Mycobacterium tuberculosis (MTB) pncA gene encoded, pyrazinamidase (PZase). Mutations in pncA are detected in >70% of PZA resistant isolates but, noticeably, not in all. In this study, we selected 18 PZA-resistant but wild type pncA (pncAWT) MTB isolates. Drug susceptibility testing (DST) of all the isolates were repeated at the critical concentration of PZA drug. All these PZA-resistance but pncAWT isolates were subjected to RpsA sequencing. Fifteen different mutations were identified in eleven isolates, where seven were present in a conserved region including, Ser324Phe, Glu325Lys, Gly341Arg. As the molecular mechanism of resistance behind these variants has not been reported earlier, we have performed multiple analysis to unveil the mechanisms of resistance behind mutations S324F, E325K, and G341R. The mutant and wild type RpsA structures were subjected to comprehensive computational molecular dynamic simulations at 50 ns. Root mean square deviation (RMSD), Root mean square fluctuation (RMSF), and Gibbs free energy of mutants were analyzed in comparison with wild type. Docking score of wild type-RpsA has been found to be maximum, showing a strong binding affinity in comparison with mutants. Pocket volume, RMSD and RMSF have also been found to be altered, whereas total energy, folding effect (radius of gyration) and shape complimentarily analysis showed that variants S324F, E325K, and G341R have been playing a significant role behind PZA-resistance. The study offers valuable information for better management of drug resistance tuberculosis.Pyrazinamide (PZA) is an important component of first-line anti-tuberculosis drugs which is converted into active form, pyrazinoic acid (POA), by   The major targets of POA that have so far been identified are ribosomal protein S1 (RpsA), which is involved in trans-translation, and aspartate decarboxylase (panD), which is involved in ATP synthesis [ΔA438) at the C-terminal showed PZA resistance and lack of binding to RpsA in Mycobacterium smegmatis. Shi et al., concluded that the C-terminal region of RpsA is the interaction site of POA as it interferes with the transfer-messenger RNA (tmRNA) complex formation during initiation of translation.Pyrazinamide (PZA) is a first-line drug used in combination with rifampin and isoniazid that kills persister bacilli, and was found to be effective in shortening the duration of TB therapy ,2. The pynthesis ,4. Shi eynthesis , while PEscherichia coli, encoded RpsA there are six S1 domains, whereas MTB has four S1 domains [CTD) may alter interactions with POA in the fourth S1 domain, leading to conformational changes in the POA binding site resulting drug resistance [In bacteria,  domains . The fir domains . Yang etsistance . Two POAsistance ,5.Here we analyzed the molecular mechanism behind the resistance due to mutations Ser324Phe, Glu325Lys, Gly341Arg present in the conserved region of RpsA. In our previous study , these m22.1pncAWT. PTRL is the only central reference laboratory of Khyber Pakhtunkhwa (KPK) province, receiving samples for drug susceptibility testing.As described in our previous findings , we coll2.2Mycobacterium tuberculosis strain ATCC 25618 / H37Rv and Mycobacterium bovis was used as negative and positive controls respectively. Growth at a critical concentration of PZA (100 μg/ml) was considered to indicate PZA-resistance.Drug susceptibility testing was performed using the automated BACTEC MGIT 960 system. 2.32, 5 μl PCR buffer, 0.8 μl Taq ), 1 μl each forward and reverse primers, 34.8 μl molecular grade water and 4 μl of genomic DNA. The PCR conditions were set as, 5 min at 94 °C for the denaturation step; 30 cycles of 30 s, 30 s at 56 °C, and 72 °C for 1 min; an extension step at 72 °C for 5 min as previously described. The PCR product was analyzed using 6 Applied Biosystems 3730xl .PZA resistant samples were subjected for genomic DNA extraction using the sonication method. ,10. The 2.4NC_000962.3) database of NCBI.To find mutations behind PZA-resistance, the sequence data were loaded into Mutation Surveyor V5.0.1 and compared with RpsA (Rv1630) from the RefSeq (2.54NNK) was retrieved from the Brookhaven Raster Display (BRAD) protein data bank (PDB) [A three dimensional structure of MTB RpsA  (PDB ID nk (PDB) . Prior tnk (PDB) . The mutnk (PDB) .The drug POA was retrieved from PubChem (PubChem CID: 1047)  and ener2.6.Protein was prepared using proteins preparation option in MOE. Incorrect hydrogen atoms were corrected while selenomethionines were changed into methionine. Shape complementarity of protein and drug was measured in the form of score using PatchDock server . This pr2.7MD simulation was run on all the complexes using AMBER while the PRODRG web server was used to generate the topology of ligand. A cubic box of 1.5 nm was solvated with each complex using a simple point charge (spc) water model . Sodium Equilibration was carried out with constant temperature, constant volume (NVT) ensemble at 300 K followed by constant temperature, constant pressure (NPT) ensemble for 300 K and 1 bar pressure with each for 100 ps. The Berendsen thermostat method was used for temperature  while pr2.8Principal Component Analysis (PCA) of a MD simulation was performed on the mass-weighted cartesian coordinates. Internal motion of the system was obtained by removing the overall rotation and its translation from the trajectory. PCA is carried with long time dynamics by recognizing low modes in proteins ,29. PCA 2.9-RpsA. The G is minimized at constant pressure and temperature to chemical equilibrium state of system. It is a thermodynamic potential at constant temperature and pressure, where reduction in G is an essential state for the freedom of processes.The available energy often called Gibbs free energy (G)  was plotted against wild type3WT  isolates harbored fifteen different mutations, whereas seven PZA R isolates were RpsAWT . MutatioWT . To explWT .Table 1M3.1Shape complementarity score of wild type was found maximum (2352) in comparison with mutants . Pocket 3.2The majority of the residues of mutant structure were found in a favorable region . Number 3.3A molecular dynamics simulation was run for 50 ns on high performance compunting of the RpsA complex with drug. Wild type structure attained a root mean square deviation (RMSD) of 2.0 Å, 4.8 Å and 1.8 Å at 0 ns, 23 ns, and 50 ns respectively to attain the stability. The mutatnt S324F showed a deviation and attained the RMSD value of 2.1 Å, 1.2 Å, and 4.2 Å at 0 ns, 28 ns and 40 ns respectively, but at 50 ns it attained some stability (3.8 Å). Mutant E325K attained the RMSD between 1.1 Å and 4.8 Å at 9 ns and 45 ns repectively. However, at 50 ns the final RMSD was found to be 3.4 Å, slightly higher than wild type. The RMSD values of G341R were found to be between 1.2 Å and 4.0 at 10 ns and 25 ns repectively. The RMSD seemed to be stable after 35 ns with a final value of 3.2 Å at 50 ns. The deviation in the mutant seemed to be low, but the final value of wild type at 50 ns was found to be lower initially but higher than mutants after some time .- RpsA. Wild type exhibit RMSF of 0.3–3.8 Å. These fluctuations appeared to be present in between residues 358–400, whereas mutant S324F exhibited 0.4-9 Å where fluctuation was observed between residues 358–434. Mutant E325K has a RMSF value between 0.7 Å and 4.7 Å and exhibited fluctuations in residues 358–434. Mutation at position G341R exhibited fluctuation in between 0.8 and 5.2 Å in which fluctuation was observed in residues 355–434. The RMSF value for S324F, E325K, and G341R demonstrated a higher flexibility, resulting in low affinity for POA. Residues of the conserved area forming the fourth S1 domain may be altered in RpsA , plotted against time. The graphs showed a variation between mutants and wild type-RpsA . Mutant 3.5Principle component analysis of wild typee and mutants were plotted . Wild-tyThe relative stability of wild type and mutants can be measured by Gibbs free energy (GFE) which is the amount of work a closed system uses when exchanging heat and work with the surroundings. The differences in Gibbs free energy values of wild type and RpsA mutants S324F, E325K, and G341R showed that mutants may alter the stability of RpsA. Wild type had a significant GFE difference with that of mutants as indicated by the peak color in the plot . The peaThe distance matrix of drug and RpsA were found to be highly deviated. The average distance was found constant throughout the simulation, however mutants exhibited a high degree of fluctuation .The total enegy measured for the wild-RpsA was significantly higher in compared to mutants. The wild type has a maximum total estimated energy of >940 kj/mol as compared with mutants throughout simulation as shown in 4pncA, but resistance may also develop due to mutations in ribosomal protein S1 (RpsA) and aspartate decarboxylase (panD) genes [The emergence of first and second-line drug resistance is a major hurdle towards WHO global end TB strategy 2020. A better insight into drug resistance mechanisms is needed for better management and success of global TB erradication programs. PZA is a key first-line drug that kills subpopulations of non-replicated MTB. Previous studies reported that resistance to PZA develops due to mutations in D) genes . In our D) genes . Thus, mD) genes .Mutations in target proteins often affect flexibility and deviation, and make them a weak target for interaction with drugs. Molecular flexibility and stability fluctuations were detected from RMSF and RMSD values. Stability is an important property in increasing function and activity of biomolecules . IncreasDegree of compactness  and folding stability was plotted against time. This degree is often measured through Radius of gyration (Rg) . A stablA drug-binding pocket is one of the most important features of resistance and is related to size and shape of proteins . Vats etpncA, rpsA, and panD wild type. The possible role in resistance may be played by efflux proteins as described in a recent study [The primary forces in protein-ligand interactions are hydrogen bonds, along with van der Waals and electrostatic forces . Hydrogent study . The quarpsA gene sequences in PZA-resistant MTB isolates with the activity of RpsA. These muations change the total energy, flexibility, stabilty and also the fluctuation of amino acid resisdues of RpsA, thereby affecting the interactions with POA. Stable interaction of drug and target is also altered due to changes in the volume of pocket of mutants S324F, E325K, and G341R, compared with wild type-RpsA (585.736 Å). Further, hydrogen bonding in interaction site residues and deviation and fluctuation also appeared to be affected. The overall analysis supports that mutations of RspA gene have certain roles in mediating PZA-resistance in pncA wild-type isolates. This is the first study of such kind where interaction between clinical mutants of RspA and POA are presented to our knowledge.In conclusion, we measured the effect of our novel mutations S324F, E325K, and G341R, and compared All the authors have no competing financial interests.SIM and DQW designed the research, MTH and SIM conducted experiments, DQW, MTH and AUR performed MD simulation and analysis, MTH, AUR and MJ wrote the manuscript.1–8/HEC/HRD/2017/8392 (http://www.hec.gov.pk/english/Pages Home.aspx) and Dong-Qing Wei which is supported by the Key Research Area Grant 2016YFA0501703 from the Ministry of Science and Technology of China and also grants from the State Key Lab on Microbial Metabolism, and Joint Research Funds for Medical and Engineering & Scientific Research at Shanghai Jiao Tong University.This study was supported by Higher Education Commission Islamabad, Pakistan under IRSIP No:


