous docking studiesonated pKa 10.63[S)‐methylbenzylamine (SMBA) as the amine donor with varying concentrations of the following additives: isopropyl alcohol (a weaker hydrogen bond donor than (protonated) IPA, with similar size and structure), sodium chloride , and ammonium chloride .To separate the different effects of increasing IPA concentrations , experiments were set up using  to (R).Thus, if the switch in enantiopreference is indeed due to competing hydrogen bonding to the reaction medium, a similar effect should be observed for ammonium chloride and to a lesser extent isopropyl alcohol. However, if it is due to increasing organic content which affects the structure of the enzyme, it should be observed only with isopropyl alcohol; and if it is due to increasing ionic strength it should be observed only with sodium chloride and ammonium chloride. As can be seen in Figure S)‐selective structure dominating in hydrophobic/organic reaction media and a more (R)‐selective structure in hydrophilic reaction media. Increasing the pH ‐selectivity of HEwT, which may be due to lower amounts of protonated amines, rendering the reaction medium more hydrophobic while lowering the ionic strength. However, in the absence of direct evidence of such structural changes, this is not a definitive conclusion, and it might indeed be the case that a more hydrophobic environment favours THF‐ketone entering the active site “oxygen‐first” and a more hydrophilic environment favours it entering “C5‐first.” Increasing ionic strength might also disrupt the hydrogen bonding to W56 or alter the solvation sphere around THF‐ketone in solution. Such solvation effects play a crucial role in the stereoselectivity of chemical reactions.This suggests that the switch in enantioselectivity may be predominantly caused by subtle structural changes of the enzyme, with a more ‐selectivity of the enzyme; however, no switch in enantioselectivity was observed. It should be noted, however, that only concentrations of up to 250 mM could be tried, which is below the range where a switch in enantioselectivity was observed with IPA.Next, the role of the structure of the amino donor and amino acceptor was investigated. As can be seen above, the switch in enantiopreference can be observed with either IPA or SMBA as amino donor. However, due to substrate inhibition by SMBA,ee with increasing substrate concentration had been observed with butanone. In light of the results with THF‐ketone this was explored further. However, as can be seen in Figure ee only varied slightly at higher substrate and IPA concentrations ‐selectivity, consistent with previous observations. On the other hand, neither the solvent excluded volume, nor the protic/aprotic nature of the solvent showed any clear trend. Rother and co‐workersS)‐selectivity and even inversion to (R)‐selectivity. This was viewed as evidence that the smaller solvent molecules can block the binding pocket for these enzymes, favouring binding of the substrate in a flipped orientation. The lack of such size‐dependency in the present case seems to preclude such a direct binding to the active site in the present case.Finally, the influence of the nature of the co‐solvents was investigated. Two protic solvents and two aprotic solvents were chosen. As can be seen in Figure S)‐selectivity of the enzyme, while increasing the ionic strength enhances the (R)‐selectivity. The effect does not appear to depend on the size of the “additive”, making a direct binding to the active site an unlikely explanation. Thus, the effect is most likely due to structural changes in the enzyme under these varying conditions, i. e. increasing the ionic strength of the medium is expected to increase the strength of hydrophobic interactions within the protein structure, while increasing the hydrophobicity of the medium would decrease those interactions, subtly affecting the structure. However, if the enantioselectivity of HEwT is indeed determined by the orientation in which the substrate enters the active site (as previously postulated), a direct effect of the reaction medium on that orientation due to solvation effects on the substrate may also be possible. A similar effect could not be observed with butanone, a substrate where the enantioselectivity is determined by steric discrimination provided by a small and large binding pocket.To summarize, attempting to intensify the previously reported synthesis of THF‐amine using HEwT, a curious switching in enantiopreference was observed. Initially this was noted at increasing substrate loading, it was then shown to be caused by an increase in ionic strength. Further experiments showed that increasing the hydrophobicity of the reaction increases the  should be addressed to the authors.Supporting InformationClick here for additional data file.