Dexterous hand function is crucial for completing activities of daily living (ADLs), which typically require precise hand-object interactions. Kinematic analyses of hand trajectory, hand velocity, and grip aperture provide valuable mechanistic insights into task performance, but there is a need for standardized tasks representative of ADLs that are amenable to motion capture and show consistent performance in non-disabled individuals. Our objective was to develop two standardized functional upper limb tasks and to quantitatively characterize the kinematics of normative hand movement.Twenty non-disabled participants were recruited to perform two tasks: the Pasta Box Task and Cup Transfer Task. A 12-camera motion capture system was used to collect kinematic data from which hand movement and grip aperture measures were calculated. Measures reported for reach-grasp and transport-release segments were hand distance travelled, hand trajectory variability, movement time, peak and percent-to-peak hand velocity, number of movement units, peak and percent-to-peak grip aperture, and percent-to-peak hand deceleration. A between-session repeatability analysis was conducted on 10 participants.Movement times were longer for transport-release compared to reach-grasp for every movement. Hand and grip aperture measures had low variability, with 55 out of 63 measures showing good repeatability (ICC > 0.75). Cross-body movements in the Pasta Box Task had longer movement times and reduced percent-to-peak hand velocity values. The Cup Transfer Task showed decoupling of peak grip aperture and peak hand deceleration for all movements. Movements requiring the clearing of an obstacle while transporting an object displayed a double velocity peak and typically a longer deceleration phase.Normative hand kinematics for two standardized functional tasks challenging various aspects of hand-object interactions important for ADLs showed excellent repeatability. The consistency in normative task performance across a variety of task demands shows promise as a potential outcome assessment for populations with upper limb impairment. Dexterous hand function is essential for successfully performing many activities of daily living (ADLs). Neurological or musculoskeletal impairments such as stroke , spinal One method of examining hand-object interactions is through kinematic analysis using optical motion capture, either to measure joint angles of the full upper body kinematic chain to infer hand function, or to directly quantify hand function through specific features of how the hand moves . HoweverGiven the importance of object interactions in ADLs and the influence of an object’s intrinsic and extrinsic proprieties on hand movement, task selection for kinematic analysis should include ecologically valid tasks for clinical assessment. Although some upper limb kinematic assessment protocols for motion capture mimic functional movements, such as hand to head , hand to shoulder , and hand to back pocket  –15, theyClinical assessments currently exist that evaluate hand function involving hand-object interactions. Performance tests, such as the Jebsen Test of Hand Function , the BoxThe objectives of this study were to develop two standardized functional upper limb tasks with hand-object interactions that result in consistent and repeatable performance in non-disabled individuals, and to use kinematic analysis to quantitatively characterize hand movement for those two tasks. The hypothesis was that the performance of the tasks in non-disabled individuals would result in consistent performance (low variability) within and across performers and good between-session repeatability due to the standardized sequencing of the task movements.The tasks were developed through iteration and consensus by a team involving a movement neuroscientist, kinesiologist, physiatrist, and occupational therapist. Current best-practice outcome measures for upper limb function were explored for commonalities in task requirements ,21,24–27Two standardized functional tasks were developed, the Pasta Box Task and Cup Transfer Task . Full taTwenty non-disabled individuals  were recruited to participate in the study. They had no upper body pathology or history of neurological or musculoskeletal injuries within the past two years. The study followed the Declaration of Helsinki guidelines and was approved by the University of Alberta Health Research Ethics Board (Pro00054011), the Department of the Navy Human Research Protection Program (DON-HRPP), and the SSC-Pacific Human Research Protection Office (SSCPAC HRPO). The individual in A 12-camera Vicon Bonita motion capture system  with an accuracy of 0.5 mm and 0.5 degrees was used to collect three-dimensional marker trajectories at 120 Hz. A rigid plate with three 11.1 mm reflective markers was attached to the dorsal side of the right hand using double-sided tape. Two 14 mm single reflective markers were attached to the middle phalange of the index finger and the distal phalange of the thumb. Additional markers and marker clusters were attached to upper body segments , but were not used in the current analysis.Prior to data collection, each participant received verbal instructions, a demonstration, and a practice trial to be familiarized with the tasks. Each participant performed a minimum of 20 successful trials for both tasks. If there was an error in performance of the task , that trial was marked as an “error trial” and the trial was repeated until a total of 20 error-free trials were recorded. The order of the tasks