The present data is reported in the article “Regulatory Focus and Regulatory Mode – Keys to Narcissists’ (Lack of) Life Satisfaction?”  [1]. The two data sets represent answers from two German samples. Data were collected via self-report questionnaires using EFS survey from QuestBack Unipark. The surveys included self-questionnaires of narcissistic grandiosity, narcissistic vulnerability, regulatory focus, regulatory mode, self-esteem, life-satisfaction, and demographic information. Specifications tableValue of the data•Ns = 297, 143) assessing narcissistic grandiosity, narcissistic vulnerability, regulatory focus, regulatory mode, self-esteem, life-satisfaction, and demographic information are provided.Raw data based on two data sets , self-esteem, life-satisfaction, and demographic information.3N = 297) was collected among university students at a large university in Western Germany and white-collar workers with an age range between 18 and 60 years .Data set 1 (N = 143) was also collected among university students at a large university in Western Germany and white-collar workers. The age ranged between 16–53 years .Data set 2  and “There is a lot that I can learn from other people”.not at all true; 5 = completely true). The mean across scale items is calculated with higher scores indicating higher vulnerable narcissism. Items include statements such as “I would really enjoy being praised for everything I do (like a child is praised by its parents)”.The NI-R consists of 36 items. Participants respond on five-point Likert scales . The mean across scale items is calculated with higher scores on either subscale reflecting individuals׳ sense of their history of promotion or prevention success in goal attainment, respectively. Sample items would be “How often have you accomplished things that got you ׳psyched׳ to work even harder?” (promotion focus) and “How often did you obey rules and regulations that were established by your parents?” (prevention focus).The RFQ contains two subscales: The promotion subscale encompasses six items and assesses individuals׳ subjective histories of promotion success whereas the prevention subscale contains five items and assesses individuals׳ subjective histories of prevention success. Participants respond on five-point Likert scales (1 = strongly agree) to 4 (strongly disagree). A sample item would be “On the whole, I am satisfied with myself”.The RSES is a widely used and validated self-report instrument for measuring explicit and global self-esteem by assessing positive and negative feelings about the self. The RSES consists of 10 items which are rated on a 4-point Likert scale format ranging from 1 (strongly disagree) to 7 (strongly agree). Items include statements such as “I am satisfied with my life”.The SWLS is a five-item scale designed to measure global cognitive judgments of satisfaction with one׳s life. The items are rated on seven-point scales ranging from 1 (strongly disagree) to 6 (strongly agree). Example items are: “When I decide to do something, I can׳t wait to get started.” (locomotion) and “I often critique work done by myself or others.” (assessment).The Regulatory Mode Questionnaire assesses locomotion with 12 items and assessment with 10 items. The items are rated on six-point Likert scales ranging from 1  were computed for each measure and can be found in M = 16.65, SD = 7.45) expressed more narcissistic grandiosity than women , F = 16.77, p < .001, ƞ2 = 0.05. In data set 2, tests for gender differences turned out to be not significant.Further, we tested for gender differences in the study variables through an ANOVA see , Table 4


Red blood cells (RBCs) transport oxygen to tissues and remove carbon dioxide. Diffuse optical flowmetry (DOF) assesses deep tissue RBC dynamics by measuring coherent fluctuations of multiply scattered near-infrared light intensity. While classical DOF measurements empirically correlate with blood flow, they remain far-removed from light scattering physics and difficult to interpret in layered media. To advance DOF measurements closer to the physics, here we introduce an interferometric technique, surmounting challenges of bulk motion to apply it in awake humans. We reveal two measurement dimensions: optical phase, and time-of-flight (TOF), the latter with 22 picosecond resolution. With this multidimensional data, we directly confirm the unordered, or Brownian, nature of optically probed RBC dynamics typically assumed in classical DOF. We illustrate how incorrect absorption assumptions, anisotropic RBC scattering, and layered tissues may confound classical DOF. By comparison, our direct method enables accurate and comprehensive assessment of blood flow dynamics in humans. Diffuse optical flowmetry is widely used to assess blood flow dynamics, but has remained difficult to interpret. Here, the authors use interferometric near-infrared spectroscopy, revealing additional information about optical phase and time-of-flight, and observe the Brownian nature of blood flow dynamics in humans. Coherent NIRS aims to assess dynamics of turbid media through fluctuations of multiply scattered light7. In particular, diffusing wave spectroscopy/diffuse correlation spectroscopy (DWS/DCS) probes red blood cell (RBC) dynamics related to blood flow deep in biological tissues from coherent light intensity fluctuations8.The separation and characterization of light paths in random media are a goal in many fields, including colloid science, fiber-optic communications, and biophotonics. Near-infrared spectroscopy (NIRS) endeavors to assess deep biological tissue in vivo by measurements of highly scattered near-infrared light, which can penetrate centimeters beneath the surface before detection. NIRS measures either incoherent or coherent light intensity. Incoherent NIRS includes continuous wave (CW-) NIRS10 is paramount, and methods of diffuse optical flowmetry (DOF) including DWS/DCS and related coherent techniques (e.g. laser Doppler11 and laser speckle12) are widely used8. In the diffuse scattering regime, relevant for probing deep tissue, while the theory connecting scatterer dynamics to light fluctuations is established13, these methods remain largely empirical, without a proven physical model for RBC motion (i.e. advection or Brownian motion). There are two major reasons for this disconnect. First, classical DWS/DCS cannot resolve light dynamics in time-of-flight (TOF), though efforts are underway to improve TOF discrimination16. Second, though DWS/DCS autocorrelation decay times correlate empirically with blood flow17; counterintuitively, the functional form of observed autocorrelations resembles theory for Brownian motion, not random flow8. At intermediate source–detector (SD) separations, these issues are further confounded by the fact that single scattering with Brownian motion and diffuse scattering with random flow both yield similar TOF-integrated intensity autocorrelations19. Numerical simulations of correlation transport theory in synthetic vascular beds support the Brownian motion model in larger vessels with laminar flow20. However, existing in vivo TOF-integrated measurements are simply too coarse to assess competing physical models, as many models fit experimental observations22.Measuring blood flow in tissues such as the brain23 for human use use Fig. , thus bruse Fig. . In contNon-contact assessment of optical field fluctuations in humans requires management of motion artifacts. A uniform axial sample velocity imparts a linear phase shift to the sample field, and thus, the estimated field autocorrelation. Consequently, if the sample velocity changes randomly during the time window for autocorrelation estimation, sample dynamics are overestimated  maximum , where ∆θbps and ∆τd are bulk Doppler phase shift and lag time resolution, respectively. Therefore, we assume a uniform Doppler velocity over this short window. The Doppler phase/frequency shift can be approximated from the peak of the Fourier transform of 27, and the fractional blood volume of most tissues is typically on the order of 5% or less29. As the sole intrinsic dynamics of static tissue are slow intracellular motility, we propose that this Doppler shift is caused by bulk axial motion of the sample. The bulk Doppler phase shift is summed cumulatively over time and unwrapped to yield the cumulative unwrapped phase, θbps. Conversion from cumulative unwrapped phase to axial shift Z based on Z(td) = θbps(td)λ0/(4π) suggests micrometer-scale bulk motion  is less striking due to the higher intrinsic decay time, but still significant. As shown in Supplementary Fig. 25.Furthermore, rotation in the mutual coherence function is eliminated by motion correction , and accounting for different center wavelengths, yields excellent correlation R2 = 0.95 , human forearm, nude mouse head, and human forehead  consistead Fig. . The staead Fig.  that decead Fig. , the staead Fig. , motion ead Fig.  are incread Fig. , which head Fig. , which w= 0 (Eq. ), as pre= 0  and bi-exponential (5-parameter) fits. Besides improving the adjusted R2 at intermediate TOFs, . The adFs, Fig.  the empigIL ~ 0.632 versus gRBC ~ 0.97533).Based on the empirical 5-parameter fit, TOF-resolved amplitudes were constructed for the static, slow, and fast components and compared across tissues Fig. . First, Next, we examined changes during various manipulations with TOF-dependent averaging. For separate nude mouse head measurements, we injected 0.1 mL of Intralipid-20% intravenously, which increases the number of dynamic scattering events and momentum transfer Fig. , and per31. Importantly, the fast dynamic component increased during all manipulations , such paths remain probable up to intermediate TOFs  of DWS/DCS is highly dependent on the fit region. On the other hand, integrating just the iNIRS fast component (red) or iNIRS early lag fits (cyan) alone yielded better agreement with DWS/DCS theory, resulting in the same BFI regardless of fit region  achieves only modest agreement with iNIRS , we also performed 3-parameter early time lag iNIRS fitting (approach 2), which has a more solid theoretical foundation in the cumulant approximation  remain challenging to interpret. Simulations have suggested that RBC migration in laminar shear flow, describable as a diffusion process39, provides a plausible explanation for Monte Carlo simulations40. However, the applicability of this concept in capillaries with single-file RBC flow, which account for a majority of microvascular volume, remains unclear. In laser Doppler or laser speckle, which do not possess TOF resolution, it is always possible to invoke contributions from longer, multiply scattered paths to explain exponential autocorrelation decays via an advection, or random flow, model19.In DWS/DCS, a Brownian motion model fits experimental autocorrelation functions better than a more intuitive random flow model. Though BFI empirically correlates with standard flow measures42. The connection of such findings to those presented here, if any, requires further investigation.On the other hand, iNIRS can assess TOF-resolved dynamics essentially independently of the TOF distribution of photons. The observation of exponential decays at early time lags and late TOFs in iNIRS autocorrelations (22 ps TOF resolution) provides the most comprehensive experimental support, to date, for a Brownian model of RBC displacement in coherent light scattering, rendering a pure advection model of RBC motion untenable. Nonetheless, our results are not inconsistent with a hybrid model that incorporates advection and Brownian motion. Our simulations showed that a hybrid model does not alter the bi-exponential character of the TOF-resolved field autocorrelations, but does change the relative decay rates and amplitudes of the fast and slow components , and its amplitude was diminished by Intralipid injection in vivo, strongly suggesting an association with RBC scattering anisotropy. Likewise, in our simulations  must dominate advection (Δr2 ~ τd2) at sufficiently short time scales. Thus, as our results support the presence of Brownian motion, to the extent that DWS/DCS succeeds in isolating the earliest time scales, DWS/DCS will observe Brownian motion. Second, our survey of literature indicates that DWS/DCS early time lag fits often deviate from long decay tails47 at short SD separations. Our deconstruction of DWS/DCS at short SD separations  flow probed at early TOFs, and higher CBF probed more at late TOFs. These data invalidate