The need to address the treatment gap in mental health services in low- and middle-income countries (LMIC) is well recognized and particularly neglected among children and adolescents. Recent literature with adult populations suggests that evidence-based mental health treatments are effective, feasible, and cross-culturally modifiable for use in LMIC. This paper addresses a gap in the literature documenting pre-trial processes. We describe the process of selecting an intervention to meet the needs of a particular population and the process of cross-cultural adaptation.Community-based participatory research principles were implemented for intervention selection, including joint meetings with stakeholders, review of qualitative research, and review of the literature. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) was chosen as the evidence-based practice for modification and feasibility testing. The TF-CBT adaptation process, rooted within an apprenticeship model of training and supervision, is presented. Clinical case notes were reviewed to document modifications.Choosing an intervention can work as a collaborative process with community involvement. Results also show that modifications were focused primarily on implementation techniques rather than changes in TF-CBT core elements.how to implement evidence-based treatments in LMIC.Studies documenting implementation processes are critical to understanding why intervention choices are made and how the adaptations are generated in global mental health. More articles are needed on  Mental health is a priority global health issue ,2. The mAll of these studies employed a task-shifting/sharing model, in which lay counselors, with little to no mental health experience, delivered the EBT. As the body of research on EBT in LMIC continues to grow, there has been increased attention and interest in the potential of task-shifting EBT to address the mental health treatment gap. For example, the World Health Organization (WHO) recommends EBTs as frontline treatments for moderate to severe symptoms of multiple mental health disorders in its Mental Health Gap Action Programme (mhGAP) .The use of EBTs in LMIC has been both heralded, given positive outcomes in RCTs, and controversial, as treatments are typically developed and transported from high-resource, “western” countries or contexts, which are culturally and contextually distinct. In the literature, some are of the opinion that efforts to address the treatment gap in LMIC should build and benefit from evidence in other settings (e.g. high-resource countries) ,13. EquaTo help guide efforts of transporting and testing EBTs, it is important to understand both how EBTs are selected and how cross-cultural adaptations are made. In the area of selection, a recent study clearly outlined a specific strategy for treatment selection in LMIC . The autTurning to cross-cultural adaptation of the EBT, a recent paper summarized adaptation and implementation of adult EBT in three RCTs conducted in Asia and Africa . The autPsychotherapeutic interventions for children differ from adult models in some important ways that could affect the choice of an EBT and its cross-cultural adaptation. First, most child and adolescent mental health EBTs include caregivers or supportive adults working throughout the model with the youth. In LMIC, this type of person may or may not be available, and the relationship between caregiver and child may be different across cultures and contexts. Second, youth EBTs span a rapidly changing developmental time period. Working with a 7-year-old versus a 16-year-old can significantly affect how the intervention is applied. Finally, working with children and adolescents usually requires additional safety and protection steps due to the lack of independence and/or legal rights of different aged children.There are data to suggest that child and adolescent mental health is a neglected area, with considerably fewer trials and overall implementation of programs than with adult populations . Yet theZambia has one of the highest HIV prevalence rates at 12.5% . HIV/AIDIn 2004, the Applied Mental Health Research Group (AMHR) at Johns Hopkins University  began thqualitative study to obtain the local population’s understanding of mental-health related problems; related causes; signs and symptoms; and what existing solutions are available. In Zambia, the qualitative study was conducted with HIV-affected children and caregivers and utilized both free listing (a convenience sample of 25 HIV-infected women and 20 HIV-affected children) and key informant interviews (N=21). Results (Step 2 in DIME) indicated a high prevalence of child trauma experiences, including sexual abuse, physical abuse, and domestic violence, resulting in trauma-related symptomatology and grief  a mepulation ; and 3) pulation   a center offering general counseling; 2) an ongoing study helping discordant HIV couples ; 3) HIV Scientific literature, web-based treatment clearinghouses, and the grey literature were reviewed by the research team to identify EBTs that addressed symptoms resulting from the experience(s) of trauma and/or grief. EBTs were also reviewed for the presence of effectiveness data, including if any cross-cultural studies had been done. Potential treatments were summarized and distributed to stakeholders via handouts in country for review. Treatments that were reviewed included TF-CBT , KidNET TF-CBT  is a manTF-CBT has 12 RCTs supporting its efficaciousness compared to supportive therapy, treatment-as-usual, and non-directive therapy in improving children’s post-traumatic stress disorder (PTSD), depression, anxiety, shame, and behavioral problems . Trials Treatment outcome and implementation research links fidelity of EBT to positive outcomes , yet thePrior to the training of the lay counselors and their local supervisors in TF-CBT, existing training materials were adapted by the lead trainer (LM) to replace technical terms, jargon, and American idioms with simple English terms and phrases. For example, the “affective modulation” component was referred to as “talking about feelings.” Adapted materials were reviewed by a TF-CBT developer and a Zambian colleague prior to the training to ensure that simplified language did not change core component goals and that the language and concepts were understandable.Two five-day TF-CBT live trainings were conducted in Lusaka, spaced by 2.5 months. All training was conducted in English, as English is widely spoken in the country. Twenty-two Zambian lay counselors  were trained in TF-CBT. Lay counselors were students from a local university (N=7), senior officials/staff at a local university (N=2), local staff of local and international NGOs (N=11), and workers from the University Teaching Hospital and the local psychiatric hospital (N=2). Trainees had varied experience and educational backgrounds in teaching or psychology; however, only three had any formal mental health training. Nineteen of the 22 lay counselors continued after the training providing TF-CBT in addition to their existing jobs and roles; three discontinued involvement due to demands at their current positions. Three local supervisors were chosen during the training based on demonstrating advanced skill at TF-CBT and leadership abilities . One local supervisor was a lecturer at the University of Zambia, one was a counselor from a NGO, and one worked as outreach staff at a local NGO. Since these local supervisors were trained alongside the lay counselors, they all participated in the adaptation process in the same way.The trainer (LM) didactically presented a component of TF-CBT and then modeled the component via a role-play. The Zambian trainees (inclusive of supervisors and counselors) then discussed the aspects that seemed appropriate and made recommendations for those that did not seem cross-culturally appropriate. For example, when parenting skills were discussed, all trainees felt that “time out” would likely not work due to logistics of the home . Following discussion, trainees broke into small groups (3-5 persons) to role-play the component themselves, with peer feedback. During this time, they were encouraged to try different implementation techniques they thought would work well with children in Zambia and report back to the larger group. The trainer rotated through groups to observe the role-plays, coach, and provide feedback. Following the role-plays, the larger group discussed effective and ineffective modifications. For example, while practicing “talking about feelings,” one counselor tried singing different songs for each emotion, which worked well. Another counselor tried playing a game that reportedly no one in the small group understood. The trainer’s role was to assess whether suggested modifications maintained fidelity to TF-CBT. At times, experiential training techniques were used to facilitate discussion about cross-cultural appropriateness. For example, to allow trainees to experience how receiving, or not receiving, praise feels, for one hour the trainer withheld praise or encouragement; during the next hour she provided frequent praise and encouragement. Trainees discussed these in-vivo experiences in the training.Following the in-person trainings, local TF-CBT practice groups were held each week for two hours led by three local supervisors (six counselors per group). Each week, counselors reviewed an agenda from the trainer with the goals of role-playing a particular component multiple times and further discussing cultural modifications. Notes were taken by the supervisor at each meeting and sent to the trainer via email, who then reviewed the modification suggestions for fidelity to the TF-CBT model. Shortly after the second training, local counselors and supervisors began participating in a one-year feasibility study on TF-CBT in which each counselor was expected to take at least one case. The primary goals of the feasibility study were to document the adaptations and assess the feasibility and acceptability of TF-CBT in Zambia. The adaptation process continued throughout the study with the local counselors and supervisors reviewing the modifications together and then presenting them to the trainer for a final “check” on fidelity to TF-CBT. The supervisors discussed modifications weekly so that these could be shared across all supervision groups.During the feasibility study, supervisors took notes at each group meeting on TF-CBT implementation with children and caregivers, as well as any cultural modifications made. Additionally, after each TF-CBT session, counselors themselves completed case notes that required documentation of components delivered, logistics  and details on implementation strategy . These notes were compiled and then reviewed by the training team  and the local supervisors , along with notes from the two trainings in Lusaka. A database was developed that detailed the implementation techniques across each component.The core components of TF-CBT were retained in Zambia. Local counselors reported in the training that they did not feel that any core components were inappropriate to the local context, although they did identify areas that needed modification. Adaptations are described in the following sections.TF-CBT “standard” psychoeducation goals addressed in the first session include 1) educating the family about trauma, trauma reminders, and related symptoms; 2) normalizing and/or validating traumatic reactions; 3) instilling hope for recovery; and 4) explaining TF-CBT. When children have been sexually abused, TF-CBT includes providing education about sexual abuse . In the initial training, local counselors warned that it was not customary for families to talk about anything sex-related, including naming genitals. Therefore, counselors introduced sexual education more gradually throughout the treatment and first gained permission