was block-randomized, with ten participants starting with the Pasta Box Task and ten with the Cup Transfer Task. Ten participants returned on a separate day for repeatability testing after the initial testing session (7.5 months ± 11 days), with the identical set up. The same two testers ran all data collection sessions.Raw marker trajectory data were filtered using a second-order, low-pass Butterworth filter with a cut-off frequency of 6 Hz . Motion Kinematic measures were selected based on commonly reported measures in assessments of individuals with upper limb impairments ,29. HandStatistical analysis was completed using the SPSS software . For each task, hand trajectory variability, movement time, peak hand velocity and percent-to-peak hand velocity were analyzed using a two-way repeated-measures analysis of variance (ANOVA) examining effects of movement  and segment . Significant interactions (p < 0.05) were examined by conducting simple main effect one-way repeated-measures ANOVA’s of movement at each level of segment. Significant main or simple main effects (p < 0.05) were followed up by conducting all pairwise comparisons with Bonferroni correction. Normality was assessed using the Kolmogorov-Smirnov Test and sphericity was assessed through a Mauchly’s Test of Sphericity. In cases where the assumption of sphericity was not met, a Greenhouse-Geisser Correction was applied and reported. For peak grip aperture, percent-to-peak grip aperture, and percent-to-peak hand deceleration a one-way repeated-measures ANOVA, with Bonferroni corrected pairwise comparisons where significant (p < 0.05), was conducted to assess potential differences between movements for the reach-grasp segment only.A between-session repeatability analysis was performed by calculating the intra-class correlation (ICC) for model , the standard error of measurement (SEM), and the minimal detectable change (MDC)  between interval . SEM andinterval .Overall performance time (from start to finish) for the Pasta Box Task was 8.84 ± 0.34 seconds, and for the Cup Transfer Task 10.60 ± 0.49 seconds. Error trials occurred at a rate of 4% for the Pasta Box Task, and 11% for the Cups Transfer Task. The most common errors were sequence hesitation , hitting a partition/obstacle , and incorrect grasp of the object .Movement times, hand distance travelled, and hand trajectory variability for each movement are listed in Tables Movement times for reach-grasp segments were significantly smaller than for transport-release segments (p < 0.001), even in the single case where transport distance was shorter than reach distance during Movement 3 in the Cup Transfer Task . For theHand trajectory graphs displaying the average hand trajectories and across-participant standard deviations are shown in Figs For the Pasta Box Task , movemenThe distinct feature of Movement 2 was that the participant had to transfer the box of pasta from the first shelf to the second shelf by moving around the middle cart barrier, which served as an obstacle. The transport-release segment of this movement had a significantly lower peak hand velocity than the other transport-release segments (p < 0.001), displayed two velocity peaks , and the peak hand velocity in reach-grasp occurred significantly earlier than that of Movement 1 (p = 0.028) and Movement 2 (p < 0.001). Peak hand velocity during transport-release of Movement 3 was similarly significantly higher than that of Movement 1 and 2 (p < 0.001), but with a lower percent-to-peak hand velocity compared to Movement 2 (p < 0.001) (but not significantly different from Movement 1 (p = 1.000)).Overall, peak velocities for the Cup Transfer Task  were sigThe Cup Transfer Task was unique in that it required two different grasp patterns, which we hypothesized would affect grip aperture and velocity of movements based on confidence in modulating grip patterns to not crush the cup and spill the contents. Movement 1 had the shortest distance to reach and the lowest peak velocity  comparedMovement 2 required a change in grasp to a side grasp of the cup, and displayed a similar peak grip aperture to Movement 3 also requiring a side grasp (p = 0.959), but was significantly different from the top grasps (p < 0.05). Although Movements 2 and 3 had similar grip apertures, there were differences in the velocity profiles. Movement 2 had a lower and earlier peak hand velocity than Movement 3, and the earliest deceleration peak of all the reach-grasp segments. This slowed movement was also seen in the transport-release segment of Movement 2, which had the lowest peak hand velocity of all the transport-release segments. The percent-to-peak grip aperture occurred significantly earlier in the reach-grasp segment of Movement 2 compared to the other 3 movements (p < 0.01).In contrast, the reach-grasp segment in Movement 3 had the highest peak hand velocity. The hand velocity for the transport-release segment of Movement 3 was not significantly different from Movement 1 (p = 1.000) and 4 (p = 0.137). Movement 4 had the largest peak grip aperture (p < 0.05). It otherwise showed similar characteristics in percent-to-peak grip aperture and percent-to-peak hand deceleration as Movement 1, which had the same grasp.Both the Pasta Box Task and Cup Transfer Task presented mostly good repeatability (ICC > 0.75) for movement time, peak hand velocity, percent-to-peak hand velocity, peak grip aperture, percent-to-peak grip aperture, and percent-to-peak hand deceleration.For the Pasta Box Task , poor toFor the Pasta Box Task , SEM valThe purpose of