the assumption of a semi-infinite homogenous medium in DWS/DCS, providing the most direct evidence, to date, of long-assumed differences11. We present a unified and comprehensive approach to characterize this process in human tissues, employing an interferometric technique to add new dimensions to experimental measurements. With TOF-resolved autocorrelations, we provide evidence of light paths sampling dissimilar dynamics in multilayered tissues. By applying DWS/DCS theory at early time lags, our approach recovers blood flow indices without explicit knowledge of absorption. At late time lags, we also identify distinct signatures of light paths experiencing small momentum transfer at dynamic scattering events . These physical insights could lay the groundwork for a more comprehensive theory that includes late time lags to yield even more information about blood flow dynamics. This work demonstrates that TOF-resolved field dynamics can provide more accurate assessments of blood flow with near-infrared light, through direct observation and also by informing our interpretation of classical techniques.Coherent light transport in vascularized tissue is a complex sequence of static and dynamic scattering events25. By measuring the interference spectrum of light traversing biological tissue and light traveling a reference path, the technique yields a mutual coherence function, Γrs between the sample and reference fields, where τs is TOF and td is delay time. From a time series in td, iNIRS provides a TOF-resolved optical field autocorrelation, s, τd),d is time lag and brackets denote expectation or averaging over td25. The iNIRS field autocorrelation is related to intrinsic medium field autocorrelation, G1, by a convolution (*) in TOF (τs) with the system instrument response function (IRF):iNIRS is a TOF-resolved method for quantifying field dynamics in turbid mediaIiNIRS(τs) = s, 0)  = G1, by IiNIRS(τs) = I(τs) ∗ IRF(τs). Therefore, while iNIRS is a coherent method, it also provides a TPSF just like incoherent TD-NIRS23. By comparison, DWS/DCS assesses, via the Siegert relationship, TOF-integrated field autocorrelations,ĪDCS is the average detected intensity. Compared to DWS/DCS, iNIRS avoids two problematic operations in Eq.  Fig. , which is in Eq. 51.a and 23. At null SD, we chose a fitting region that starts at a lower TOF of 100 ps for all samples, to ensure validity of the diffusion approximation for radiative transport, while the upper TOF was adjusted based on SNR , measured at SD = 7.6 mm, where iNIRS recovers iNIRS provides a TPSF, which can be fitted with the convolution of the system instrument response function (IRF) and the TOF-resolved diffusion approximation, to extract the absorption and reduced scattering coefficients, μe2 and 1 mW with a limiting aperture of 3.5 mm, for iNIRS and OCT respectively, adheres to ANSI limits. The bulk Doppler phase shift is given byz and ∆x are motion in the axial and lateral directions, respectively, αSD is the angle between iNIRS illumination and detection, and λ0 is the center wavelength (855 nm for iNIRS and 1320 nm for OCT). Note that no additional steps were taken to stabilize the forearm.The configuration for validating iNIRS estimation of bulk phase shifts is shown in Fig. r2(τd)>. For diffusion, <Δr2(τd)> = 6DBτd where DB is the effective Brownian diffusion coefficient. For this model, BFI = αDB has been proposed8. For random flow, <Δr2(τd)> = v2τd2, where v is the standard deviation of the velocity distribution. For this model, BFI = αv2 has been proposed22. For hydrodynamic diffusion, <Δr2(τd)> = 6DB{τd − τC[1 − exp(−τd/τC)]}, where DB is the hydrodynamic diffusion coefficient and τC is the time scale required to establish Brownian motion21. For this model, BFI = αDB has been proposed22. A hybrid model including random flow and Brownian motion, where <Δr2(τd)> = 6DBτd + v2τd2, has also been investigated.The goal of coherent optical flowmetry is to infer motion of scattering particles from field autocorrelations. Particle motion is characterized by the mean-squared displacement as a function of lag time, <Δ11 that tissue light scattering is a sequence of intravascular dynamic and extravascular static scattering events  with magnitude q = |q|, static scattering fraction ηc, and dynamic scattering fraction ηf = 1− ηc,Here we adopt the view7, the normalized TOF-resolved field autocorrelation s, τd) is given byL = cτs/nr is the photon path length, c is the speed of light in vacuum, nr is the group refractive index , k = 2πnr/λ0 is the medium wavenumber, and λ0 is the free space central wavelength. A probability of dynamic scattering, α, is included in DWS theory to account for the presence of static scatterers46. Comparing dynamic components of DLS (Eq. (In the diffusing wave spectroscopy (DWS) regimeDLS (Eq. ) to DWS iNIRS affords the unique ability to measure TOF-resolved autocorrelations spanning from the DLS to the DWS regimes. We might expect that DLS theory (Eq. ) describa and s, τd) = s, τd)/IiNIRS(τs) with Eq.  versus τs. The extra τs dimension provided by iNIRS yields a richer data set than DWS/DCS to evaluate candidate BFI models, and does not require knowledge of, or assumptions about, absorption. However, the convolution (TOF-integration) in Eq. (d) and a random flow model (Gaussian decay in τd), fine TOF resolution, not mere TOF discrimination14, is essential. In this study, the iNIRS TOF resolution, δτs = 21.9 ps, corresponding to a path length resolution of 6.6 mm in vacuum, is the highest value reported to date53.DWS/DCS provides a TOF-integrated field autocorrelation (Eq. ) via thewith Eq.  to yield) in Eq.  may resu52:If is the TOF-dependent coefficient accounting for the dynamic component of the field, while Ic accounts for the possible presence of static paths. While Eq.  and DWSNote that while the 3-parameter fit is well-founded in DLS and DWS theory, we provide no theoretical justification for the 5-parameter fit. Though the 5-parameter fit was generally required, in the DWS regime, at long TOFs and early time lags, decays are purely exponential. In such circumstances, to reduce the number of parameters, it is reasonable to use a 2-parameter fit:Finally, well into the DWS regime, the normalized autocorrelation is described even more succinctly by a 1-parameter fit:In DWS (Eq. ), for Brs,0 = 0, we allow for a non-zero intercept with the TOF axis. This semi-empirical adjustment to theory is believed to account for in vivo media with a thin superficial layer that has comparatively little blood flow relative to the deeper layers, such as the outer layers of the skin in humans, or the scalp and skull in mice. Applying Eq.  and αDB = 1.18 × 10−8 cm2 s−1  resolution of 10 μs. A lag time resolution of 10 μs for an exponential field autocorrelation is equivalent to a lag time resolution of 5 μs for the corresponding exponential intensity autocorrelation. The end-to-end tuning range was 64.7 GHz, enabling a TOF resolution of 21.9 ps (IRF FWHM). This TOF resolution exceeds that of state-of-the-art TD-NIRS systems53 as well as TD-DCS14. The spectral interference signal from the balanced detector was acquired continuously in blocks of 2.5 s at a 200 MHz sampling rate, along with laser sweep triggers. Forward and backward sweeps were segregated, resampled, reshaped, and Fourier transformed as previously described26, forming a complex mutual coherence function time series, Γrs, at each TOF (τs) with 250,000 delay time (td) points, from which autocorrelations s, τd) were calculated. All samples were illuminated with 20 mW across a spot size of ~2 mm (1/e2), strictly adhering to the tissue irradiation limits set by the American National Standard Institute (ANSI). The single mode source and detector fibers are collimated with off-the-shelf adjustable aspheric FC collimators (Thorlabs CFC-2X-B). Mouse experiments were performed with the animal in a stereotaxic frame under 1–1.5% isoflurane in a mixture of air and oxygen. All procedures and protocols involving human subjects research were approved by the UC Davis Institutional Review Board and all procedures involving animal subjects were approved by the UC Davis Institutional Animal Care and Use Committee (IACUC).The iNIRS light source Fig.  is an 8552, we reduced the source–detector separation here to collect light from intrinsically static tissue and increase the number of detected photons at all times of flight37. In this approach, the large backscattered/few-scattered component at early TOFs can obscure later TOFs if the IRF has sidelobes. In contrast with TD-NIRS, the iNIRS TPSF is obtained by Fourier transforming the measured interference signal, enabling apodization techniques to reduce sidelobes, and in turn, increase dynamic range as described in Supplementary Fig. Compared to our previous work26. In contrast, iNIRS, without gating, achieves comparable dynamic range (~70 dB) to state-of-the-art TD-NIRS systems54, without exhibiting afterpeaks, and maintaining high peak-to-sidelobe ratio (~40 dB)26. Finally, our interferometric approach is uniquely suited for operation under ambient light conditions.The interferometric strategy also obviates photon counting detectors (i.e. PMTs and SPADs) susceptible to afterpulses and/or diffusion tails, which reduce dynamic range and contaminate information at long times of flightFurther information on research design is available in the Supplementary InformationReporting Summary


Background: Sweetpotato, being a vegetatively propagated crop is prone to seed degeneration, and a continuous source for high quality sweetpotato seed is critical for an efficient seed system.  In most Sub-Saharan African countries, the National Agricultural Research Systems use tissue culture to produce limited quantity of pre-basic sweetpotato seed which is then used as starting material to maintain and produce basic seed in mini-screen houses, net tunnels or open field multiplication in low-virus pressure areas by either the private seed companies or vine multipliers. Soil is the predominant media for pre-basic seed multiplication. Multiplying pre-basic sweetpotato seed in sand with fertigation, also known as ‘sandponics’ is a possible opportunity towards sustainable production of pre-basic sweetpotato seed. It would be beneficial to examine the feasibility and the potential to replace soil system with ‘sandponics’ for growing pre-basic sweetpotato seed.Methods: Pot experiments were conducted to study how sweetpotato vine propagation is affected by sequentially omitting nitrogen, phosphorus, calcium, sulfur and boron from fertilizer applications on cv. Kabode. The experiment was laid in a randomized complete block design with five levels of the factor fertilizer, replicated four times with two blocks. The effect of fertilization of nitrogen at , phosphorus at , calcium at , sulfur at  and boron at  ppm on sweetpotato vegetative growth parameters was measured 45 days after planting.Results: The obtained results showed that application of 200, 60, 200, 120 and 0.3 ppm of N, P, Ca, S and B respectively recorded the highest values in sweetpotato vegetative growth parameters.  