from a caregiver. In some instances, they invited the caregiver into session to explain to the child that is was “okay and not disrespectful” to speak about sex in this particular context. While explaining the TF-CBT program, counselors also provided information about how TF-CBT differed from local “counseling.” Counselors explained that this modification was important because in Zambia the most common counseling experience is with Voluntary Counseling and Testing (VCT) for HIV. Counselors defined VCT in this context as receiving advice and usually lasting only for 1-2 sessions (5-20 minutes each).Zambian counselors, personal communication, 2007]. In TF-CBT, non-physical, positive parenting techniques  are taught. Counselors felt praise was appropriate but said it was also uncommon between caregiver and child. They collectively decided to use experiential scenarios and role-plays to introduce praise and determine caregiver perception of the utility. For instance, counselors described or role-played scenarios with mothers about a husband never giving praise for a good meal and then discussed how it felt if the husband verbalized that the meal was very good. The counselor then asked whether the parent would likely make that meal again. Counselors felt this approach was more culturally appropriate because parents may not automatically understand why one would praise a child or see the impact that praise can have on behavior. A qualitative study examining caregiver perspectives on TF-CBT indicated that praise was utilized and liked . Finally, local counselors did incorporate positive rewards, but needed to brainstorm first themselves and then with each family to identify non-tangible or non-purchased rewards for good behavior since much of the population struggled with poverty. Rewards most commonly used were: 1) release from a chore, 2) extra time with friends, 3) bringing a friend home to play, and 4) participation in extracurricular activities.In TF-CBT, “time out,” as a non-physical disciplinary strategy, is often taught. In Zambia, time out did not seem to be appropriate and was not taught to parents, as many of the families counselors were working with lived in a one-room “hut,” and there was no place to implement time-out. Moreover, as most children cared for younger siblings, parents found it unconstructive to have older children “waste” time unproductively in time-out. Clear, positive communication and effective commands were skills that local counselors liked and felt had value, but stated a challenge that “Zambian parents do not typically communicate with their children about daily events, thoughts, and feelings” .This paper describes the process for choosing an EBT for children in a LMIC and the adaptation of the treatment chosen—TF-CBT. This process involves a number of steps that build on one another using community-based participatory research principles . The trewith local counselors and stakeholders to make culture-specific applications [Like most EBTs, TF-CBT is manualized, with positive outcomes posited to be associated with high fidelity or adherence to the manual. Given the need for both fidelity and adaptation, it is critical to work collaboratively ications ,78, rathications  creates ications .The modifications made to TF-CBT in Zambia can be grouped into several major themes. First, engagement in treatment throughout included a larger family system, which is similar to other studies . GainingThis paper addresses a significant void in the literature by documenting the implementation processes of choosing and modifying an EBT, which are critical to reducing the youth mental health treatment gap in LMIC ,80. Thestechniques,” rather than alterations in core TF-CBT components or goals. This is similar to other research examining adaptations of EBTs in adults [Upon review of all the case notes, the adaptations made to TF-CBT were conceptualized by the authors as “modifications in n adults ,18,84. MAMHR: Applied Mental Health Research Group; CBT: Cognitive Behavioral Therapy; CPT: Cognitive Processing Therapy; CETA: Common elements treatment approach; CBO: Community-based organization; CBCR: Community-based participatory research; DIME: Design, implementation, monitoring, and evaluation; EBT: Evidence-based treatment; IPT: Interpersonal Psychotherapy; IPT-A: IPT for Adolescents; LMIC: Low- and middle-income countries; mhGAP: Mental health gap action programme; MDGs: Millennium development goals; NGO: Non-Governmental Organization; OVC: Orphans and vulnerable children; PTSD: Post-traumatic stress disorder; PTSD-RI: Post-Traumatic stress disorder reaction index Revision; RCT: Randomized clinical trial; TF-CBT: Trauma-focused Cognitive Behavioral Therapy; VCT: Voluntary Counseling and Testing; WHO: World Health Organization.The authors declare that they have no competing interests.LM conceived the idea for the manuscript and was the PI leading all activities. MK, and MI are local Zambians who significantly participated in the cross-cultural adaptation of TF-CBT in Zambia. LM, SD, SS, and JC discussed the fidelity of TF-CBT as it was designed. SD, PB, JB, and JC were involved in developing the research and methodology. All authors contributed to the writing of this manuscript. All authors read and approved the final manuscript.


MicroRNAs (miRNAs) are an emerging class of gene expression modulators with relevant roles in several biological processes, including cell differentiation, development, apoptosis, and regulation of the cell cycle. Deregulation of those tiny RNA molecules has been described frequently as a major determinant for the initiation and progression of diseases, including cancer. Not only miRNAs but also the enzymes responsible for miRNA processing could be deregulated in cancer. In this review, we address the role of miRNAs in the pathogenesis of breast cancer, since there are oncogenic, tumor-suppressive, and metastatic-influencing miRNAs. Additionally, the different detection platforms and normalization strategies for miRNAs will be discussed. The major part of this review, however, will focus on the capability of miRNAs to act as diagnostic, predictive, or prognostic biomarkers. We will give an overview of their potential to correlate with response to or benefit from a given treatment and we will consider their ability to give information on prognosis in breast cancer. We will focus on miRNAs validated by more than one study or verified in independent cohorts or where results rely on preclinical as well as clinical evidence. As such, we will discuss their potential use in the personalized management of breast cancer.The online version of this article (doi:10.1186/s13058-015-0526-y) contains supplementary material, which is available to authorized users. Histologically, breast cancer can be divided into in situ and invasive carcinoma, both of which can be further subdivided into ductal and lobular. Stratification by integrative clustering is based on genomic and transcriptomic data . mi. mi72]. Little is known about the correlation of histological subtypes and specific miRNA expression patterns and it is definitely worthwhile to further investigate this relation in the future.in situ and invasive ductal carcinoma (IDC). Giricz and colleagues [in situ to invasive lobular carcinoma. Van der Auwera and colleagues [Volinia and colleagues  found a lleagues  revealedlleagues  showed alleagues .Predictors help to individualize therapy and diagnosis of breast cancer, correlate with response to a given treatment, and determine the treatment benefit. Recently, several miRNAs have been described to serve as putative therapeutic targets. . Loss of MTDH restored sensitivity to tamoxifen and correlated with disease-free survival (DFS) in tamoxifen-treated patients [patients .miR-342 He and colleagues [lleagues  found thlleagues  verifiedmiR-221/222 The miR-221/222 cluster is an inhibitor of ERα and is being associated with tamoxifen resistance in breast cancer cells [er cells -84. Thiser cells .Let-7f Aromatase inhibitors are used in endocrine therapy since they decrease estrogen production by blocking the aromatase gene CYP19A1, a direct target of let-7 f. MiRNA expression profiling before and after treatment with letrozole showed an increase in let-7f in preclinical as well as clinical settings [settings .miR-210 Jung and colleagues [+ breast cancer before  and after neoadjuvant chemotherapy (NCT) that included trastuzumab. MiR-210 was the only miRNA with a significant upregulated baseline expression in the residual disease group before treatment. Therefore, high miR-210 baseline expression was associated with resistance to trastuzumab-included chemotherapy. Results were validated by comparing miR-210 expression in trastuzumab-sensitive and -resistant breast cancer cells and in an independent set of pre- and post-operative plasma samples. A significantly higher miR-210 level was found in the trastuzumab-resistant cells and in the independent patient cohort before surgery.lleagues  examinedDrug sensitivity varies with each patient, making predictors of benefit or resistance toward proposed chemotherapeutic agents essential. In this way, the proportion of patients with a beneficial treatment would increase and toxicity of ineffective treatments would be avoided.miR-125b Zhou and colleagues [lleagues  reportedlleagues , who replleagues  reportedmiR-30c Bockhorn and colleagues [lleagues  describelleagues .miR-21 Mei and colleagues [lleagues  reportedlleagues . The inclleagues .miR-34a Low levels of miR-34a rendered breast cancer cells more resistant to radiotherapy [otherapy . These fotherapy , who posotherapy .Since patients at higher risk might acquire differential therapeutic interventions, the search for prognostic biomarkers remains a continuous work in progress. Several gene-expression studies have identified new or improved miRNA prognostic markers, giving information on the course and outcome of disease in different subgroups of patients. To narrow this extensive area, we will emphasize those prognostic miRNAs that are being validated  but verified in more than one cohort or dataset. An overview of the miRNAs described in this review can be found in Table Let-7b and miR-205 Quesne and colleagues [in situ hybridization to study miRNA expression in a population-based breast tumor cohort and validated their findings by use of qRT-PCR. Deregulation of let-7b, which targets the oncogenes H-RAS and HMGA2, often occurs early in breast cancer progression and its expression is known to be downregulated during EMT and associated with less aggressive tumors [lleagues  revealede tumors ,98-100. Additionally, the authors reported miR-205 as another miRNA with positive prognostic value . MiR-205Two independent studies verified these results. Ma and colleagues  showed hmiR-375 Wu and colleagues [lleagues  applied lleagues . A diffelleagues .miR-30a The prognostic features of miR-30a were investigated in 221 patients with IDC [with IDC , showingwith IDC -107, negwith IDC . Reducedwith IDC  on a hetwith IDC .miR-342-5p miR-342-5p has a role in cell cycle progression and cell growth regulation. The latest research by Leivonen and colleagues [lleagues  demonstrmiR-497 miR-497 is a tumor-suppressive miRNA and its biological role is found in the regulation of the nervous system. Several studies examined miR-497 and found its expression to be significantly decreased in breast cancer compared with normal breast and negatively correlated with adverse clinicopathological characteristics. Shen and colleagues [lleagues  reportedlleagues .miR-122 Wu and colleagues [lleagues  identifimiR-27b-3p The miR-27 family is known to regulate cell cycle progression and survival by targeting the tumor-suppressive FOXO1 gene and is highly expressed in breast cancer [t cancer . In a ret cancer  aimed tot cancer .miR-21 miR-21, which has its biological role in