developing new standardized functional tasks representative of real-world ADLs was to create a meaningful assessment metric for clinical populations with upper limb impairments, that specifically focused on quantifying hand kinematics. Reach-grasp tasks have been shown to provide insights into altered motor control strategies in populations with impaired upper limb function ,30,35–37The tasks had specific movement sequences that were standardized, repeatable, of short duration, and consistently performed by individual participants. Other tasks used in literature have shown low within-participant variability ,13,35, hThe task design with specific sequencing allowed for segmentation of movements into the crucial phases of reaching and grasping, and transporting and releasing objects within the same task. This allows examination of discrete characteristics of hand movement pertaining to hand trajectory, hand velocity, and grip aperture for each of these phases. This is important as many clinical populations will have impaired dexterity impacting grasp, which has been extensively investigated ,44; howeThe influence of an object’s intrinsic and extrinsic parameters on hand kinematics was consistent with prior literature. Location of the object influenced several parameters, particularly the first movement of the Pasta Box Task where the box of pasta was not within the direct field of view and required a turn of the body and the head for the grasp. This misalignment of the body space to the visual space has been shown to increase the latency of the movement towards a target and decrease accuracy ,46. ThisThe location of the cups in the task space and the required grasp conformation also influenced reaching strategies. The first reach-grasp of the Cup Transfer Task showed the smallest grip aperture, suggesting confidence with the upcoming grasp of the top of the cup, but a slowed velocity of the reach likely due to the short distance. The two cylindrical side grasps showed similar grip apertures, but were different in movement strategies in that the first cylindrical side grasp showed several features suggesting it was the reach with the highest perceived risk, with lower, earlier peak velocity and the earliest deceleration. This is consistent with previous studies where hand velocity was lower during the reach when the task following the approach required precision ,49. ThreBoth tasks involved obstacle avoidance; in the vertical plane for every movement of the cups, and in the horizontal plane for the second movement of the box of pasta. As previously shown by Chapman & Goodale, obstacles change the spatiotemporal characteristics of hand movement by increasing movement time and decreasing peak hand velocity . This efThe challenges presented by these varied intrinsic and extrinsic properties is expected to result in significant performance differences in conditions with impaired hand sensation and impaired upper limb function. Reaching and grasping are functionally linked to the specific task, with the characteristics of the object determining the relative timing of peak grip aperture and peak hand deceleration . AbnormaThe assessment of normative hand movement characteristics demonstrated consistent trends across varying task challenges. The limitations of the current study include the assessment of only between-session repeatability, not the repeatability among different test administrators and study sites. Further study of inter-rater repeatability will assist with determining reproducibility of the task assessment. Considering that the presented normative data set establishes an ideal young adult performance standard, further work may focus on establishing differences between the sexes or with aging cohorts to obtain a fully comparative data set for populations with impairment. Finally, future work will also test the application of this methodology in populations with upper limb impairments, and validate the measures against other clinically validated hand outcome assessments in these populations.Standardized upper limb functional tasks which mimic ADLs and incorporate elements of risk and accuracy, lateral reaches, reaches crossing the body’s midline, objects of different shapes and sizes, and different grasp patterns to assess hand movements were developed. A normative dataset for hand movement was created based on non-disabled performance characterizing hand trajectory, hand velocity, and grip aperture features for reach-grasp and transport-release segments of the movements. These features verified that the tasks challenged a variety of motor control strategies, and these unique movement characteristics were reflected in the quantitative results while being highly consistent within-performers. In addition to the low within-participant and between-participant variability for these complex tasks, a repeatability analysis showed that this novel assessment approach has good between-session repeatability. This assessment promises to be a valuable tool for future research in populations with upper limb impairments.S1 Text(PDF)Click here for additional data file.S2 Text(PDF)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.