Conclusions: These results imply that pre-basic sweetpotato vine yields in sandponics could be increased by using this optimized media. Ipomea batatas L.) is a staple food for smallholder farmers in much of Sub-Saharan Africa. The crop has an annual worldwide production of more than 105 million metric tons  and prolonged droughts that either compromises the quality or availability of vines from the previous season’s crop. Insufficient planting materials limit the adoption and utilization of improved sweetpotato varieties . MultiplCrop Nutrition Laboratories, Kenya for nutrient analysis using colorimetric , Muguga, Kenya, located at 1° 11’ 0” South, 36° 39’ 0” East at an altitude of about 1950m above sea level. The study involved sequentially increasing levels of nitrogen, phosphorus, sulfur, calcium and boron on sweetpotato vine yields in sandponics . The firimetric  and specimetric  methods All the fertilizers used in the study  easily doC  was used to schedule fertigation frequency.Data on petiole length, internode length, vine length, vine girth, leaf area and nodes produced were recorded 45 days after planting (Dataset 001 ). PetiolPetiole length (cm); this was determined by measuring the point between leaf attachment to the main stem and the leaf, the measurements were done on the fifth leaf from the tip of the main stem.Vine length (cm); this was determined by measuring the main stem length from the surface of the soil in the pot to the tip.Internode length (cm); this was determined by measuring the fifth internode from the tip of the main stem.2);Leaf area (cm this was determined by measuring leaf length (L) and width (W) at the widest part of the 5th leaf from the tip of the main stem and the product L × W was used to compute for leaf area (cm2/plant).Vine girth (cm); this was determined by measuring the fifth internode girth diameter from the tip of the main stem using vernier caliper.Nodes produced; these were counted on the main stem from the surface of the pot to the fully open leaf at the tip of the vine.Nutrient disorders; nutrient disorders were visually observed and recorded.Shoot fresh and dry mass (g); at harvesting, four vines from each replication for each treatment were sampled to constitute a composite sample for above ground biomass determination. Harvested fresh shoot samples were separated from roots for each treatment, weighed and then heated to a constant weight in an oven for 48h at 65°C. These were re-weighed to determine the dry weight (Dataset 002 (set 002 ).Fresh and dry root mass (g); composite samples for fresh root samples from four plants for each replication from each treatment were harvested, weighed and heated to a constant weight in an oven for 48h at 65°C and these were then reweighed to determine the dry weight (Dataset 003 (set 003 ).Leaf tissue analysis; the blades of the 7th to 9th youngest leaves from the shoot tip were randomly selected as the index tissue to form a composite sample  pots exhibited N deficiency symptoms two weeks after planting when the crop had two fully expanded leaves. Plants showed stunting with minimal expansion of the leaf area  applied resulted in reduction but not significant growth of internode length, leaf area, petiole and vine length compared to plants grown at 200 ppm N . NitrogeResults in the growth of internode length, leaf area, petiole length, nodes production, above ground fresh weight and N tissue accumulation suggest that optimal growth in these parameters can be achieved when N concentration is 200 ppm. This data showed that as N rate increased from 0 – 250 ppm, there was an increased significant growth in the vine length, vine internode length, leaf area, petiole length and nodes production. Increase in above ground fresh biomass accumulation was also noted , howeverSophora secundiflora), Anthurium (Anthurium andraeanum Lind.) and bell pepper (Capsicum annum L.), which all reported a similar range of nitrogen fertilization rate for optimal haulm growth Chlorosis, curling and distortion of younger growing apical leaves in calcium omitted nutrient media corroborated with report byThe present data  additionThe positive effect of calcium on the significant growth of sweetpotato vegetative internode length, leaf area, vine girth and vine length might have been due to the calcium functions as a second messenger in the signal conduction between environmental factors and plant responses in terms of growth and development . MoreoveThe superior effects of calcium at 200 ppm in enhancing the growth parameters described above may also be due to its physiological effects on sweetpotato plants. The positive effects of calcium on vine yield and its components might be due to calcium being a component of the middle lamella and is essential for intracellular membrane transport. Likewise, calcium is known to act as a signaling molecule that regulates metabolism, controlling respiration and reducing ethylene production in plants . TherefoThere was a non-significant decrease in growth in leaf area  and lessIncreased fertilization with sulfur caused a significant increase in internode length at P≤0.05 . There wth to 9th open leaf blades from the shoot tip as a percentage of each of the five treatment levels resulted in a luxury consumption within the plateau region  which reported that a transient deficiency of boron can lead to irreversible damage thus seriously affecting yields  vine multiplication in sandponics: Unlocking the adoption and utilization of improved varieties,/HK3T4. The dataset contains the following files:Dataset. 001. Relationship between sweetpotato vegetative growth parameters and the supply of N P Ca S & B across a range of levels.Dataset: 002. Composite fresh and dry above ground biomass of sweetpotato vines as affected by increased fertilization of N, P, Ca, S & B.Dataset. 003. Composite fresh and dry root biomass of sweetpotato vines as affected by increased fertilization of N, P, Ca, S & B.Data is available under a CC.0 1.0 Universal License Generally the paper is well written and scientifically sound in terms of design and conduct of the experiment. However, I have some suggested editorials for consideration.Petiole length (cm) second line: Consider adding “lamina” after the second “…leaf” Page 4, under   Results and Discussion Page 4, under Nitrogen rate, first paragraph: Consider replacing “on received all nutrient” with “that received all nutrients” Page 4, under Nitrogen rate, fourth paragraph, line 4: Change “N concentration” to “N application rate” Page 4, under Nitrogen rate, fourth paragraph, line 12: consider replacing “level” with “concentration” Page 4, under Nitrogen rate, fourth paragraph, line 13: Replace “when its value was relatively lower than” with “till”. Page 4, under Nitrogen rate, fourth paragraph, line 14: consider replacing “level” with “concentration” Page 4, under Nitrogen rate, fourth paragraph, line 16: Replace “increment of N levels in the plant tissue” with “advantage in increasing N levels.” Page 4, under Nitrogen rate, fourth paragraph, line 17: Replace “when N tissue was approximately 5.01% or above it” with “N application levels beyond 200 ppm” Page 4, under Nitrogen rate, fourth paragraph, line 20: Insert “levels” between “fertilization” and “increased” Page 4, under Nitrogen rate, fourth paragraph, line 20: Replace “until 5.01% N accumulation in plant tissue when” with “plant tissue N concentration to 5.01% beyond which” Page 4, under Nitrogen rate, fourth paragraph, line 22: Insert “in plant” between “N” and “tissue” Page 5, under Nitrogen rate, figure 2(f): Reverse the axis so that “N supplied (ppm)” becomes the x-axis so the picture can become clearer. Page 6, under Nitrogen rate, Table 3: This table can be fused into Table 4 by adding two columns to Table 4 to accommodate the two extra columns (N leaf level (%) and AGFW (g)) included in Table 3. Page 6, under Nitrogen rate, Table 3: For the 150 ppm level, the AGFW (g) is much higher than what was obtained for the much higher levels of 200 and 250 ppm N application. This needs to be explained. Page 6, line 3: Insert “below” between “approximately” and “4.0%” Page 6, under Boron leaf tissue accumulation as affected by increased nitrogen application, second paragraph, line 4: Replace “greenhouse studies” with “greenhouses”. Page 6, under Boron leaf tissue accumulation as affected by increased nitrogen application, third paragraph, line 3: Insert “accumulation in” between “nitrogen” and “tissue”. Page 6, under Boron leaf tissue accumulation as affected by increased nitrogen application, second paragraph, line 5: Replace “above 5.01% nitrogen tissue” with “leaf tissue nitrogen concentration of above 5.01%”. Page 6, under Boron leaf tissue accumulation as affected by increased nitrogen application, second paragraph, line 10: Insert “; respectively” before the citation. Page 6, under Phosphorus rate, first paragraph, line 4: Replace “growth” with “length”. Page 9, under Phosphorus rate, first paragraph, line 2: Insert “accumulation” before “reached” Page 9, under Phosphorus rate, first paragraph, line 5: Replace “leaf tissue” with “application levels”. Page 9, under Phosphorus rate, first paragraph, line 1-5: Check P leaf tissue % at 120 ppm, it went up contradicting your statement. Please clarify. Page 9, under Phosphorus rate, second paragraph, line 9: Delete “documented”. Page 9, under Phosphorus rate, third paragraph, line 17: Insert “beyond 60 ppm” before “resulted” Page 10, under Calcium rate, first paragraph, line 7: Delete “above” Page 11, under Sulfur rate, second paragraph, Line 1: The internode length was not consistently increasing with increased levels of the S applied. From your data (Table 4) S does not seem to be affecting internode length that much as the variation up and down attests. In some cases, no S had longer internodes than 30 and 60 ppm. Page 13, under Boron rate, fourth paragraph, line 1: Consider replacing “documented by preceding” with “reported by previous” The information in Table 4 is also repeated in Tables 3, 5, 6, 7 and 8. My suggestion is that you delete Table 4 and add the summary statistics  at the bottom of the respective tables. The subtitle “unlocking the adoption and utilization of improved varieties" does not seem to have been addressed. You may need to consider dropping it.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. To better design the experiment and optimize the nutrient media, the composition of the sand soil should be assessed.1, how to prove the symptoms of yellow leaves was caused by B deficiency?Why choose the trace elements of Boron? The fertilizer composition used in the experiment is 2.5% B and 0.036% Mo. We know Mo is also an important trace element in leaf growthDuplicate content reduction. The content of tables and figures needs to be simplified, for example, we can obtain the information from Figure 3 in Table 4.The study is designed appropriately and the work is technically sound, but somethings need to be refined.We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Paralytic ileus is characterized by the signs and symptoms of intestinal obstruction but without any mechanical lesions in the intestinal lumen. Several medical and surgical conditions can lead to this ailment, such as electrolyte disturbances that impair intestinal motility. However, hypercalcemia secondary to multiple myeloma as a major cause of paralytic ileus has rarely been reported.The patient got severe constipation with difficulty in the passage of both gas and feces for 7 days.The patient was diagnosed with a small intestinal obstruction initially and then developed type II respiratory failure. Investigations revealed hypercalcemic crisis, and examination of a bone marrow aspirate was consistent with multiple myeloma.Conservative treatment was administered for the intestinal obstruction, consisting of food and water deprivation, gastrointestinal decompression, colonic irrigation, intravenous fluid transfusion, anti-inflammatory therapy. Invasive respiratory support was provided after type II respiratory failure occurred and salmon calcitonin was used to reduce the blood calcium level. Further therapy was given by the Department of Hematology and Oncology in our hospital after the diagnosis of multiple myeloma.Spontaneous respiration and gastrointestinal function were restored after the correction of hypercalcemia.An appropriate diagnostic approach is needed in emergency practice to identify the paralytic ileus and type II respiratory failure caused by hypercalcemia secondary to multiple myeloma. Nevertheless, the condition can be difficult to diagnose because it can be caused by a diverse array of conditions, including postoperative intra-abdominal adhesions, superior mesenteric vessel thrombosis, electrolyte disturbances, and even occult diseases.29/L (3.5 × 109–9.5 × 109/L); neutrophil count, 6.97 × 109/L ; hemoglobin, 98 g/L (115–150 g/L); and platelet count, 272 × 109/L (125 × 109–350 × 109/L). Owing to the increased blood calcium level, hyperparathyroidism was suspected; however, the parathyroid hormone (PTH) level was found to be normal .A 47-year-old woman was admitted to our hospital because of severe constipation with difficulty in the passage of both gas and feces for 7 days. Approximately 3 weeks before admission into our hospital, she had been diagnosed with renal inadequacy at a local hospital. Blood tests at that hospital revealed a serum creatinine (SCr) level of 238 μmol/L  and a blood urea nitrogen (BUN) level of 14.6 μmol/L . During the course of medical treatment for her renal condition, she developed ileus. Upon presenting to our hospital, she reported no history of abdominal surgery. An examination revealed mild tenderness in the epigastrium on palpation, with slightly increased muscle tone and no rebound tenderness. Abdominal auscultation showed decreased bowel sounds (about 3 per minute). An abdominal computed tomography scan displayed small intestinal obstruction . Although receiving this conservative therapy, the patient developed type II respiratory failure. At that time, her blood calcium level was 3.70 μmol/L. Invasive respiratory support was provided, and salmon calcitonin  was used to reduce the blood calcium level. Additionally, we performed tests for inorganic phosphorus, serous free-λ light chains, B2-microglobulin, and 24-hour urinary λ-light chains and κ-light chains to explore the etiopathogenesis of the hypercalcemia. The results  were as follows: 24-hour urinary λ-light chains, 1035.00 mg/24 h (<7.8 mg/24 h); serous free-λ light chains, >1230 mg/L (8.30–27.00 mg/L); and B2-microglobulin, 20.00 mg/L (0.7–1.8 mg/L). From these results, multiple myeloma was suspected. Therefore, a bone marrow needle biopsy was performed, and the results confirmed a diagnosis of multiple myeloma (Figs. 3,4 Multiple myeloma is a malignancy of the plasma cells; the condition is initially localized to the bone marrow, from where cells eventually disseminate and form bone lesions. Multiple myeloma accounts for approximately 10% of all hematological malignancies. Hypercalcemia, which can range in presentation from mild to severe and life threatening, is the most common metabolic complication of multiple myeloma and occurs in approximately one-third of patients. The primary cause of hypercalcemia in myeloma is widespread tumor-induced bone destruction. This is primarily because of increased osteoclastic bone resorption induced by potent cytokines expressed or locally secreted by the myeloma cells or overexpressed by other cells in the local microenvironment. This bone resorption in turn leads to the efflux of calcium into the extracellular fluid, leading to hypercalcemia.In our patient, multiple myeloma presented as renal dysfunction, paralytic ileus, and ultimately type II respiratory failure because of hypercalcemic crisis. Hypercalcemia is an uncommon cause of small bowel obstruction. The most common causes of hypercalcemia are primary hyperparathyroidism and malignancy. Most studies emphasize that it is associated with rapid deterioration of the central nervous system as well as cardiac, renal, and gastrointestinal dysfunction, resulting in renal failure, encephalopathy, cardiac dysrhythmias, and even death.The clinical presentation of hypercalcemia is frequently dependent on the blood calcium level. With a blood calcium level of 3 mmol/L or less, patients may be asymptomatic. At levels of 3 to 4 mmol/L, patients may present with symptoms such as dry mouth, anorexia, vomiting, polyuria, polydipsia, depression, abdominal pain, constipation, or confusion. With a calcium level of 4 mmol/L or greater, a life-threatening coma, known as hypercalcemic crisis, may develop. reported a case of acute colonic pseudo-obstruction secondary to hypercalcemia. Cases of paralytic ileus caused by hypercalcemic crisis because of adult T-cell leukemia or because of chemotherapy for multiple myeloma have also been reported.–13 However, few cases of hypercalcemic crisis secondary to multiple myeloma itself and presenting with paralytic ileus have been reported. In this case, we believe hypercalcemia played a crucial role in the pseudo-obstruction of the intestine, because no definite mechanical cause for the ileus was found in our patient. Moreover, the occurrence of ileus was accompanied by a rise in serum calcium levels, and correction of hypercalcemia rapidly relieved the paralytic ileus and restored gastrointestinal motility. Furthermore, no other electrolyte disturbance was found during the course of ileus. Additionally, type II respiratory failure occurred when the blood calcium level reached 3.70 μmol/L. We considered that the respiratory failure was attributable to respiratory muscle paralysis or pulmonary calciphylaxis secondary to hypercalcemia.Hypercalcemia can also lead to paralytic ileus. Tsai et al4Hypercalcemia secondary to multiple myeloma may create conditions that lead to paralytic ileus and type II respiratory failure, and thus, a diagnostic approach that can identify this condition is needed in emergency practice.


Neuropsychology, Volume 32, Issue 7, October 2018 http://dx.doi.org/10.1037/neu0000493) the copyright attribution was incorrectly listed and the Creative Commons CC-BY license disclaimer was incorrectly omitted from the author note. The correct copyright is “© 2018 The Author(s)” and the omitted disclaimer is below. The online version of this article has been corrected.In the article “The Ipsilesional Attention Bias in Right-Hemisphere Stroke Patients as Revealed by a Realistic Visual Search Task: Neuroanatomical Correlates and Functional Relevance” by Björn Machner, Inga Könemund, Janina von der Gablentz, Paul M. Bays, and Andreas Sprenger (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Copyright for this article is retained by the author(s). Author(s) grant(s) the American Psychological Association the exclusive right to publish the article and identify itself as the original publisher.”“This article has been published under the terms of the Creative Commons Attribution License (


The treatment effect of dapoxetine in real-world practice is not well established. This study was to investigate the factors influencing efficacy of dapoxetine for the treatment of Premature ejaculation (PE) in the real-world setting.Altogether 154 patients were followed up between Jan 2015 and Dec 2015. The clinical global impression of change (CGIC), premature ejaculation profile (PEP), the estimated intravaginal ejaculation latency time (eIELT) and estimated number of intravaginal thrusts before ejaculation (NITBE) were collected. The clinical characteristics of patients with CGIC = 0 and CGIC≥1 were compared.P < 0.001) and mean NITBE . The proportion of patients with a self-evaluation of at least “slightly better” and were categorized into “CGIC≥1” group was 70.1%. There were significant differences between patients in the “CGIC = 0” and “CGIC≥1” groups regarding mean NITBE (P = 0.010) and PEDT (P = 0.009) score at baseline. The adverse effects were acceptable.After 4 weeks treatment, an obvious improvement compared with the baseline was found regarding mean eIELT (2.4 ± 1.6 min vs 1.0 ± 0.7 min, Dapoxetine was well-tolerated and improved the sexual satisfaction of patients with PE. The severity of PE based on PEDT and NITBE suggest that there could be an effectiveness change with dapoxetine use in real-world practice. N = 6081) [Premature ejaculation (PE) is one of the most of prevalent male sexual disorders, with a reported incidence of 21–33% in some populations [ = 6081)  and by a = 6081) .Most data on the efficacy of dapoxetine are derived from clinical trials involving Western participants, and results from clinical trials may not be consistent with the results observed in the real-world practice. Clinical trials follow strict protocols involving patients with pre-defined inclusion criteria and results are obtained under ideal conditions. In contrast, clinical practice has several associated challenges including low rates of compliance, economic considerations, and a lack of awareness of the condition by the spouse, and these factors may influence the real-world utility of treatments for PE. In real-world setting dapoxetine treatment discontinuation was high. Mondaini et al.  reportedFurthermore, stopwatch-determined intravaginal ejaculation latency time (IELT) is the most common measure to diagnose and evaluate treatment efficacy in clinical trials, which is not appropriate in real world practice. In the clinical setting, stopwatch-determined IELT is substituted by self-estimated IELT, which is often overestimated by patients .In this study, we sought to evaluate the treatment effect of dapoxetine on Chinese patients with PE in the real-world practice, and to investigate factors influencing treatment efficacy of dapoxetine.This open-label, retrospective and observational study included patients with PE who accepted dapoxetine treatment in real-world practice. All patients reported short intravaginal latency, and at least ‘moderate’ distress or interpersonal difficulty relating to their PE at baseline. To be included in the study, patients had to be over 18 years, and were required to be in a heterosexual, stable, and monogamous sexual relationship with the same partner for at least 6 months. The Premature Ejaculation Diagnostic Tool (PEDT) was used to diagnose PE , 10. PatAfter a 4-week run-in period, patients were asked to take dapoxetine 30 mg 1–3 h before planned sexual intercourse. No other PE therapies were provided during the study period. Patients were assessed after 4 weeks of treatment, and were required to engage in sexual intercourse at least 6 times during the 4-week study period.All measures including eIELT and estimated number of intravaginal thrusts before ejaculation (NITBE) were evaluated at baseline and at week 4. The definition of NITBE was the frequency of penile moving forward and backward in female vaginal. The patients were demanded using the similar frequency and depth of insertion as before and recorded the average NITBE.Patient were required to answer the question from CGIC “Compared to the start of the study, would you describe your premature ejaculation problem as much worse, worse, slightly worse, no change, slightly better, better, or much better?” and the answers were scored from 0 to 3  respectively. Patients were also assessed based on the Premature Ejaculation Profile (PEP) ; a validPatient Health Questionnaire (PHQ-9) and General Anxiety Disorder-7 (GAD-7) questionnaire were used to evaluate patients’ depression and anxiety , 13. TheStatistical analysis was carried by using SPSS 20.0 . Continuous variables normally distributed were expressed as mean ± SD, otherwise median and range  were used. For categorical variables, frequency and percentile were used to describe the data. Patients were categorized into two groups based on their answer to CGIC after 4 weeks treatment: “CGIC = 0” group vs “CGIC≥1”.P value of less than 0.05 was considered as statistically significant. The receiver-operating curve for treatment effect was also analyzed.Clinical characteristics between the two groups were compared using Chi-square or Mann-Whitney test. The comparison of IELT and NITBE before and after treatment was performed using paired T test. All statistical tests were two-tailed and a P < 0.001) and mean NITBE   for 4 weeks were included in this study. One hundred fifty-four patients were followed up and their data were analyzed and compared at baseline and after dapoxetine treatment. The mean age was 32.5 ± 6.8 range: 21–61) years. After 4 weeks treatment, there was an obvious improvement compared with the baseline regarding mean eIELT . At baseline, 20.1 and 0% of patients reported fair or good satisfaction with sexual intercourse which increased to 35.1 and 35.7% at week 4, respectively (P < 0.001). At baseline, 30.5 and 41.6% of patients reported moderate or quite a bit of ejaculation-related personal distress which decreased to 19.5 and 7.8% at week 4, respectively (P < 0.001). At baseline, 35.7 and 15.6% of patients reported moderate or quite a bit of interpersonal difficulty which decreased to 16.9 and 4.6% at week 