development, morphogenesis, and differentiation, is known to be overexpressed in breast cancer [t cancer . The sigt cancer  found sit cancer . In a mot cancer .miR-210 Volinia and colleagues [lleagues  used deelleagues ,117.miR-9 The functional significance of miR-9 is evidenced by its regulative role in neurogenesis, development, and apoptosis. Dysregulation of miR-9 influences proliferation or metastasis formation and has been reported in cancer [+ cases, a lower 10-year LR-free survival was seen in patients with high miR-9 expression by using miRNA arrays [n cancer . In brean cancer . Zhou ann cancer  found miA arrays .miR-187 Using an in silico method in two independent breast cancer cohorts, Mulrane and colleagues [lleagues  identifimiR-155 Several studies demonstrated the involvement of miR-155 in biological processes, such as cell survival, growth, migration, and invasion [invasion ,25. Songinvasion  found a invasion  verifiedinvasion .MiRNA biogenesis (see Figure A differential expression of miRNA-processing enzymes may result in an altered turnover of pri- and pre-miRNAs, which may influence the biology and etiology of cancer. We  and otheBlenkiron and colleagues  demonstrAside from affecting the quantity, the miRNA biogenesis cascade may also affect the quality and function of miRNAs. MiRNAs exert their function in collaboration with various proteins in the RISC complex, such as the processing enzymes AGO2, DICER1, and TARBP2. When overexpression of a certain miRNA results in a predictive or prognostic potential, this property could be negated by inadequate expression of AGO2, the catalytic subunit of RISC. Therefore, the prognostic or predictive capability of certain miRNAs may depend on the status of particular miRNA-processing enzymes, which may in fact explain the discrepancy found between several studies.The role of miRNA-processing enzymes in breast cancer prognosis was also examined in different studies. For example, lower DICER1 levels are significantly associated with lower metastasis and DFS rates . In termOver recent years, several research groups have explored the regulatory potential of the miRNA class of small non-coding RNAs. Differences in expression of these miRNAs were used to explain the heterogeneity and disease pathology of several types of cancer. Aside from understanding the biochemical mechanisms these molecules have in gene regulation, we are beginning to understand the carcinogenic mechanisms and pathways these small molecules could influence. Due to their obvious association with carcinogenesis, and considering their promising diagnostic and therapeutic potential, miRNAs will steadily be investigated to discover their effect on a patient’s disease.Additionally, miRNAs represent a novel class of potential biomarkers for diagnosis, prediction of treatment, or prognosis, which are essential to improve patient management. In this review, we focused on miRNAs validated by more than one study or where results rely on preclinical as well as clinical evidence. However, it needs to be emphasized that the major challenge in identifying diagnostic, predictive, and prognostic miRNAs still resides in the need to firmly validate these findings in additional independent cohorts or by additional preclinical/clinical verification studies. Also, it is important to integrate multivariate testing since many individual identified miRNAs lose their significance when correcting for multiple testing. One should also take into account that some inconsistencies can be partly attributed to differences in subtype distribution or cells of origin. In this way, sufficient experimental evidence can be obtained in order to provide more power to the currently insufficiently strong miRNA markers so that they could be employed in clinical decision-making.


Mini-implant loss is often associated with physical and mechanical aspects thatresult from choosing an inappropriate placement site. It is worth highlightingthat:a) Interdental alveolar bone crests are flexible and deformable. For this reason,they may not offer the ideal absolute anchorage. The more cervical the structures,the more delicate they are, thus offering less physical support for mini-implantplacement; b) Alveolar bone crests of triangular shape are more deformable, whereasthose of rectangular shape are more flexible; c) The bases of the alveolar processesof the maxilla and the mandible are not flexible, for this reason, they are morelikely to receive mini-implants; d) The more cervical a mini-implant is placed, thehigher the risk of loss; the more apical a mini-implant is placed, the better itsprognosis will be; e) 3D evaluations play a major role in planning the use ofmini-implants.Based on the aforementioned considerations, the hypotheses about mini-implant lossare as follows:1) Deflection of maxillary and mandibular alveolar processes when mini-implants aremore cervically placed; 2) Mini-implants placed too near the periodontal ligament,with normal intra-alveolar tooth movement; 3) Low bone density, low thickness and lowalveolar bone volume; 4) Low alveolar cortical bone thickness; 5) Excessive pressureinducing trabecular bone microfracture; 6) Sites of higher anatomical weakness in themandible and the maxilla; 7) Thicker gingival tissue not considered when choosing themini-implant. Dental implants conceptually required months for crown placement and functionalrecovery. It was believed that it took weeks or months for cells to colonize the implantsurface, produce matrix and mineralize it by efficient osseointegration. Sciencedeveloped and now it is possible to apply a functional load nearly immediately afterimplants are placed, provided that they are mechanically interlocked in a previouslymineralized bone. Appropriate mechanical interlocking between implant and bone surfacesallow mini-implants to withstand masticatory forces while gradual osseointegrationoccurs. The type of bone and clinical condition will determine whether immediate-loadimplants are recommended or not.2 orminiplates9 placed in thickcortical bone and dense trabecular bone. Mini-implant threads must be perfectly fittedor adapted to the bone where they are inserted, allowing stability and nearlyimmediately withstanding the forces applied. Mini-implants are also known asmicro-implants, micro-screws or anchorage screws, and comprise what is known astemporary anchorage devices (DAT).Absolute anchorage during orthodontic treatment may be obtained withmini-implants12Some specialists suggest that forces may be applied 3 days after mini-implant placement,while others recommend a waiting period of 21 or 40 days. As for immediate loading forabsolute anchorage mini-implants, the waiting time is shorter - in fact, it could beimmediately applied.7Cortical bone thickness and trabecular bone density are important factors to beconsidered when determining a mini-implant placement site. Moreover, the material,surgical technique, patient's hygiene care and patient control performed by theprofessional are also of paramount importance.The main mechanism related to the efficiency of mini-implants for absolute anchorage inOrthodontics is their mechanical adaptation to previously mineralized bone structures.Such mechanism is also known as interlocking. After a few weeks or months,osseointegration, represented by cell colonization and bone formation on the surface ofmini-implants, will be of secondary importance, given that, at this point, mini-implantscan be removed after fulfilling their role of orthodontic anchorage.2Osseointegration is the essence of Implantodontics and is responsible for the success inthe esthetic and functional recovery of lost teeth. For this reason, mechanicaladaptation allows the application of immediate load within the first weeks/months. InOrthodontics, on the other hand, mechanical adaptation explains the use of mini-implantsfor absolute anchorage, while osseointegration is secondary and belated. Orthodontictreatment with mini-plants lasts 30% less. Furthermore, the use of such devices alloworthodontic movement to be performed without further side effects on otherteeth.11 placed mini-implants indogs and histomorphometrically determined that partial osseointegration occurred in allspecimens 6 months after skeletal anchorage. Mini-implants placed in thinner bone andcortical bones may require osseointegration. In these cases, titanium alloy pure gradeIV is used, with acid attack on the surface of mini-implants to increase contactsurface.Osseointegration may hinder mini-implant removal and increase the risk of fracture. Forthis reason, mini-implants are made of titanium metal alloy, pure grade V. In 2007,Vannet et alThread shape and length are essential for mini-implant placement. Resistance to fracturemay be improved with cone-shaped mini-implants and perforating threads. Thesecharacteristics aid dissipation of compression forces exerted by bone structuressurrounding the mini-implant while it is being installed.6and Reynders et al,8 mini-implant success depends on the surgeon's ability,patient's condition, appropriate placement site, initial stability, orthodonticmechanics, type of mini-implant and oral hygiene. The most frequent complications andaccidents are contact between adjacent tooth roots  and mini-implant length must be greater.1 conducted anin vivo study to assess microbial contamination by using DNA probesfor 40 species of bacteria and the molecular biology technique of Checkerboard DNA-DNAhybridization. Bacterial endotoxin and inflammatory cytokines found in lostmini-implants were also used. The author concluded that microbial contamination and theamount of endotoxin found in the mini-implants did not act as a determining factor forloss of stability.Bacteria that reach tissues and mini-implants during placement are isolated. They are inlow numbers and, therefore, not enough to trigger an inflammatory process that is worsethan inflammation resulting from surgical procedures. Bacteria isolated from microbialbiofilms are easily controlled by phagocytosis and destroyed by inflammatory exudate andinfiltrate. Alone, they are not able to trigger inflammatory processes or consequentialbone resorption that could lead to mini-implant loss. These bacteria are the same thatcause periodontal disease; however, they do not promote mucositis or peri-implantitis inconventional implants either, provided that they do not form microbial biofilms. In2013, AndruciolliThe biology of cells and bacteria do not explain mini-implant loss. Our cells as well asour immune system readily accept titanium alloys, as reported by many researches. As forbacteria, they are the same of our microbiota. Thus, when they reach a tissue, they aresoon defeated, as microbiota bacteria are. Mini-implant loss is often associated withphysical and mechanical aspects that result from choosing an inappropriate placementsite.It is worth highlighting that:Interdental alveolar bone crests are flexible and deformable. For this reason,they have little mobility to offer and may not provide the ideal absoluteanchorage. The more cervical the structures, the more delicate they are, thusoffering less mechanical interlocking for mini-implant placement.Alveolar bone crests of triangular shape are more deformable, whereas those ofrectangular shape are more flexible.The bases of alveolar processes of the maxilla and the mandible are not flexible,for this reason, they are more likely to receive mini-implants.The more cervical a mini-implant is placed, the higher the risk of loss. The moreapical a mini-implant is placed, the better its prognosis will be.Before mini-implant placement, it is advisable that a 3D analysis be carried outon the site by means of periapical radiographs, particularly by bisection andinterproximal techniques, and occlusal radiograph with periapical film. Volumetriccomputed tomography with its several evaluation slices may replace conventionalradiography.