Bacteriocins are a huge family of ribosomally synthesized peptides known to exhibit a range of bioactivities, most predominantly antibacterial activities. Bacteriocins from lactic acid bacteria are of particular interest due to the latter’s association to food fermentation and the general notion of them to be safe. Among the family of bacteriocins, the groups known as circular bacteriocins and leaderless bacteriocins are gaining more attention due to their enormous potential for industrial application. Circular bacteriocins and leaderless bacteriocins, arguably the least understood groups of bacteriocins, possess distinctively peculiar characteristics in their structures and biosynthetic mechanisms. Circular bacteriocins have N-to-C- terminal covalent linkage forming a structurally distinct circular peptide backbone. The circular nature of their structures provides them superior stability against various stresses compared to most linear bacteriocins. The molecular mechanism of their biosynthesis, albeit has remained poorly understood, is believed to possesses huge application prospect as it can serve as scaffold in bioengineering other biologically important peptides. On the other hand, while most bacteriocins are synthesized as inactive precursor peptides, which possess an N-terminal leader peptide attached to a C-terminal propeptide, leaderless bacteriocins are atypical as they do not have an N-terminal leader peptide, hence the name. Leaderless bacteriocins are active right after translation as they do not undergo any post-translational processing common to other groups of bacteriocins. This “simplicity” in the biosynthesis of leaderless bacteriocins offers a huge commercial potential as scale-up production systems are considerably easier to assemble. In this review, we summarize the current studies of both circular and leaderless bacteriocins, highlighting the progress in understanding their biosynthesis, mode of action, application and their prospects. Over the past decade, there has been a growing interest on bioactive peptides of ribosomal origin also known as ribosomally synthesized and post-translationally modified peptides (RiPPs) produced by a wide range of bacterial species . AlthougIn the era of genomics, wherein bacteriocin-dedicated databases and online platforms with diverse tool for the automated characterization  and screCircular bacteriocins are a family of RiPPs that are clustered based on their structurally conserved circular peptide backbone arising from the covalent linkage of their N- and C-terminal residues. In this review, the term “circular” (and circularization for the process of) should not be confused with the cyclic structures of non-C- and N-terminal ligated bioactive peptides such as that of other bacteriocins containing lanthionine rings and disulfide bridges. This should also be clearly distinguished from the cyclic structures found in many non-ribosomally antimicrobial peptides. The most remarkable property of circular bacteriocins is their superior stability compared to their linear counterparts. But perhaps the greatest promise of this group of bacteriocins lies on the understanding of their biosynthetic mechanism, although still has remained the biggest challenge.On the other hand, leaderless bacteriocins are peculiarly different from other bacteriocins. While most bacteriocins are synthesized as an inactive precursor peptide containing N-terminal leader moiety, leaderless bacteriocins are synthesized without these leader sequences hence the term. This peculiar characteristic of leaderless bacteriocins disqualifies them in the family of RiPPs as they do not undergo any post-translational modifications. Nonetheless, the ribosomal nature of their biosynthesis and their innate “bacteriocin” characteristics makes them undeniably a close relative to most RiPPs. Moreover, the simplicity of leaderless bacteriocins holds their most remarkable potential as it makes them easily adaptable to any expression systems for their eventual scale-up production systems.This review summarizes these two emerging groups of bacteriocins highlighting the progress in our understanding of their biosynthesis, mode of action, application and their prospects.Head-to-tail ligated RiPPs are not limited to bacterial origin as many circular antimicrobial compounds have been found from many eukaryotic organisms such as mammals, plants, and fungi . AttentiTable 1).To date, there are only 14 circular bacteriocins that have so far been characterized. Enterocin AS-48, the representative of the group was first reported in 1986 , but itsBacillus subtilis, was initially considered to be a circular bacteriocin . However, in the context on their possible biosynthetic mechanisms wherein the leader peptides are presumed to playing a key role, a different clustering scheme based on the length of their leader peptides has also been suggested  (Table 1).The sub-classification among circular bacteriocins appears to be difficult since they display very little sequence similarity. Nevertheless, circular bacteriocins share a common structural fold known as the saposin fold  and thesigure 1) . It is wFigure 2). For lactocyclicin Q only the sequence of its structure gene has been reported while the details of its biosynthetic gene cluster have not yet been described. Except the peptide product of the structure gene, majority of the putative proteins encoded in these gene clusters are hydrophobic and hence are presumed to be membrane associated. Interestingly, despite the low sequence homology among the putative proteins encoded by these genes, similarity on their architecture and deduced characteristics are still apparent. Interestingly, all biosynthetic gene clusters of circular bacteriocins possess a gene encoding a protein belonging to a conserved hypothetical protein superfamily known as SpoIIM .Just as in the case of other bacteriocins, the genetic determinants of circular