4, respectively (P < 0.001).Substantial improvements were found in all PEP measures Fig. . At baseP = 0.010) and mean PE severity at baseline measured by the PEDT was 15.7 ± 2.7 and 14.5 ± 2.6, respectively (P = 0.009), which indicated that the severity of PE and reduced NITBE prior to treatment may be associated with reduced treatment effect. A ROC curve was made to illustrate the relationship between PEDT scores and treatment effect . Baseline characteristics were also similar, including age, PE duration, previous treatment, and intercourse frequency .Overall, 108 patients (70.1%) answered the CGIC question with “slightly better”, “better” or “much better”, and were categorized into “CGIC≥1” group , side effects (n = 5), and low frequency of sexual intercourse (n = 3). Of the patients who completed the 4-week treatment regimen, 72.2% would like to continue dapoxetine therapy. Treatment emergent adverse events (TEAEs) were reported in 32 patients (20.8%), that mainly included headache (7.1%), dizziness (7.1%), nausea (4.5%), somnolence (1.9%) and nasal congestion (1.9%). Most TEAEs were mild or moderate in severity and resolved without treatment.Regarding adverse effects, 21 patients (13.6%) eventually discontinued dapoxetine treatment, and the reasons included lack of efficacy . Dapoxetine also improved overall sexual satisfaction, and reduced mental consequences including personal distress and interpersonal difficulty [Based on a pooled analysis of five randomized, placebo-controlled, phase 3 clinical trials, dapoxetine, given on-demand, could delay ejaculation approximately 2.5–3 fold and the therapy efficacy were better in those with lower baseline IELT. After 12 weeks 30 mg or 60 mg dapoxetine treatment, 62.1 and 71.7% of subjects reported that their PE was at least “slightly better”, while in the control group this proportion was only 36.0%  [In this study, a total of 70.1% of patients reported that their PE was at least “slightly better” with dapoxetine treatment, and 40% of patients evaluated their treatment effect as “better”. Yang et al.  reportedDapoxetine was well-tolerated with 72.2% of patients stating that they would continue dapoxetine therapy. In our study, 64.4% of patients who discontinued dapoxetine treatment complained of lack of efficacy which was consistent with the main reasons for discontinuation of dapoxetine or SSRIs in phase 3 clinical trials .In the reported phase 3 trials, 64.9% of the study population were primarily categorized as patients with lifelong PE [P = 0.5) and estimated baseline IELT (P = 0.16) did not affect CGIC rating of “slightly better” in 285 Asia-Pacific men with PE. Patients with a lower PEDT score and a higher NITBE at baseline responded better to dapoxetine.Several factors may impact IELT and thus causing strong interpersonal differences which are reflected in the distribution of IELT values , includiInterestingly, eIELT was not significantly different between” CGIC = 0″ and” CGIC≥1″ groups, suggesting that eIELT might be poorly estimated in the real-world setting. Lee et al.  comparedThe stopwatch-determined IELT measured by female partner might not be suitable in real world practice, although it is considered the most objective measure for PE evaluation in clinical trials. Therefore, there is a need for a simple, relative and reliable tool for PE evaluation in real world practice. In this study, we have introduced NITBE as a measure for PE evaluation. We found that baseline NITBE could predict dapoxetine treatment efficacy, and therefore, might be a useful measure for PE evaluation and might be more accurate than eIELT.Waldinger et al.  proposedOur study has several strengths, including the analysis of co-existing clinical factors that potentially impact PE, and we firstly used NITBE to evaluate PE and found better role of NITBE on PE evaluation than eIELT. In further studies, we will compare NITBE with stopwatch-determined IELT in healthy men and patients with PE. Despite its novel findings, the present study does have some limitations. This was a retrospective, open-label study and the sample size was small relative to clinical trials; there might be some inevitable bias due to the retrospective nature. A further prospective study would be required to reduce bias and increase the strength. A further limitation of the study was that objective stopwatch-determined IELT is difficult to obtain accurately in real world practice, thus clinical trials are required to testify the impact of frequency of penile movement on NITBE. Therefore, patients were included in the study based on the PEDT score, and patient-reported measures included PEP, CGIC and NITBE. Besides although PEP questionnaire has been used in previous studies focusing on Chinese patients , the linDapoxetine treatment increased CGIC, eIELT and NITBE and was well-tolerated with an acceptable safety profile. Patients with less severe PE based on PEDT and higher NITBE seemed to have better efficacy with dapoxetine.Additional file 1. Part of the database. Some information of the database, including IELT, NITBE and PEDT.


Scientific Reports 10.1038/s41598-017-02456-y, published online 24 May 2017Correction to: The authors felt they should cite the following article by Ohashi M, et al. 2015), which is included below as Reference 5, which Specifically, in the Introduction the sentence,23.”“Recently, Li et al. have achieved high efficiency (8–76%) of genome editing by using an episomal vector to express Cas9 and gRNAshould read:23, 1.”“Recently, two groups have achieved high efficiency of genome editing by using an episomal vector to express Cas9 and gRNA in both human somatic cells and mouse iPSCsIn addition, in the Discussion, the sentence:23.”“When we were preparing the manuscript, another group reported that the episomal CRISPR/Cas9 system could work efficiently in HeLa cells and mouse iPSCsshould read:23, 1.”“Two groups have reported that the episomal CRISPR/Cas9 system could work efficiently in both human somatic cells and mouse iPSCs


As per the AHI, 75% protrusion was effective in severe cases, whereas 50% protrusion was effective in moderate cases. Analysis of different surrogate outcomes indicated that 75% protrusion was more effective. Further, well-designed, larger trials should determine the benefits for patients. Additionally, investigations of adherence and side effects with long-term follow-up are needed.This systematic review clarifies the amount of effective protrusion in mandibular advancement devices of oral appliances required for obstructive sleep apnea (OSA). The systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Review Manager 5 and GRADEpro were used to combine trials and analyze data. The present review included three studies. In mild to moderate OSA cases, measured using the apnea–hypopnea index (AHI), 50% protrusion was more effective than 75% protrusion. However, 75% protrusion was more effective for severe cases. Sleep stage, Epworth Sleepiness Scale (ESS), snoring index, and side effects significantly differed between the groups. Additionally, 75% protrusion was more effective (AHI: 0.38, 95% CI: −0.89 to 1.65,  More than 3 million people have sleep disorders such as obstructive sleep apnea (OSA), which also includes latent sleep apnea. OSA has been shown to be associated with hypertension, depression, and lifestyle-related diseases ,2,3. OSAThis systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this review was registered with the international prospective register of systematic reviews (PROSPERO) with the registration number CRD42019136242.Equipment that acquires upper and lower jaw impressions for every patient, which is thus precisely produced.A device that exerts an effect by maintaining the lower jaw in the forward direction.The definition of OAThe diagnostic and therapeutic effects of OSA are determined by either polysomnography (PSG) or out-of-center sleep testing (OCST).Subject is under 18 years of age.The device is ready-made.The device exerts an effect by maintaining the tongue in the forward orientation.Equipment size, designMaterial characteristics ThicknessDetailed design of the device Excluding comparison with forward movement of 0 mm (placebo)The primary database used was MEDLINE (via PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL), and Japan Medical Abstracts Society Research (Ichushi-Web). No limits were set with respect to the year of study or language. We selected only randomized controlled trials (RCTs) in the OAm design. A thorough literature search was conducted that was completed on 27 April 2019. A search strategy was executed using the keywords shown in Box 1#1. “Sleep apnea”[TIAB] OR “Sleep apnoea” OR “Sleep Apnea Syndromes”[MeSH] OR “Sleep apnea syndrome”[TIAB] OR “Sleep apnoea syndrome”[TIAB] OR “Sleep apnea hypopnea syndrome”[TIAB] ”Sleep apnea, Obstructive”[MeSH] OR “Obstructive sleep apnea”[TIAB] OR “Obstructive sleep apnoea” OR “Obstructive sleep apnea syndrome”[TIAB] OR “Obstructive sleep apnoea syndrome”[TIAB] OR “Obstructive sleep apnea hypopnea syndrome”[TIAB] OR “Sleep disordered breathing”[TIAB] OR “Sleep related respiratory disorder”[TIAB] OR “Sleep respiratory disorder”[TIAB].#2. “Orthodontic appliances”[MeSH] OR “Orthodontic appliance”[TIAB] OR “Orthodontic device”[TIAB] OR “Orthodontic splint”[TIAB] OR “Oral appliance”[TIAB] OR “Oral device”[TIAB] OR “Oral splint”[TIAB] OR “Mandibular advancement appliance”[TIAB] OR “Mandibular advancement device”[TIAB] OR “Mandibular advancement splint”[TIAB] OR “Dental appliance”[TIAB] OR “Dental device”[TIAB] OR “Dental splint”[TIAB] OR “Mandibular repositioning appliance”[TIAB] OR “Mandibular repositioning device”[TIAB] OR “Mandibular repositioning splint”[TIAB] OR “Prosthetic mandibular advancement”[TIAB] OR “Mandibular Advancement/instrumentation”[MeSH].#3.  NOT .#4. #1 AND #2 AND #3The search strategy used for MEDLINE:#1. ((Sleep apnea) OR (Sleep apnoea) OR (Sleep apnea syndrome) OR (Sleep apnoea syndrome) OR (Sleep apnea hypopnea syndrome) OR (Obstructive sleep apnea) OR (Obstructive sleep apnoea) OR (Obstructive sleep apnea syndrome) OR (Obstructive sleep apnoea syndrome) OR (Obstructive sleep apnea hypopnea syndrome) OR (Sleep disordered breathing) OR (Sleep related respiratory disorder) OR (Sleep respiratory disorder)):ti,ab,kw#2. ((Orthodontic appliance) OR (Orthodontic device) OR (Orthodontic splint) OR  OR  OR  OR (Mandibular advancement appliance) OR (Mandibular advancement device) OR (Mandibular advancement splint) OR  OR  OR  OR (Mandibular repositioning appliance) OR (Mandibular repositioning device) OR (Mandibular repositioning splint) OR (Prosthetic mandibular advancement)):ti,ab,kw#3. #1 AND #2The search strategy used for Cochran Central Register of Controlled Trials:#1. “Sleep apnea, obstructive”[TH] OR “Obstructive sleep apnea”[TA] OR “Sleep apnea syndrome”[TH] OR “sleep apnea syndromes”[TA] OR “Sleep apnea”[TA] OR “Sleep hypopnea”[TA] OR “sleep disordered breathing”[TA] OR “sleep related respiratory disorder”[TA] OR “Sleep respiratory disorder”[TA]#2. “Oral appliance”[TA] OR “Oral splint”[TA] OR “Occlusal splints”[TH] OR “Sleep splint”[TA] OR “Splint”[TH] OR “Mandibular advancement device”[TA] OR “Mandibular advancement”[TA]#3. #4. #1 AND #2 AND #3The search strategy used for Igaku Chuo Zashi (Ichushi-Web):The selection of papers was made in two stages. First, two authors individually selected the articles from titles and abstracts. If in doubt, another author checked for confirmation. In the second stage, full-text papers were reviewed by two authors, and if in doubt, three authors examined them.2, arousal index, sleep efficiency, sleep stage (NREM stage 3), subjective daytime sleepiness , and snoring index (SI). Surrogate outcomes #2–4 were adherence (the duration of OA usage at night and the number of days the device was used in the preceding week), sleep-related quality of life , and hypertension (systolic blood pressure and diastolic blood pressure), respectively. Surrogate outcome #5 consisted of side effects, including temporomandibular disorders , tooth pain, occlusal changes (overbite or