Background: Exposure to cadmium (Cd) has long been recognized as a health hazard, both in industry and in general populations with high exposure. Under the currently prevailing health risk assessment, the relationship between urinary Cd (U-Cd) concentrations and tubular proteinuria is used. However, doubts have recently been raised regarding the justification of basing the risk assessment on this relationship at very low exposure.Objectives: Our objective was to review available information on health effects of Cd exposure with respect to human health risk assessment.Discussion: The associations between U-Cd and urinary proteins at very low exposure may not be due to Cd toxicity, and the clinical significance of slight proteinuria may also be limited. More importantly, other effects have been reported at very low Cd exposure. There is reason to challenge the basis of the existing health risk assessment for Cd. Our review of the literature found that exposure to low concentrations of Cd is associated with effects on bone, including increased risk of osteoporosis and fractures, and that this observation has implications for the health risk assessment of Cd. Other effects associated with Cd should also be considered, in particular cancer, although the information is still too limited for appropriate use in quantitative risk assessment.Conclusion: Non-renal effects should be considered critical effects in the health risk assessment of Cd.http://dx.doi.org/10.1289/ehp.1307110Citation: Åkesson A, Barregard L, Bergdahl IA, Nordberg GF, Nordberg M, Skerfving S. 2014. Non-renal effects and the risk assessment of environmental cadmium exposure. Environ Health Perspect 122:431–438;  Exposure to cadmium (Cd) has long been recognized as a health hazard, both in industry and in general populations with high exposure. There is widespread low-level Cd contamination of agricultural soil in many areas of the world. Because Cd is easily taken up by crops such as rice, wheat, vegetables, and potatoes and occurs in high concentrations in shellfish, offal, and certain seeds, the exposure to Cd from food in many areas is high enough to be of importance to human health . AdditioThe toxic effects of Cd were initially considered to be limited to lung and kidney damage  and kidney damage, osteomalacia, and fractures . Because of the small size of MT, Cd-MT is readily filtered through the glomeruli and reabsorbed by the proximal tubuli and thus accumulates in the kidney cortex, where a major part of the body burden is located . BecauseRenal tubular dysfunction. Proteinuria is well-established as an adverse effect of Cd exposure. Long-term exposure resulting in U-Cd > 4 μg/g creatinine (cr) and/or B-Cd > 4 μg/L impairs renal tubular reabsorptive function, as shown by increased urinary excretion of low-molecular weight proteins (LMWP) such as β2-microglobulin (B2M), α1-microglobulin (A1M), and retinol-binding protein , based on serum cystatin C or serum creatinine, was statistically significantly lower at U-Cd 0.75–1.0 μg/g cr than at U-Cd < 0.5 μg/g cr  in Cd-exposed workers and populations . In an eRenal failure. Several studies of high Cd exposure have shown associations between U-Cd and mortality from renal diseases  and Cd-MT for reabsorption in the proximal tubule. LMWP and Cd-MT seem to have similar affinity for tubular binding sites , and so Although there is no reason to question the effect of Cd exposure on renal tubules at high exposure (U-Cd > 4 μg/g cr), the associations observed at low levels could be influenced by the factors mentioned above. Other factors should also be considered, such as the ability to synthesize MT and the occurrence of MT antibodies . Thus, aThe effects of renal physiology are most likely eliminated when B-Cd, instead of U-Cd, is used as a marker of Cd exposure in relation to kidney effects markers in urine. Studies using B-Cd and LMWP in never-smokers would shed light on this issue, but such studies are demanding regarding population size and analytical performance. One study observed a statistically significant association in never-smokers between B-Cd and LMWP excretion (U-A1M) within the normal range . A U-Cd Although long-term Cd-induced tubular proteinuria  may be a risk factor for renal failure and mortality , the pubIt has long been well-established that excessive exposure to Cd may cause itai-itai disease, which occurs after manifestation of kidney damage and leads to osteomalacia and/or osteoporosis with multiple fractures .z-score or T-score.A long series of recent cross-sectional and prospective studies of different populations, mainly from Belgium, Sweden, the United States, and China—some of them very large—clearly demonstrate associations between Cd exposure and low bone mineral density, as well as an increased risk of osteoporosis . Most ofThe relationship between osteoporosis and fracture risk is well-established ; osteopoMost bone studies have used U-Cd to explore associations . AlthougAnother aspect in the interpretation of the studies on bone effects is the potential confounding by smoking . BecauseFour studies failed to establish any statistically significant Cd-related effect on bone mineral density . These nThe levels of Cd exposure associated with decreased bone mineral density and increased risk of osteoporosis and fractures vary . Cross-sThe mechanisms of bone effects considered secondary to kidney damage include deficient reabsorption of calcium in the renal tubuli and compromised activation of vitamin D in the renal cortex. Several of the studies of bone effects also assessed kidney effects in parallel. The current understanding is that kidney effects are important in high Cd exposure situations , and thein vitro, as well as in vivo in animals displaying no nephrotoxicity  and heavy (3.7 mg/kg) exposure after their cessation of consuming Cd-polluted rice . The decIn conclusion, the data point toward a direct effect of Cd on bone. Even in the absence of Cd-induced renal tubular dysfunction, low-level environmental exposure to Cd seems to mobilize bone minerals from the skeletal tissue. Effects on bone mineral density, osteoporosis, and increased fracture risk are reported to occur at U-Cd as low as 0.5–2 μg/g cr . SimilarFragility fractures represent a considerable public health problem, causing suffering as well as a burden to the individual and the society . Hence, In their most recent evaluation, the Studies of Cd exposure and cancer in the general population have found positive associations. In a Belgian prospective cohort of 994 persons, in vivo effects of estrogen in reproductive tissues , statistically significantly increased incidences of endometrial , breast , and prostate  cancer (but not ovarian cancer) were observed in study subjects in the highest tertiles of Cd exposure , 2012b. In conclusion, Cd is carcinogenic, and some but not all recent data suggest an association with certain cancer forms, even at the low dietary Cd exposures encountered in the general population. The association is present whether smokers are included or only never-smokers are studied. It appears that lung cancer and estrogen-dependent cancers are of particular importance.Cd is suspected to cause several other adverse health effects in humans, also at exposure levels found in the general population; however, results have not been consistent or causality had not been definitely demonstrated. Examples include neurodevelopmental effects , 2012b, Tubular proteinuria is a well-established adverse effect associated with Cd exposure at U-Cd > 4 μg/g cr and/or B-Cd > 4 μg/L in occupationally as well as environmentally exposed populations. Cd-induced proteinuria has been associated with increased mortality in renal and cardiovascular diseases. However, in recent years, a considerable number of publications have presented evidence of an association between increased urinary excretion of proteins and the much lower U-Cd concentrations found in general populations. However, the apparent dose–response relationship for proteinuria at these low U-Cd concentrations may be noncausal . EvidencAssociations with bone effects, including a decrease of bone mineral density and increased risk of osteoporotic fractures, seem to occur at low Cd exposures. In the case of bone effects, associations based on U-Cd are more conclusive than in the case of proteinuria, at least in studies of never-smokers. Moreover, low-level dietary Cd exposure  has been associated with bone effects, further supporting a causal relationship between low-level exposure and adverse effects on bone. Bone effects are also of greater public health concern than increased urinary protein excretion.The available information shows that associations with bone effects occur in population strata with low dietary Cd intake, corresponding to U-Cd as low as 0.5–2 μg/g cr. Such exposure is greatly exceeded in large populations in many parts of the world and is present even in the areas with the lowest exposure range, such as the United States  and EuroCd is classified as a human carcinogen, and recent data have shown associations between low-level environmental Cd exposure and several forms of human tumors, including lung, kidney, bladder, endometrial, and breast cancer. For such common cancers, even a slight increase of risk may carry a considerable public health burden.Therefore, based on the available information, we suggest that Cd health risk assessments for the general population should consider effects other than proteinuria. Adverse effects on bone apparently occur at lower exposures than kidney effects . The effects are also more important for public health. Although the available information on risk is more limited than for proteinuria, it is still sufficient for a meaningful risk assessment. The data described above strongly indicate that estimates of the risks of bone effects in never-smoking, elderly women at present constitute the most substantial information on which estimates of exposure–response considerations may be based. At the same time, for future risk assessments, more information on other non-renal effects (including cancer) is needed, with reliable data on low-level dietary Cd exposure and/or body burden.Agricultural soils are widely contaminated with Cd to such a degree that vegetable crops accumulate the element in concentrations sufficiently high to be a threat to public health. This exposure has not decreased over the last few decades, at least not in women . The sitCurrent information urges a shift in the strategy for assessment of Cd risks in the general population, moving away from a unique focus on renal tubular proteinuria. Bone effects will likely contribute more than kidney effects to the overall risk. Bone effects, along with other non-renal effects such as cancer, should also be considered in the health risk assessment of Cd.(139 KB) PDFClick here for additional data file.