bacteriocins are either encoded chromosomally or on plasmids. The gene clusters involved in the biosynthesis of enterocin AS-48 , circulaas-48-ABCC1DD1, cirABCDE, gaaBCADITE, cclBITCDA, garAXBCDE, enkBB1B2B3B4, acnACDEF, and plcADITEB revealed the indispensability of these genes in the productions and immunities of enterocin AS-48, circularin A, gassericin A, carnocyclin A, garvicin ML, enterocin NKR-5-3B, amylocyclicin and plantaricyclin A, respectively. However, the expressions of an accessory operon encoding an ABC transporter protein complex could enhance both production and immunity such as in the case of enterocin AS-48 and carnocyclin A. Higher bacteriocin production and immunity were observed when the genes as-48EFGH .The biosynthetic gene cluster of circular bacteriocins shares some basic features which include (i) a gene encoding the precursor peptide, (ii) a gene encoding a dedicated immunity protein, which is a small, cationic, and hydrophobic protein, (iii) genes encoding an ABC transporter composed of an ATPase and a membrane protein, which is thought to be involved in the bacteriocin secretion but can also confer partial immunity [such as the case of EnkB1 and EnkB3 of enterocin NKR-5-3B ], and  were only able to produce the precursor peptide and linear forms of garvicin ML suggesting that these knocked-out mutants lost the capacity for the circularization reaction . WhereasBut perhaps, the understanding the circularization process of these peptides is the most challenging. It is still a mystery how the enzyme(s) catalyze the reaction leading the “free” C-terminal end to be subject to attack by the amino group of the residue at the N-terminal end. Some clue may be found in the mature forms of circular bacteriocins. Interestingly, the ligation sites of all circular bacteriocins are located within a helical structure, a region composed mainly of hydrophobic residues. It was previously thought that these hydrophobic patches surrounding the ligation site are crucial for the interaction with their cognate biosynthetic enzyme(s) . Indeed,Escherichia coli and Agrobacterium tumefaciens . Whereas, in the case of enterocin NKR-5-3B, Enterococcus and Lactobacillus served as successful host for its heterologous expression (With respect to the nature and type of enzyme(s) catalyzing the reactions during circular bacteriocin maturation, no clear evidence has so far been reported. Up to now, it is certain that the enzymes catalyzing these reactions are encoded in the gene clusters of four to five genes. In the case of enterocin NKR-5-3B, production of the mature circular bacteriocin was blocked when the phenotype is devoid of a single gene in its biosynthetic gene cluster. Analyses of the gene clusters of other circular bacteriocins showed similar pattern suggesting that no single protein is responsible for the maturation, particularly the circularization and secretion of these bacteriocins. It is highly possible that the enzymes encoded in these biosynthetic gene clusters would form a membrane-located complex and jointly process the three events in succession to complete the circular bacteriocin biosynthesis. However, the absence of any peptidase domain in the biosynthetic enzymes encoded by these genes punctuates the enigmatic event of the leader peptide cleavage. It has been suggested that the enzyme responsible catalyzing this reaction could be encoded elsewhere outside the biosynthetic gene cluster such as in the case of the chromosomally encoded signal peptidases (SPases) cleaving the N-terminal sequences of other bacterial circular peptides from efaciens . Proponeefaciens , as wellefaciens . While ipression .With regards to the regulatory mechanisms of the production of circular bacteriocins, it has remained so far to be largely unknown. While genes encoding proteins that are commonly involved in the regulation of most bacteriocins such as histidine kinase and response regulator proteins were found in the vicinity of the biosynthetic gene clusters of some circular bacteriocins such as that of butyrivibriocin AR10, circularin, uberolysin, and enterocin NKR-5-3B, their cognate activator molecules have not been identified. Nonetheless, some hints pointing to the possible regulation by quorum sensing three component system are apparent .The mechanism of the antimicrobial action of circular bacteriocins is based on its ability to directly interact with the bacterial cell membrane that would cause its permeation resulting to the leakage of ions, dissipation of membrane potential, and eventually, cell death. The common characteristics of circular bacteriocins of having high net positive charge is believed to facilitate their electrostatically driven interaction to the negatively charge bacterial membrane without requiring any receptor molecule. It was previously shown that enterocin AS-48 can cause molecular electroporation on target membranes by forming non-selective ion channels in the cytoplasmic membrane leading to the leakage of ions and low-molecular weight solutes . While gThe identification of two different oligomeric states of enterocin AS-48 provided the detailed mechanism on its membrane interaction. X-ray crystallography analysis revealed that enterocin AS-48 exists in water-soluble dimeric form (DF-I) that would rearrange into its membrane-bound dimeric form (DF-II) facilitating its insertion into the membrane . Howeverin vivo inhibitory concentrations  serves as a recognition site for the biosynthetic enzymes, (ii) protects the producer strain from the bacteriocin’s inhibitory