overjet), changes in occlusal contact, and changes in bite force. Finally, surrogate outcome #6 was patient preference. If the standard error of the mean (SEM) was reported for outcomes in the examined studies, the standard deviation (SD) was then calculated from the number of subjects in the study and the reported SEM.Data were extracted independently by three authors. The following important information was collected: author name, year of publication, duration of the study arms, age of participants, study design, number of patients and dropouts, mean age, severity of AHI, and mean body mass index (BMI). The primary outcomes were mortality rates and cardiovascular events. Surrogate outcome #1 consisted of treatment effect, including AHI , lowest SpOThe Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Approach was used to evaluate the overall quality of the evidence utilizing Review Manager 5 . Quality assessment of the study and any discrepancies were resolved by discussion among the seven authors.The search identified 617 articles from the database  . After rThe Aarab (2009)  study waThe primary outcome of OSA treatment is the improvement of life prognosis and the prevention of cardiovascular disease. However, surrogate outcomes are often used as read outs because they require long-term research. A list of surrogate outcomes based on available reports was charted out ,9. As a p = 0.58), and if classified according to severity, 75% protrusion is effective in moderate-severe OSA . At mild to moderate levels, 50% protrusion was effective . ESS has been reviewed in two papers, and overall, 75% protrusion was more effective . REM sleep in stage 3 was found to be more often associated with 75% protrusion , and SI improved with 75% protrusion . The horizontal axis of the forest plot in Using AHI as the standard measurement, 75% protrusion is effective .Side effects were reviewed in two papers, and 75% protrusion had fewer side effects than in 50% protrusion (RR: 1.89; 95% CI: 0.36–9.92; The evidence profile was calculated using the GRADEpro software, as shown in There are two types of OAm: the monobloc type device and the bibloc-apnea splint type. In Japan, the monobloc type is widely used and the upper and lower parts of the device are fixed with resin. Therefore, the initial position of the device is important. Many dentists set mandibular protrusion at 70% at the beginning of treatment; however, whether this position is the best is unclear. This review revealed that 75% protrusion was effective for severe OSA and 50% protrusion was effective for moderate OSA. It is thought that 50% protrusion in severe cases does not ensure a sufficiently open airway. Improvements in sleep stage 3, ESS, and SI were observed with 75% protrusion compared with 50% protrusion. OAm have better effects when a larger forward protrusion is used. An increased protrusion ensures that a wide airway is opened, thereby ameliorating drowsiness. OAm causes the lower jaw enclosure to widen, and thus, the size of the airway is increased . A largeHowever, side effects such as temporomandibular disorder and discomfort may be increased. Adverse effects of OAm, such as long-term use, tooth movement, short-term temporomandibular joint, and muscle pain, have also been reported, but only a few studies seem to compare the amount of forward movement . Less thThrough this review, we recommend that for patients with severe OSA, it is beneficial to begin with a mandibular protrusion of approximately 70%, and in cases of mild to moderate OSA, begin with that of approximately 50%. Further, well-designed, larger trials are required to determine the long-term benefit for patients. Specifically, investigation of adherence and side effects of long-term follow-up are needed.


Elevated levels of serum homocysteine (Hcy) have been associated with cardiovascular diseases and endothelial dysfunction, conditions closely associated with erectile dysfunction (ED). This meta-analysis was aimed to assess serum Hcy levels in subjects with ED compared to controls in order to clarify the role of Hcy in the pathogenesis of ED.  Medline, Embase, and the Cochrane Library were searched for publications investigating the possible association between ED and Hcy. Results were restricted by language, but no time restriction was applied. Standardized mean difference (SMD) was obtained by random effect models. p < 0.0001. Subgroup analysis based on prevalence of diabetes showed significantly higher SMD in subjects without diabetes (1.34 (95% CI 1.08–1.60)) compared to subjects with diabetes (0.68 (95% CI 0.39–0.97), p < 0.0025 versus subgroup w/o diabetes).  A total of 9 studies were included in the analysis with a total of 1320 subjects . Pooled estimate was in favor of increased Hcy in subjects with ED with a SMD of 1.00, 95% CI 0.65–1.35, CRD42018087558. Results from our meta-analysis suggest that increased levels of serum Hcy are more often observed in subjects with ED; however, increase in Hcy is less evident in diabetic compared to nondiabetic subjects. This study is registered with Prospero registration number  Prevalence of erectile disorders increases steadily with aging, from 1 to 10% in men younger than 40 years up to 70–100% in men older than 70 years . It is wHowever, given the importance of hemodynamics in allowing adequate erection, it should come as no surprise that ED shares the same risk factors of many cardiovascular (CV) affections .μmol/l in serum Hcy levels, whereas Clarke et al.  OR (“erectile”[All Fields] AND “dysfunction”[All Fields]) OR “erectile dysfunction”[All Fields]) OR ((“penile erection”[MeSH Terms] OR (“penile”[All Fields] AND “erection”[All Fields]) OR “penile erection”[All Fields] OR “erectile”[All Fields]) AND (“physiology”[Subheading] OR “physiology”[All Fields] OR “function”[All Fields] OR “physiology”[MeSH Terms] OR “function”[All Fields])) OR  OR “sexual behavior”[All Fields] OR “sexual”[All Fields]) AND (“physiopathology”[Subheading] OR “physiopathology”[All Fields] OR “dysfunction”[All Fields])) AND (“homocysteine”[MeSH Terms] OR “homocysteine”[All Fields]). The search, which accrued data up to February 28th 2018, was restricted to articles written in English, Italian, or French and studies including human participants. The identification of relevant studies was performed independently by two of the authors  into two separate standard Excel templates which were then cross-checked by the other author. Extracted data included data sources, eligibility, methods, participant characteristics, and results. Heterogeneity in serum Hcy levels was assessed using I2 statistics. Even when low heterogeneity was detected, a random effect model was applied, because the validity of tests of heterogeneity can be limited with a small number of component studies. We used funnel plots and the Begg adjusted rank correlation test to estimate possible publication or disclosure bias ; however, undetected bias may still be present because these tests have low statistical power when the number of trials is small. Statistical analysis was performed independently by two authors (SA and CA) with the meta package on the statistical software R (version 3.4.2) [Data from retrieved study were extracted and entered twice by two authors (n 3.4.2) .Out of 30 retrieved articles, 9 were included in the study . The stuI2 in studies assessing serum Hcy in men with or without ED was 85.3% ). Serum Hcy was significantly higher among subjects with ED compared to controls )  suggested no publication bias (The 5–1.35)) . A funneion bias .p < 0.0025 versus subgroup w/o diabetes). Despite remaining higher in the subgroup with “mixed” prevalence of diabetes, heterogeneity is remarkably reduced in both other subgroups.Sensitivity analysis was then performed based on prevalence of diabetes. Five studies –28 had dThe results of our meta-analysis suggest that Hcy is significantly associated with ED, showing a mean increase of 1.00 standard deviation between controls and ED patients. Among patients with ED, sensitivity analysis has shown that when stratified for presence of diabetes, subjects without diabetes are more likely to have increased levels of serum Hcy compared to diabetic subjects; conversely, this association appears evident in patients with diabetes even for small variation of Hcy, or rather, it could be argued that in diabetic patients, a small increase of Hcy is enough to negatively affect erectile function. In fact, the difference between diabetic and nondiabetic patients might suggest that in the presence of comorbidities, small changes in serum Hcy might negatively be involved in erectile function, based on the premise that multiple risk factors might act in a synergistic, rather than additive, fashion , 34. ThiAs previously stated, HHcy is closely associated with endothelial dysfunction. Studies in animal models have proven that HHcy markedly inhibits NO formation in rabbit isolated corpus cavernosum . NO actsOur study has some limitations, most notably the small number of studies involved and the lack of a clear definition of ED. A single study  assessedResults from our meta-analysis suggest that increased levels of serum Hcy are more often observed in subjects with ED: based on existing literature on this topic, a causative role for HHCy as an independent risk factor for ED can be postulated, although confirmation would require interventional studies aimed to decrease serum Hcy levels considering erectile function as primary outcome. Actually, only in rat model of HHcy has been observed an improvement in erectile function after being treated with a demethylation agent . We also


Excess weight and unexpected weight loss are associated with multiple disease states and increased morbidity and mortality, but weight measurement is not routine in many primary care settings. The aim of this study was to characterise who has had their weight recorded in UK primary care, how frequently, by whom and in relation to which clinical events, symptoms and diagnoses.A longitudinal analysis of UK primary care electronic health records (EHR) data from 2000 to 2017. Descriptive statistics were used to summarise weight recording in terms of patient sociodemographic characteristics, health professional encounters, clinical events, symptoms and diagnoses. Negative binomial regression was used to model the likelihood of having a weight record each year, and Cox regression to the likelihood of repeated weight recording.A total of 14,049,871 weight records were identified in the EHR of 4,918,746 patients during the study period, representing 26,998,591 person-years of observation. Around a third of patients had a weight record each year. Forty-nine percent of weight records were repeated within a year with an average time to a repeat weight record of 1.92 years. Weight records were most often taken by nursing staff (38–42%) and GPs (37–39%) as part of a routine clinical care, such as chronic disease reviews (16%), medication reviews (6–8%) and health checks (6–7%), or were associated with consultations for contraception (5–8%), respiratory disease (5%) and obesity (1%). Patient characteristics independently associated with an increased likelihood of weight recording were as follows: female sex, younger and older adults, non-drinkers, ex-smokers, low or high BMI, being more deprived, diagnosed with a greater number of comorbidities and consulting more frequently. The effect of policy-level incentives to record weight did not appear to be sustained after they were removed.Weight recording is not a routine activity in UK primary care. It is recorded for around a third of patients each year and is repeated on average every 2 years for these patients. It is more common in females with higher BMI and in those with comorbidity. Incentive payments and their removal appear to be associated with increases and decreases in weight recording. Excess weight is associated with increased risk of multiple disease states such as type 2 diabetes, cardiovascular disease, osteoarthritis and cancer, with increased morbidity and mortality –4. GPs uWeight loss is a feature