Increasing number of eQTL (Expression Quantitative Trait Loci) datasets facilitate genetics and systems biology research. Meta-analysis tools are in need to jointly analyze datasets of same or similar issue types to improve statistical power especially in trans-eQTL mapping. Meta-analysis framework is also necessary for ChrX eQTL discovery.meta-eqtl, for fast eQTL meta-analysis of arbitrary sample size and arbitrary number of datasets. Further, this tool accommodates versatile modeling, eg. non-parametric model and mixed effect models. In addition, meta-eqtl readily handles calculation of chrX eQTLs.We developed a novel tool, meta-eqtl as fast and comprehensive tool to meta-analyze multiple datasets and ChrX eQTL discovery. Meta-eqtl is a set of command line utilities written in R, with some computationally intensive parts written in C. The software runs on Linux platforms and is designed to intelligently adapt to high performance computing (HPC) cluster. We applied the novel tool to liver and adipose tissue data, and revealed eSNPs underlying diabetes GWAS loci.We demonstrated and validated  Expression quantitative trait loci (eQTLs) are genomic loci that regulate expression levels of mRNAs, and eQTLs play important roles in genetics and systems biology studies. To date, multiple eQTL datasets  exist for a given tissue type, e.g. liver and lung ,2. It isβ and pvalue) of every transcript-SNP pair per individual dataset, and (2) combine the statistics using meta-analysis approach. However, this strategy is not practical in eQTL setting, where each dataset requires evaluation of >1011 tests. Storing the raw statistics of every test is prohibitive due to massive disk and I/O demand. The common practice is only recording the top hits  per dataset and meta-analysis. This strategy will miss the eQTLs that have consistent small-to-moderate effect in multiple datasets [meta-eqtl offers versatile features: implementation of peak finding algorithm, various statistical models (eg. non-parametric and mixed effect model), consistent handling of missing data, easy deployment on high performance computing (HPC) clusters, etc.The typical strategy of meta-analysis has two steps: (1) calculate and record raw test statistics  is used to fit linear models in absence of missing values. When missing values are present, in either the gene expression or SNP data, C code is called to compute the pairwise minimal sufficient statistics. The data format is based on plain text, tab-delimited files, which make the data easy to inspect and manipulate with standard UNIX utilities. Within meta-eqtl, several modules are dedicated to specific functionality, and can be called individually by user.lm-meta. The computation occurs in multiple threads, where the number of threads corresponds to the number of datasets in the meta-analysis. The multiple threads proceed concordantly, therefore, the same set of gene expression-SNP tests are evaluated in each individual dataset at the same moment. When statistics are obtained from multiple threads, the meta-analytical test statistic is computed as:2), T statistics (T) and pvalues (p). The T and p were presented for both meta-analysis and each individual cohort. A separate utility, lm-fdr, compares the output from observed and permuted data and quantify FDR. In brief, the meta-analysis results enter the downstream peak finding and empirical FDR calibration by permuting the sample IDs in the gene expression files. To our experience, this empirically estimated FDR is more robust than Benjamini-Hochberg procedure, such as used in MatrixEQTL [eqtl-sex-peaks utility, specially designed for meta-analysis of regression results by gender. kruskal is provided as a non-parametric Kruskal-Wallis test for eQTL detection. Since eQTL computation involves big data sets, gene expression and SNP data are accessed sequentially and concordantly by each thread, and results are reported on the fly, as they are computed. This allows for the analysis of files of arbitrary sample size and arbitrary number of datasets with constant memory usage. Also, this framework enables a natural deployment on HPC and Hadoop clusters as it can trivially distribute the analysis into multiple computing nodes.Linear regressions meta-analysis is implemented in the R script trixEQTL , which imeta-eqtl is the first software to perform meta-analysis on arbitrary number of eQTL datasets. We thus compared our results with those obtained with METAL [Meta-eqtl distributed the computation on a cluster of 800 computing cores , and was able to complete within three days. The top eQTLs (10% FDR) statistics were identical to those computed by the R package “meta”. On a single cohort, we further conducted head-to-head comparison to the MatrixEQTL software [meta-eqtl was about 2–3 times slower, reflecting the expense of missing data handling and the more flexible pipeline. Nevertheless, meta-eqtl is still one of the fastest eQTL tools available.To our knowledge, th METAL ,6, a tooWe also leverage another large-scale published eQTL study data , where cmeta-eqtl. To our knowledge, it is the only tool to allow fast meta-analysis of eQTLs for today's large genotype and gene expression data with reasonable memory requirement and fast speed. It can also be used as a flexible and fast tool for eQTL discover on a single dataset, where it features flexible model specification (e.g. non-parametric and mixed effect models), missing data handling and implements significance peaks extraction. Meta-eqtl features computation speed comparable to the fastest alternative available to date, and is further well suited to distribute parallel jobs onto a HPC system. Another major advantage is the ability to handle chrX eQTLs. In recent year, increasing number of eQTL studies and dataset become available [Meta-eqtl enables meta-analysis of arbitrary number of eQTL dataset and will greatly facilitate this research field.In summary, we describe a novel package, vailable ,7,11, jometa-eQTL software package is freely available to all readers under https://haok01.u.hpc.mssm.edu/meta_eQTL/The Project name:meta-eQTLProject home page:https://haok01.u.hpc.mssm.edu/meta_eQTL/Operating system(s): LinuxProgramming language: R (version 3.0.2) and CLicense: noneAny restrictions to use by non-academics: none


Moreover, we demonstrated that L-Arginine significantly attenuates Angiotensin II-induced mitochondrial oxidative stress in human endothelial cells. In conclusion, our findings indicate for the first time that oral L-Arginine supplementation significantly improves cognitive impairment in frail hypertensive older adults.Cognitive impairment is a prevailing event in hypertensive patients and in frail older adults. Endothelial dysfunction has been shown to underlie both hypertension and cognitive dysfunction. Our hypothesis is that L-Arginine, which is known to ameliorate endothelial dysfunction, could counteract cognitive impairment in a high-risk population of hypertensive frail older adults. We designed a clinical trial to verify the effects of 4-weeks oral supplementation of L-Arginine on global cognitive function of hypertensive frail older patients. The study was successfully completed by 35 frail hypertensive elderly patients assigned to L-Arginine and 37 assigned to placebo. At follow-up, we found a significant difference in the Montreal Cognitive Assessment (MoCA) test score between the L-Arginine treated group and placebo (www.ClinicalTrials.gov, identifier: NCT04962841. Hypertension is linked to endothelial dysfunction contributing to atherosclerosis, inflammation, and oxidative stress in the arterial wall –8. PhysiCognitive impairment is often observed in hypertensive patients as well as in frail older adults –21. HencL-Arginine is an amino acid involved in a number of biological processes and is a substrate of two enzymes: nitric oxide (NO) synthase (NOS) and arginase (NOA) –28. L-ArWe designed a placebo-controlled clinical trial to study hypertensive frail older patients presenting from March 2021 to October 2021 at ASL  Avellino, Italy. All of them met the following inclusion criteria: a previous diagnosis of primary hypertension ; age >65 years; a frailty status; Montreal Cognitive Assessment (MoCA) test score <26.Exclusion Criteria were: age <65 years; presence of neurodegenerative diseases; absence of frailty status; absence of hypertension; left ventricular ejection fraction <25%, with previous myocardial infarction or previous coronary revascularization.®, 1.66 g, twice a day) or placebo (n = 37) parallel groups and followed-up for 4-weeks. The dose of L-Arginine was based on previously published clinical trials , as we previously described ; this coA physical frailty assessment was performed following the Fried Criteria  as we pr- Weight loss .- Weakness (handgrip strength).- Exhaustion .- Slowness .