activity, and (iii) ensure a suitable conformation essential for the enzyme–substrate interaction . QuestioN-formyl-methionine after cyanogen bromide treatment did not have any negative effect on the bioactivities of lacticins Q and Z. Moreover, in vitro-synthesized lacticin Q with non-formyl methionine at its N-terminal still exhibited comparable antimicrobial activity (unpublished data). Furthermore, lacticin Q and aureocin A53 obtained from overexpression in E. coli BL21 (DE3) yielding a non-formylated N-terminal methionine peptides both demonstrated intact antimicrobial activities . Leaderless bacteriocins have comparable pI values and net cationic charge with class i circular bacteriocins but are significantly higher than of group ii circular bacteriocins. Most notably, leaderless bacteriocins are significantly less hydrophobic than circular bacteriocins .The first reported leaderless bacteriocin, enterocin L50, is composed of two peptides (enterocin L50A and L50B) that exhibit synergistic activity . HoweverFigure 3). The aureocin A53-like single leaderless bacteriocins are highly cationic and are Trp-rich peptides. The Trp residues of these group are believed to play a key role in their antimicrobial action as it facilitates their interaction with the bacterial membranes (11 to Leu29 with aureocin A53 as reference) and relatively variable C-terminal region . Whereas, LsbB-like sub-group, with members LsbB, enterocins EJ97, K1, and Q, show relatively conserved C-terminal region (Lys17 to Glu26 with LsbB as reference) and a less conserved N-terminal region . On the other hand, although weissellicins Y and M belong to single peptide leaderless bacteriocins (for the reason that they do not show synergistic activity and encoded in separate operons) they exhibit high similarity to two-peptide leaderless bacteriocins . Two other bacteriocins identical to enterocin MR10 produced by other strains have been reported with other names; enterocins DD14 (DD14A and B) and enterocin 7 (Ent7A and B) (Table 2).Leaderless bacteriocins display high sequence homology to most members within their sub-groups . Sequence homology analysis of garvicin KS facilitated the discovery of cereucins V, X, and H from unannotated genes of some Bacillus cereus strains found in genomic database. The antimicrobial activity of all these bacteriocins was confirmed with synthetic peptides and all were shown to have broad spectrum antimicrobial spectra  leaderless bacteriocin was described . Althoug spectra .Figure 4), only in the case of lacticins Q and Z  seem to be encoded in the chromosomal DNA of its producer strains ca QU 13  and Ente MRR10-3 , respect MRR10-3 , lactoli MRR10-3 , garvici MRR10-3 , cereuci MRR10-3 , and epi MRR10-3  have alslnqBCDEF and consequently its production . The overall fold of the amphipathic helices of both groups resulted in the formation of a hydrophobic core as a consequence of the packing of the hydrophobic residues   .Figures 5C,E) . It would be interesting to experimentally verify the correlation between the structural consensus shared among these bacteriocins and their mode of action. However, it is worth noting that most circular and leaderless bacteriocins are highly cationic peptides . It has been proposed that saposin fold exhibiting bacteriocins interact with the bacterial membrane through electrostatic interaction (Table 1) . This data is in perfect agreement with the hydrophobicity index exhibited by these bacteriocins . Thus far, the majority of circular and leaderless bacteriocins have been shown to disrupt bacterial membranes and cause cellular component leakage through pore formation. However, there are still some disagreement on whether a receptor molecule is required for their mode of action as in the case of the circular garvicin ML. Whereas the receptor molecule-requiring-mode of action of the leaderless bacteriocin, LsbB, should not be attributed to the above-mentioned structural consensus since this bacteriocin does not display such a fold. LsbB, and its related leaderless bacteriocins , assume a single α-helical structure at the N-terminal with an unstructured C-terminal region rather than the above-mentioned saposin-like fold   . This ches 5C,E) . Apparenes 5C,E)  and the es 5C,E) . The dises 5C,E) . Coincideraction . It is aTable 1) . Moreovegure 5D) .Leishmania , these leaderless bacteriocins have been demonstrated to have no cytotoxic and hemolytic activities, thus underlining the safety of their application (Sec-pathway. As already mentioned above, enterocin L50A and L50B have been successfully produced using the yeast Saccharomyces cerevisiae and Pichia pastoris through the general secretion systems of these eukaryotic hosts. The yeast mating pheromone α-factor 1, MFα1, directed the efficient secretion of the bacteriocins through the Sec-system of both hosts cells when it was fused to the N-terminal region of the bacteriocins (On the other hand, the application of leaderless bacteriocins across different industries are equally promising. Some leaderless bacteriocins show bioactivity even at very low concentrations. Lacticin Q displays strong bioactivity even at nanomolar concentrations whereas many other non-leaderless bacteriocins are active at a relatively higher concentration . Althouglication ,b. Simillication . But pereriocins , 2010. IBacteriocins, particularly from LAB, are excellent antimicrobials that are traditionally appreciated for their effectiveness in food preservation. However, in the past decade, an extra attention geared toward their possible