of a wide range of conditions, such as cancer, anorexia, frailty and thyrotoxicosis , 11. UneThe UK NHS’s Quality and Outcomes Framework (QOF) was introduced in 2004, linking remuneration for general practices to recorded quality of care for chronic conditions . QOF indComprehensive data on weight recording in primary care are not available. We therefore characterised weights recorded in the UK primary care EHR over time and the relation to clinical events, symptoms and diagnoses.We accessed the Clinical Practice Research Datalink (CPRD) GOLD database, an ongoing primary care database of anonymised EHR data covering 6.9% of the UK population, representative in terms of age, sex and ethnicity, in which information is recorded as Read codes . PatientTo ensure that we only included episodes of weight recording, we extracted weight measurement values associated with each Read code for weight recording and used a published method to identify and drop implausible values . BrieflyBaseline characteristics (at study entry) were determined for the closest record prior to each patient’s study entry date. These were gender, age group, smoking status, alcohol intake, ethnicity, BMI group, IMD deprivation quintile and consultation rate in the year before study entry.People were classified as having a comorbidity if they had a code indicating this, using a list of the most common comorbidities reported in primary care –22 plus We assessed whether particular clinical events that we thought might prompt weight recording were indeed related to weight recording. We discussed this list of clinical events and checked the codes that indicated these using the CPRD Read code library. These were as follows: registration, health check, chronic disease monitoring, medication review, contraception, pregnancy, weight monitoring and lifestyle advice. The profession of the staff member recording the weight was categorised as follows: GP, nurse, midwife/health visitor, pharmacist, administrator and dietician.We classified the presenting problem using the International Classification of Primary Care (ICPC) using code lists for symptoms/complaints and other diagnoses developed for a recent study .The proportion of patients with a weight record each calendar year was calculated. We assessed whether this differed by patient characteristics and over time, calculating 95% confidence intervals, allowing for partial overlapping samples . LikewisA mixed effects negative binomial regression (NBR) model with an offset term for log-person-years of follow-up was used derive the incident rate ratio (IRR) for relative likelihood of having a weight record in each calendar year whilst allowing differing follow-up periods. Patient sociodemographic characteristics, including consultation rate in the previous year, were included as fixed effects with the patient identifier included as a random effect. All characteristics were included in both univariable and multivariable models without selection. Due to computational difficulties, this model could only be fitted for a 10% random sample of 491,171 patients.To examine the likelihood of patients having a repeat weight record, we measured the time from first weight recording during the study period until second weight recording or study exit (censored). Adjusted hazard ratios (HR) were derived for all patients using multivariable Cox regression. Models included sociodemographic and ICPC symptom and diagnostic characteristics related to the consultation in which the first weight record occurred and the consultation rate in the previous year.The baseline characteristics of the cohort can be found in Table Of 4,918,746 adults in CPRD during the study period, 3,372,536 (68.6%) had at least one weight record: representing 62.7% of males and 73.6% of females. By year, the proportion of patients with at least one weight record increased from 19.9%  in the year 2000 to 38.5% (38.4–38.6%) in 2012, falling back to 31.5% (31.4–31.7%) in 2017  records were repeated within a year; 2,126,504 (15.1%) between 1 and 2 years; 1,429,614 (10.2%) between 2 and 6 years and 212,323 (1.5%) in longer than 6 years, and 3,372,536 (24.0%) were never repeated. For those with at least one measurement, the average rate of weight recording was one record every 1.92 years . This interval was shorter for females (1.77); those aged 70–79 years (1.58) and 60–69 years (1.62); with low BMI (1.81), obesity (1.55) and morbid obesity (1.08); and with lower deprivation and increasing comorbidity ; lifestyle advice (10.4%); a contraception consultation 10.3%); a health check (6.2%); a medication review (6.1%) and practice registration (2.1%). GPs (38.8%) and nurses (37.9%), and other healthcare professional groups  (12.2%) recorded weight most often. Similar patterns were observed in previous years, although it appeared that nurses provided a declining proportion of weight recording over time , within which the most common items “W14 Contraception other” (7.8%) and “W11 Contraception oral” (5.2%); “R – Respiratory” (5.0%)” within which the most common items “R02 Shortness of breath/dyspnoea” (3.0%) and “R05 – Cough” (1.6%); “A – General and Unspecified” (4.6%), “A23 Risk factor NOS” (2.2%), A29 – General symptom/complaint other” (0.35%); “K- Cardiovascular” (4.3%); “D – Digestive” (2.6%); and “L – Musculoskeletal” (2.5%)  within which the most common items being “T99 Endocrine/metab/nutrit. dis. other” (12.8%), “T90 Diabetes non-insulin dependent” (1.9%) and “T82 Obesity” (0.9%); “A – General and Unspecified” (8.1%), “A98 Health maintenance/prevention” (6.78%), “A92 Allergy/allergic reaction NOS” (1.0%), “A99 General disease NOS” (0.8%); “R – Respiratory” (5.3%), “R96 Asthma” (3.7%), “R95 Chronic obstructive pulmonary dis” (1.0%), “R74 Upper respiratory infection acute” (0.2%); “S – Skin” (1.5%); “K – Cardiovascular” (1.2%); L – Musculoskeletal” (0.8%) ) and a repeat weight record (HR 1.30 (1.29–1.30)  each demonstrated a distinct pattern of association Fig. a, b. ComA sensitivity analysis removing weight records at practice registration only slightly attenuated these associations (data not shown).This analysis of over 14 million weight records in 5 million patients’ EHRs shows that only a third of UK adult patients have a weight recorded in primary care in any given year. Those with a weight record had a repeat record within 2 years on average. Weight records were most often taken by GPs and nursing staff as part of activities such as a health checks, chronic disease and medication reviews, or were associated with consultations for contraception, obesity and respiratory disease. Patient characteristics independently associated with an increased likelihood of weight recording were as follows: female sex, younger and older age, almost all ethnic groups bar the white group, non-drinkers, ex-smokers, low or high BMI, being more deprived, being diagnosed with a greater number of comorbidities and consulting more frequently.This is the largest and most comprehensive analysis of the determinants of weight recording and repeat weight recording in primary care to date. We are aware of no other study adjusting for consultation rate, which has enabled us to report independent associations with repeat weight recording. We ensured we only counted true weight records by using established methods to identify erroneous records .However, our dataset is limited to recorded weights that were coded within the structured EHR, because access of free text data is not possible in the CPRD. However, chronic disease reviews and health checks, and less frequently contraception and medication reviews, are completed using EHR templates that facilitate structured data entry, so that there may be few data hidden in the free text, although such entries may be clinically significant. For example, weight recording outside of templates may be associated with symptoms and diagnoses that prompt the clinician to think about weight, such as possible cancer. Even so, by including only coded weight information, our analysis may overemphasise clinical events with templates driving weight recording.To acknowledge variation in clinical practice, we adopted a broad and inclusive approach to capturing symptoms and diagnoses associated with weight recording (ICPC). “General and unspecified” featured as one of the most common ICPC categories for symptoms and diagnoses associated with weight recording representing some overlap with chronic disease review, health check and registration events. Furthermore, the characteristics we selected for investigation were clinically driven, but other researches may have chosen different ones. However, we developed our code lists from pre-existing published lists and both clinical and non-clinical researchers reached consensus on which codes to include. To enable readers to judge this, the code lists are available on request from the corresponding author.A final key issue is that we can only assess that a weight was recorded, but not whether it was measured. For example, many UK practices ask patients to complete a short questionnaire on registration with the practice, which asks for patients’ weight and height. Whilst we did exclude records likely to relate to registration, it is impossible to separate reported from measured weights in this study.A systematic review from 2017 reported a third of adults had their BMI recorded within a year in UK primary care, half within 3 years and two thirds within 5 years . OverallWhilst QOF may have increased the completeness of weight recording in UK primary care, there are concerns that QOF has had a selective effect on increasing weight recording. For example, in one study in 2015, 97% of people with diabetes had a weight recording but only 54% of people without diabetes . Other sWe are not aware of any other study that has reported frequency or determinants of repeated weight recording. Previous authors have hypothesised that higher consultation rates drive increased weight recording but none have investigated this formally , 27. We During routine care, GPs and nurses report that concerns about alienating patients, limited time, and a poor understanding about obesity care prevent them from broaching the topic of weight . Our stuFor those with a lower BMI, increased weight recording may represent monitoring a patient known to have a low BMI or be an opportunistic weight measurement when a patient attends with (or without) a weight-related complaint. Little is published about patient or clinician preference for weighing underweight patients, but this is an important area to understand if weighing is to become a routine activity for people without an existing disease.Patients with a healthy BMI were less likely to have weight recorded. If it were routine to measure weight, as recommended in international obesity guidelines , concernPrevious authors have suggested that patterns of weight recording could be used in prediction modelling as recording weight is an informative process (not missing at random) if careful attention is given to developing appropriate methods to avoid bias . FurtherWeight recording is not routine in UK primary care. It is recorded for around a third of patients each year and is repeated on average every 2 years for these patients. It is more common in females with higher BMI and in those with comorbidity. Incentive payments appear to be associated with increases and decreases in weight recording.Additional file 1.Box S1. Comorbidities included in the comorbidity variable. Table S1. Detailed Breakdown of weight recording by International Classification of Primary Care (ICPC) symptom coding group with the most common groups expanded to subgroups. Table S2. Detailed breakdown of weight recording by International Classification of Primary Care (ICPC) diagnosis coding group with the most common groups expanded to subgroups. Table S3. Univariable and multivariable negative binomial regression and Cox regression to estimate the unadjusted and adjusted likelihood of weight recording (incident rate ratio) and repeat weight recording (hazard ratio) by covariate.