- Low physical activity level .2  were cultured in EGM-2 medium  and incubated at 37°C and 5% CO2 . Experimescribed , 40.clinicaltrials.gov (NCT04962841).Informed consent was obtained by all patients before testing, and the experimental protocol was approved by the Ethical Committee of Campania Nord. The trial was registered in *POWER. A multivariable linear regression analysis, while adjusting for likely confounders, was used to investigate the association between L-Arginine treatment and MoCA score. Statistical significance was determined by a p value <0.05. All calculations were performed using SPSS 26 .Data are presented as group mean ± SD or SE or numbers and percentages. Based on our preliminary findings, we calculated the minimum number of patients required for the study to reject the null hypothesis 95% of the time using Gn = 35) or placebo (n = 37) parallel groups, successfully completed the study  with or without addition of L-Arginine, measuring mitochondrial ROS generation via MitoSOX. We found that the co-treatment of HUVECs with Ang II and L-Arginine significantly attenuated mitochondrial ROS production compared to Ang II alone , because the latter has been shown to be conditioned by demographic variables including age and years of education –61. Morein vitro the effects of L-Arginine on mitochondrial function in human endothelial cells, showing that L-Arginine significantly attenuates the generation of mitochondrial ROS induced by Ang II. Intriguingly, this finding is consistent with recent observations linking frailty and cognitive decline to mitochondrial dysfunction  were kindly provided by Farmaceutici Damor S.p.A., Naples, Italy, which had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data, preparation, review, or approval of the manuscript and decision to submit the manuscript for publication.The Santulli's Laboratory is supported in part by the National Institutes of Health (NIH): National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK: R01-DK123259 and R01-DK033823), National Heart, Lung, and Blood Institute (NHLBI: R01-HL146691 and T32-HL144456), National Institute on Aging (NIA: R56-AG066431) to GS, by the Irma T. Hirschl and Monique Weill-Caulier Trusts (to GS), and by the Diabetes Action Research and Education Foundation (to GS). SJ and FV hold postdoctoral fellowships from the American Heart Association . Both placebo and L-Arginine (BioargininaThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Electroencephalography (EEG)-based motor imagery (MI) paradigm is one of the most studied technologies for Brain-Computer Interface (BCI) development. Still, the low Signal-to-Noise Ratio (SNR) poses a challenge when constructing EEG-based BCI systems. Moreover, the non-stationary and nonlinear signal issues, the low-spatial data resolution, and the inter- and intra-subject variability hamper the extraction of discriminant features. Indeed, subjects with poor motor skills have difficulties in practicing MI tasks against low SNR scenarios. Here, we propose a subject-dependent preprocessing approach that includes the well-known Surface Laplacian Filtering and Independent Component Analysis algorithms to remove signal artifacts based on the MI performance. In addition, power- and phase-based functional connectivity measures are studied to extract relevant and interpretable patterns and identify subjects of inefficency. As a result, our proposal, Subject-dependent Artifact Removal (SD-AR), improves the MI classification performance in subjects with poor motor skills. Consequently, electrooculography and volume-conduction EEG artifacts are mitigated within a functional connectivity feature-extraction strategy, which favors the classification performance of a straightforward linear classifier. The cognitive ability of motor imagery (MI) is one of the most active areas of Brain-Computer Interface (BCI) research; it allows handling external devices merely by imagining movement, without the involvement of peripheral nerves , having Concerning MI-based paradigms, Electroencephalography (EEG) is widely used to record brain neural activity because of its high time resolution, portability, and cost-effectiveness compared to other neuroimaging methods . HoweverIn practice, simple classification algorithms that follow signal processing techniques to increase the SNR ratio are employed to classify MI tasks since they are fast training, have lower computational complexity, provide a better explainability, and demand light data techniques, such as spatial filtering . Thus, aSD-AR, has been evaluated on two real-world databases, demonstrating its ability to tackle the influence of artifacts and intertrial/inter-subject amplitude variability, improving the classifier performance and enhancing interpretability in subjects with poor motor imagery skills.In this paper, we propose an approach for subject-dependent preprocessing to reduce the low SNR phenomenon in subjects performing poorly in motor imagery tasks by selectively removing the artifacts according to the classifier accuracy achieved by each individual. The preprocessing methods are Surface Laplacian Filtering and Independent Component Analysis to remove artifacts related to EOG signals and the volume conduction effect. Nonetheless, instead of relying on commonly-used spatial patterns that extract mostly event-related desynchronization features , severalThe rest of the paper is organized as follows: SD-AR approach. SD-AR allows building a discriminant preprocessing strategy based on Surface Laplacian filtering and Independent Component Analysis to feed a Functional Connectivity-based feature extraction stage for further classification.The main mathematical fundamentals of the well-known Surface Laplacian filtering method are given. Then, the Independent Component Analysis technique is described. Finally, we outline our Subject-dependent Artifact Removal n, Let Thus, the Laplacian filter of EGG data, puted as : XL=HX⊤GBrain and artifact sources are assumed to mix linearly in  follows : (2)w^q=Q is fixed to C, i.e., the number of EEG-montage channels. Therefore, to recover the sources and separate them between brain or artifact signals [Consequently, the maximization procedure described above is performed over every  signals , the unmIn the presence of a reference electrooculography signal Equation . That isSD-AR approach introduces the selector coefficient, noted as In addition, applying both Surface Laplacian Filtering and Independent Component Analysis approaches to EOG-artifact removal and volume conduction effect relies on the principle of a similar influence over the whole set of individuals. Instead, for subject-dependent effectiveness, we select either method of preprocessing based on the quality attained by each individual. For this purpose, the -Power-based connectivity correlates between couples of electrodes over time founded on power fluctuations. Regarding this FC, the following pairwise measures are evaluated [valuated ,38,39:The classifier performance is computed using Functional Connectivity (FC) as the feature extraction method. In particular, the following FC measurements extracted on a trial basis are considered:In the above-considered FC measurements, the expectation operator averages across the whole time set of each trial.(i)SD-AR). According to the highest individual classifier accuracy, removing artifacts over each subject is conducted according to one of the following combinations of the ICA and Laplacian filters in Equation (Ind-AR) using both filters of artifact subtraction over every individual regardless of his achieved classifier performance, and no removal filtering (Raw) of all acquired EEG data.Subject-dependent preprocessing for artifact removal (Equation : both fi(ii)Feature Extraction for testing the power-based and phase-based FC measurements. As suggested in , the setDBII see . The feaistances ; and theistances .(iii)Estimating classification performance using a linear discriminant analysis (LDA) algorithm evaluated through a 10-fold cross-validation strategy over the training set provided for DBI and a simple ten-iteration 20–80% training-testing split for DBII. Of note, DBI provides a predefined testing set, which is used to report the final performance. Note that the preprocessing parameters are tuned at this stage according to the achieved classifier performance.The proposed methodology of selective preprocessing is based on the well-known methods of Surface Laplacian filtering and Independent Component Analysis. Namely, our SD-AR automatically switches each one of the techniques mentioned above concerning the BCI accuracy score. In this sense, SD-AR aims to improve each subject’s classification performance and the interpretability of elicited brain activity responses along groups of subjects with different skills and abilities for MI practice. As shown in https://github.com/mtobonh/SD-AR, accessed on 30 June 2022).All experiments were carried out in Python 3.8, with the sklearn and MNE libraries, on a Google Collaboratory environment  that holds EEG data from EEG data were recorded using a 22-channel montage with Ag/AgCl electrodes, according to the 10/20 system (DBII: This collection is publicly available at (http://gigadb.org/dataset/100295 accessed on 1 April 2022), and it holds EEG data from 52 healthy subjects  format. Aside from the MI recordings, real left-hand and right-hand movements were also collected, along with six types of noise, including blinking eyes, eyeball movement up/down, eyeball movement left/right, head movement, jaw clenching, and resting state.The EEG data were collected through Initially, a five-order high pass Butterworth filter of 1 Hz is performed to remove low-frequency drifts affecting the quality of the ICA filtering algorithm. In addition, the unmixing matrix Equation  is approAs an illustrative example, Z-scored values (see red dashed lines). Note that this procedure is twice performed.The source selection is based on the similarity between every ICA source and the electrooculogram available for DBI. Then, the similarity is measured on a trial basis over the whole subject set through the Pearson Correlation value. Since DBII does not provide the EOG data, the similarity with the ICA components is assessed using the three frontal electrodes, as suggested in . Across o to 10, the smoothing constant We assess the influence of Surface Laplacian Filtering on the connectivity measurements. To this end, we adjust the parameters of the surface Laplacian filter as suggested in : the higloped in  that expCz channel, placed over the sensorimotor area, and the remaining electrodes. For illustration’s sake, Cz channel along with the FC matrix. Both FC representations are obtained for DBI (top row) and DBII (bottom row) by averaging across the trial and individual sets. As can be seen, the left-side heatmap matrix extracted from the raw data visualizes many more relationships between electrodes so that the resulting topoplots exhibit neural responses spread throughout the scalp surface.Specifically, we examine the functional connectivity between the Cz electrode with a reduced amount of spurious connectivities caused by volume conduction. The EEG montage of