application in the health industry was apparent. Their viability as an alternative to conventional antibiotics, particularly for the control of multi-drug resistant pathogens is now being evaluated. A growing number of bacteriocins belonging to the group known as circular and leaderless bacteriocins possessing unique features both in their structures and biosynthetic mechanisms are increasingly attracting more attention due to their enormous industrial potential. However, there is still so much to know about their biosynthesis and mode of action in order to materialize their full potential. A better understanding on how these antimicrobials inhibit their target bacteria is important in minimizing possible development of resistance mechanisms in the future. Furthermore, knowledge on the mechanisms of their self-immunity could serve as a reference point in their bioengineering to further curtail any future resistance mechanism among their targets. But with the rapid development in science and technology, particularly in fields of genomics, genetic engineering, structure biology and biotechnology, a better understanding on the biology of their origin and molecular nature should be attained sooner and this would facilitate for their large-scale application across industries.All authors defined the topic of the review. RP drafted the manuscript. TZ and KS polished it. All authors read 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.


We report a comparison of inhaled corticosteroid (ICS)-related adverse events between patients co-prescribed Aerochamber compared to the licensed Volumatic® spacer. We utilised two historical cohorts: questionnaire-based and electronic medical record (EMR)-based, to assess patient-reported and EMR-recorded adverse events in patients with asthma prescribed non-EF BDP. Marginal effect estimate (MEE) was calculated to determine non-inferiority of Aerochamber compared to Volumatic in terms of patient-reported oral thrush and hoarseness with margin of 0.13. Other patient-reported adverse events , and EMR-recorded adverse events were also assessed. Rate of patient-reported oral adverse events were non-inferior in 385 patients prescribed Aerochamber compared to 155 patients prescribed Volumatic . Total patient-reported adverse events did not differ significantly between Aerochamber and Volumatic (53.3 vs 49.7% with ≥1 adverse event). The EMR-based study of 1471 matched pairs of subjects did not show significantly different number of EMR-recorded adverse events between Aerochamber and Volumatic (12.5 vs 12.8% with ≥1 adverse events). Co-prescribing Aerochamber with non-EF BDP does not increase the risk for patient-reported and EMR-recorded ICS-related adverse events compared to co-prescribing Volumatic.Co-prescription of Aerochamber A study of spacer devices for use with asthma inhalers shows no significant difference in the incidence of side-effects between licensed and unlicensed spacers. Spacers offer a way of improving the dose inhaled, particularly in children and those adults who struggle to use asthma inhalers correctly. However, non-extrafine beclomethasone dipropionate (like Clenil Modulite) inhalers are frequently co-prescribed with unlicensed Aerochamber spacers rather than the Volumatic spacer which is licensed for this drug. David Price at the University of Aberdeen, UK, and co-workers analysed data from two historical studies to verify whether Aerochamber use enhanced the risk of unpleasant side effects for patients, such as oral thrush or hoarseness. They found no significant difference between licensed and unlicensed spacers and the chances of adverse events, suggesting both are suitable for use with non-extrafine beclomethasone dipropionate inhalers. National and international guidelines recommend inhaled corticosteroids (ICS) as the first-line therapy for treatment of asthma.13 Oral thrush is a well-documented adverse event associated with regular use of ICS in patients with asthma.15 Approximately 5–10% of patients prescribed ICS reported adverse events in the oral cavity and pharynx,12 with the occurrence of clinically significant oropharyngeal candidiasis as high as 10% in adults17 and between 1 and 3% in children.19 The reduction of the local immune response,20 or growth stimulation of Candida albicans21 through an increase in salivary glucose, are believed to be responsible for the development of candidiasis. Multiple factors have been reported to contribute to the incidence of oral thrush in patients with asthma, including the type and dose of ICS prescribed, the delivery device used, and patient adherence to medication instructions.24 This relationship between risk of oral thrush and the type, dose, and delivery device of ICS has also been observed in chronic obstructive pulmonary disorder (COPD) patients.6Oropharyngeal adverse events associated with ICS use include oral candidiasis , hoarseness, dysphonia, pharyngitis, and cough reflex.25 and careful mouth rinsing after using dry powder inhalers can reduce the risk of oral thrush.18 Spacers are recommended by asthma treatment guidelines for patients under the age of 16 years, for those who have problems coordinating actuation, for those prescribed high-dose ICS, for those at risk of suffering from local side effects, and for elderly patients.26 The addition of a spacer to a pMDI has proven to consistently reduce aerosol velocity and particle size in the aerosol plume, thus reducing the amount of prescribed therapy deposited in the oropharyngeal cavity and increasing the amount of active