DBII with a much higher number of electrodes can better illustrate this situation.Consequently, the MI rehearsing is masked by a high field spread effect. On the contrary, the Surface Laplacian filter impacts the functional connectivities calculation positively, reducing considerably the number of links outside the sensorimotor area activated by MI, as shown in the connectivity matrix. Furthermore, the estimated topoplot presents a focused neural activity neighboring the By using the functional connectivity estimators above-described in In all performance metrics, we show their testing set values of the mean ± standard deviation averaged across two different evaluating strategies: (i) Global assessment by averaging over the whole set of individuals; (ii) Group-level assessment by averaging over a concrete category of subjects. Namely, we are interested in evaluating the effectiveness of the suggested preprocessing methodology for enhancing the classifier performance of the so-called inefficiency individuals .Raw), (b) EEG data after both preprocessing procedures for Independent Component Analysis and Laplacian Filtering (center column—Ind-AR), (c) the suggested preprocessing approach that switches either procedure selectively as explained before (right column—SD-AR).Here, we estimate the performance in three training scenarios for classifying MI tasks: (a) the classifier is fed by EEG data without preprocessing  result in the worst bi-class classification scenario and harm average over all individuals rather than improving the performance, as expected. This effect is contrary to the case for subject-dependent preprocessing, which improves classifier performance for all FC metrics considered (see right column). A noteworthy fact is that the mean values of performance achieved by the power-based FC estimators outperform the corresponding phase-based metrics. As a result, GFC yields the best mean estimates of all feature extraction methods, while PLV comes in last.On the other hand, SD-AR preprocessing on the subjects executing the MI tasks the worst. As the GCF measure has the best performance .By analyzing each performance measure  individually, we cluster the separateness in terms of the variability between subjects. Concretely, clustering is carried out based on the classifier measures through the adjusted . For evaAccording to the considered training scenarios of MI classification, the classifier performances  are grouped into the following three partitions of skills in practicing MI tasks see , as alsoRaw training scenario. Moreover, Ind-AR scenario delivers even fewer best-performing subjects (10) while reducing the worst-performing set by upgrading six individuals. Nonetheless, some subjects are severely downgraded, as is the case for #42 and #40.mplement . AfterwaSD-AR approach results in the most extensive best-performing set (14) while providing the least number of individuals with poor skills (13). In other words, SD-AR reduces the group of poor-performing individuals from SD-AR does not downgrade individuals compared with the other training scenarios.Lastly, the proposed SD-AR overperforms in all scenarios of preprocessing evaluated for artifact removal. SD-AR has also performed better than the average achieved by Ind-AR for all individuals.SD-AR approach, we will consider the enhanced interpretability of GFC extraction to decode the brain neural responses elicited by MI paradigms. Here, we compute the topoplots based on the absolute value of individual LDA coefficients estimated within all four bandwidths and normalized between As part of the proposed i-th subset of MI skills , yielding a matrix with dimension i-th subset. The group-level relevance GFC matrix summarizes the joint contribution, from which the maximum value in each column  becomes the connectivity link having the most significant contribution to discriminating between MI tasks.Afterward, we compute the group-level GFC representation by joining the relevance-weight vectors estimated for all Ind-Ar among the evaluated training scenarios. Regarding the proposed SD-AR approach, the discriminating neural responses are the most localized within the premotor and motor cortex. Therefore, the classifier is more accurate since more contributing GFC relationships are evaluated.SD-AR. In particular, the estimated topoplots show that in comparison with the SD-AR are the most localized within the premotor and motor cortex, as expected in MI paradigms. To illustrate this finding, sbj45 that is included by the Raw training scenario in the worst-performing group. After applying SD-AR, this subject achieves a high gain in classifier accuracy (more than 8%) so that he is newly incorporated into G II with adequate performance. As can be observed, the brain neural activity of Furthermore, to decrease training efforts and encourage user-centered MI responses, the neurophysiological explanation of spatial patterns generated is enhanced by SD-AR approach can achieve a competitive classifier accuracy for both EEG databases evaluated. In addition, the SD-AR approach decreases the group of poor-performing individuals, improving the use of MI paradigms. Still, the validation of DBII reveals that very few subjects may not benefit from the suggested subject-dependent preprocessing for artifact removal.The suggested preprocessing approach entails functional connectivity measures for feature extraction that encode most meaningful relationships of elicited brain neural responses between electrodes to tackle better MI tasks performed by poor-performing subjects. Several widely known power-based and phase-based methods of FC are tested, showing that subject-dependent preprocessing improves the classifier’s performance, with Gaussian Functional Connectivity being the most accurate. As a result, compared with several state-of-the-art methods recently reported for classification of MI tasks, SD-AR approach improved the performance of the motor imagery classifier in subjects with poor motor skills. We investigate the reduction of two common artifacts in EEG data (electrooculography and volume conduction) that distort the extraction of feature sets and, thus, severely degrade the classifier performance of MI tasks. Surface Laplacian and Independent Component Analysis have been reported as two main preprocessing procedures for removing them. Still, their effectiveness strongly depends on the low-SNR phenomenon that becomes especially weak in subjects with poor skills in practicing MI tasks. To cope with this issue, we propose a selective subject-dependent preprocessing, termed SD-AR, that switches the application of either procedure depending on the classifier accuracy performed by each individual. The validation results obtained in the evaluated real-world databases indicate that the proposal overperforms in all scenarios of preprocessing evaluated for artifact removal. Nevertheless, even though neither preprocessing method requires any subject-specific parameter tuning, its effectiveness is enhanced as the EEG montage dimensions increase.We develop an approach for subject-dependent preprocessing to reduce the low SNR phenomenon in subjects performing poor motor imagery tasks by selectively removing artifacts combined with feature extraction using Functional Connectivity measures. As a result of the evaluation to remove electro-oculography artifacts and volume conduction effects, the proposed The authors plan to evaluate the developed approach for subject-dependent preprocessing in databases containing more subjects and lower-quality EEG data for future work. Furthermore, to reduce the low SNR phenomenon in subjects performing poor motor imagery tasks, more elaborate feature extraction methods are to be investigated. One more issue of consideration is to explore the effectiveness of the developed approach for artifact removal in modern architectures of deep learning . Moreove


Sex and gender differences in presentation and characteristics of out-of-hospital cardiac arrest (OHCA) are established in cohorts with presumed cardiac aetiology but not non-cardiac etiology. This study investigated the effect of sex on incidence and outcome of OHCA according to presumed and adjudicated aetiology within a local health network.Population-based observational cohort study of emergency medical services (EMS) attended OHCAs within an Australian local health network. Cases identified from an EMS registry between 2012-2016 were linked to a hospital registry. Age-standardised incidence and baseline characteristics were stratified by sex for EMS-treated OHCA, non-EMS witnessed presumed cardiac and obvious non-cardiac sub-cohorts, and hospitalised cases. Logistic regression was used to explore the primary outcome of survival to hospital discharge.We identified 2,024 EMS-attended and 780 EMS-treated OHCAs. The non-EMS witnessed sub-cohorts comprised 504 presumed cardiac and 168 obvious non-cardiac OHCAs. Adjudicated aetiology was recorded in 123 hospitalised cases. Age-standardised incidence for women was almost half that of men across all groups. Across cohorts, women were generally older and arrested with a non-shockable initial rhythm in an area of low socioeconomic status. There was no sex difference in the primary outcome for the main EMS-treated cohort or in the non-cardiac sub-cohorts. The sex difference in outcome in the presumed cardiac sub-cohort was not present after multivariable adjustment.There are sex differences in incidence and outcome of EMS-treated OHCA that appear to be driven by differences in susceptibility to cardiac arrhythmias and underlying etiology, rather than treatment delays or disparities. Incidence, characteristics, and outcomes of out-of-hospital cardiac arrest (OHCA) differ according to sex. Women represent around 40% of the OHCA population attended by emergency medical services (EMS) but present with fewer established predictors of survival including increased age, unwitnessed arrest, arrest within a private residence, and non-shockable initial rhythm compared with men , 2. PrecThe primary study objective was to investigate the effect of sex on survival to discharge in a cohort of EMS-treated OHCAs and sub-cohorts of non-EMS-witnessed presumed cardiac and obvious non-cardiac cases. The secondary objectives were to report incidence stratified by age and sex, explore the effect of SES on survival according to sex, and to investigate sex differences in adjudicated aetiology in the sub-cohort transported to hospital.This was a retrospective observational study of all adult OHCAs within the Northern Adelaide Local Health Network (NALHN), South Australia. The study cohorts were generated by linking an EMS-based and a hospital-based OHCA registry for all cases occurring within a NALHN catchment as defined by postcode. The STROBE  guidelines  were fol2 within the northern metropolitan area of Adelaide, SA. Compared with the rest of Australia, both SA and NALHN are characterised by low SES and are ranked in the 37th and 19th percentiles according to the Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD), respectively (The SA Ambulance Service (SAAS) provides a two-tier EMS where patients are treated by paramedics on scene across the state of South Australia (SA). NALHN comprises two public hospitals that service a population of 395,000 across 631 kmectively . SAAS anectively . CardiacThe SAAS Cardiac Arrest Registry (SAAS-CAR), described previously , was seaThe Northern Adelaide Local Health Network (NALHN) OHCA registry is a hospital-based quality assurance initiative . VariablThe 2011 IRSAD was generated from census data by the Australian Bureau of Statistics (abs.gov.au) according to postal area code (POA) and linked to postcode of arrest. Although residential postcodes better reflect individual SES, they were not available for analysis. Higher national deciles indicate low levels of disadvantage and high levels of advantage.The primary outcome was survival to hospital discharge. Secondary outcomes included incidence per 100,000 person-years, whether the patient was transported to hospital (excluding patients transferred for certification of death), and survival with good neurological recovery  in hospitalised patients.Crude and age-standardised incidence rates per 100,000 person-years were explored according to sex for EMS-attended OHCAs with attempted resuscitation aged ≤ 20 years, to match with available population data. To account for dynamic changes in the at-risk population over the study period, enumerated NALHN population data  was averaged between data available for 2011 and 2016 . AdjusteDescriptive statistics were used to explore differences between males and females in all cohorts. Comparisons between sexes were performed using Wilcoxon Sum Rank Tests, Chi-Squared Tests or Fisher's Exact Tests as appropriate for skewed continuous and categorical variables.P-value are presented.Exploratory binary logistic regressions investigated the association between sex and survival to hospital discharge for both the main cohort and presumed cardiac sub-cohort, while adjusting for available survival predictors . The obvious non-cardiac sub-cohort was too small and survival rate too low to permit multivariable analysis. Interactions between sex and each covariate were tested in the adjusted models and removed if insignificant. Odds ratios (OR), 95% confidence intervals (95%CI), and comparison and global P-values less than or equal to 0.05 were regarded as significant and adjustments were not made for multiple comparisons. Analyses were performed using SPSS 26 .p > 0.05). In the sub-cohorts of non-EMS witnessed cases, 504 were of presumed cardiac origin and 168 were of obvious non-cardiac origin. The hospitalised sub-cohort consisted of 123 cases with adjudicated aetiology documented in the NALHN OHCA registry, excluding 24 with unknown etiology.There were 9,026 EMS-attended cardiac arrests aged ≥18 years identified from SAAS-CAR between 2012–16, of which 2,024 (23%) occurred within a NALHN postcode and 780 were EMS-treated . There wCrude and age-adjusted incidence rates of OHCAs aged ≥20 years according to sex are presented in Sex differences in characteristics of the main adult EMS-treated OHCA cohort and sub-cohorts are presented in p = 0.099). Exploratory analyses were performed and an interaction between sex and shockable rhythm, but not sex and age, SES, or other predictors, was observed. On multivariable analysis, higher odds of survival were associated with shockable rhythm in both males and females, decreasing age, bystander witness, and EMS witness, as well as IRSAD deciles, such that for every increase in IRSAD decile the odds of survival increased by 11% (p = 0.14).There was no significant sex difference in unadjusted survival to hospital discharge observed in the main cohort . No interactions were observed between sex and age, SES, or other predictors. Multivariable analysis revealed that sex was not associated with higher odds of survival to hospital discharge , nor was bystander CPR . Decreasing age , bystander witness , shockable rhythm , and increasing IRSAD deciles  were associated with higher odds of survival to hospital discharge.In unadjusted analyses of the presumed cardiac sub-cohort, women were less likely than men to survive to hospital discharge . Women with cardiac aetiology were younger than men, but there were no other statistically significant sex differences in arrest characteristics or outcomes within groups. In cases with a pre-hospital presumed cardiac diagnosis, precipitating aetiology was confirmed as cardiac in fewer women than men when cases with unknown diagnoses were included .Sex differences in survival to hospital discharge were explored according to adjudicated aetiology  in a small sub-cohort of non-EMS witnessed OHCAs transported to NALHN hospitals . CardiacWe report sex differences in incidence and outcome of consecutive EMS-attended and -treated OHCA within a local health network. Within these populations, women were almost half as likely to experience OHCA compared with men after age-standardisation. Although women in the sub-cohort with non-EMS-witnessed presumed cardiac OHCA were less likely to survive to hospital discharge than men in unadjusted analyses, this association was not present in the adjusted model. Exploratory analyses highlighted the discrepancy between presumed and adjudicated aetiologies and pointed to a survival advantage for hospitalised women with adjudicated non-cardiac aetiology.Few studies have reported sex differences in age-standardised incidence of EMS-attended and EMS-treated adult OHCAs, irrespective of etiology. Unadjusted and age-adjusted rates stratified by sex were consistent with comparable previous studies, confirming that men consistently experience OHCA at a rate more than double that of women , 26–28. n > 10,000) report unadjusted survival and favourable neurological prognosis at hospital discharge as consistently higher in men than women, with no difference  the sex difference in outcome disappeared. It is likely that a smaller magnitude of difference in outcome between sexes exists for the main cohort of EMS-treated OHCAs, but the sample may not have been sufficiently powered. Only a few studies have reported sex differences in outcome of all-cause OHCA with the survival rate for men ranging from 1 to 5.5% higher than women , 30–32. fference –14, 30 ofference  after adThere were no significant interactions in adjusted models between sex and age, bystander witness, or bystander CPR, respectively. Similar to Bray et al.  our findConsistent with international studies, we found that SES was a predictor of survival after OHCA in adjusted analyses , 41. EacCause of arrest documented by EMS providers does not reflect true aetiology in many cases and these discrepancies may contribute to observed differences in outcome between sexes . We perfThis is a small retrospective study conducted within a local health network in Australia and care should be taken when generalising the findings. Crude and age-adjusted incidence calculations were made using enumerated population data that was averaged between 2011 and 2016 to account for dynamic population changes and may not accurately reflect the true at-risk population. OHCA incidence calculations may be underestimated due to missing cases within SAAS-CAR during the study period . Arrest Women were less than half as likely to experience OHCA than men and the incidence of OHCA in women of any given age group was similar to that of men 10 years younger within a local health network. The effect of sex on survival to discharge after EMS-treated OHCA was influenced by precipitating etiology. Women with non-EMS witnessed presumed cardiac OHCA were more likely to present with unfavourable predictors of survival and were more likely to arrest in location associated with low SES, but there was no sex difference in adjusted survival. Analysis of adjudicated aetiology in the hospitalised sub-cohort suggests that survival after non-cardiac OHCA may be higher in women than men, but this finding requires further validation.melanie.wittwer@adelaide.edu.au.The datasets presented in this article are not readily available because access to participant identifiable data is subject to relevant institutional approval(s). Requests to access the datasets should be directed to MW, The studies involving human participants were reviewed and approved by Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.MW: conceptualisation, methodology, investigation, formal analysis, and writing—original draft. EA: conceptualisation and writing—original draft. CH: data curation, writing—review, and editing. MT: data curation, writing—review, and editing. CZ: supervision, writing—review, and editing. JB: supervision, writing—review, and editing. MA: conceptualisation, supervision, writing—review, and editing. All authors take responsibility for the integrity of the data and the accuracy of the data analysis. All authors read, critically reviewed, and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.