compound that reaches the lung.29 Previous studies have suggested that spacers used with non-extrafine (non-EF) particle ICS may result in reduced rates of oropharyngeal candidiasis.31The use of spacers with pressurised metered dose inhalers (pMDIs)® Modulite®) is licensed for use only with the Volumatic® spacer.32 However, our previous study found that the Aerochamber® spacer has also been frequently prescribed, off-label, in conjunction with Clenil Modulite.33 There is concern that the use of unlicensed spacers may result in a greater number of adverse events compared to the use of licensed spacers. Large spacers, such as the Volumatic device, have been shown to have more effective drug distribution compared to smaller spacers, such as the Aerochamber.35 However, the ease of use and carriage of the smaller Aerochamber device make it a more attractive choice for both patients and prescribers, even if it is not licensed.36 The aim of this study was to characterise both patient-perceived and electronic medical record (EMR)-recorded possible ICS-related adverse events in patients with asthma co-prescribed the licensed Volumatic or the unlicensed Aerochamber spacer with their non-EF BDP therapy. This was conducted using two historical cohort studies: a questionnaire-based study and an EMR-based study for assessment of patient-reported and EMR-recorded adverse events, respectively.Spacers are licensed for use with specific inhalers. Non-EF beclometasone dipropionate (BDP) (Clenilp = 0.003) . However, the number of patients who experienced at least one severe asthma exacerbation during the 1-year baseline period was not significantly different between the Aerochamber- and the Volumatic-prescribed groups .A total of 1471 matched pairs were included in the EMR-based study after 1:1 matching Fig.  with thePatient-reported oral adverse events  were reported in 27.7% patients co-prescribed the unlicensed Aerochamber compared to 29.9% of patients co-prescribed the licensed Volumatic spacer. The marginal effect estimate (MEE) was −0.043 , −0.133 to 0.047). As the upper limit of the 95% CI was less than the pre-defined non-inferiority margin of 0.13, the Aerochamber was determined to be non-inferior to the Volumatic spacer in terms of local oral adverse events  from the questionnaire-based study.There were no significant differences in the total number of overall patient-reported adverse events  between patients co-prescribed Aerochamber and patients co-prescribed Volumatic spacer  and 1283 (87.2%) patients did not have any EMR-recorded adverse events, respectively. The number of patients with exactly one recorded adverse event were 169 (11.5) and 171 (11.6%), respectively, and 15 (1.0) and 17 (1.2%) had 2 or more adverse events in the Aerochamber and Volumatic groups, respectively , the rates of EMR-recorded adverse events were also not significantly different in patients prescribed Aerochamber compared to patients prescribed Volumatic spacer .This real-life study in a population of patients with asthma provides a unique perspective of both patient-reported and EMR-recorded ICS-related adverse events. Data from both patient questionnaires and EMR demonstrated that the co-prescription of the unlicensed Aerochamber spacer with non-extrafine beclometasone was not associated with higher patient-reported or EMR-recorded adverse events than the co-prescription of the licensed Volumatic device with non-extrafine beclometasone.38 National and international guidelines offer advice on which patients should receive specific therapies.26 However, these are often not strictly followed by healthcare professionals as patients may be unwilling to carry, or unable to use the device. Off-label and unlicensed prescriptions may also be given due to the lack of a licensed therapy available for a patient’s age group.36 Our recent study found that national guidelines for spacer prescription were not followed for a large proportion of patients prescribed non-EF BDP.33 Of those patients who were prescribed spacers, the majority were prescribed the unlicensed Aerochamber spacer (59.0%) followed by the licensed Volumatic device (18.9%).33The combination of the right medication and the optimal delivery device with the patient’s cognitive and physical abilities are essential to ensure optimum therapy delivery. The prescription of devices that are not easily used by patients can result in incorrect inhaler technique, leading to decreased drug delivery, poor disease control, and culminating in decreased therapy adherence.31 To account for this, we adjusted our analysis for ICS dose in the questionnaire-based study and matched for ICS daily dose in the EMR-based study. Thus, any difference in ICS-related adverse events would not have been caused by the ICS dose. Other reported local side effects of ICS use include dysphonia, cough reflex, and pharyngitis. These are also considered to be an immediate cause of clinical discomfort, which in turn reduce patient adherence to therapy, possibly resulting in a decrease in asthma control.12 This study clearly demonstrated that this was not the case for co-prescription of the unlicensed Aerochamber spacer with non-EF BDP asthma therapy. In terms of patient-perceived occurrence of oral thrush and hoarseness, the Aerochamber was non-inferior to the licensed Volumatic spacer. This was further confirmed by doctor-recorded data (diagnostic read codes), where patients prescribed the Aerochamber spacer did not suffer significantly more ICS-related adverse events than those prescribed the Volumatic spacer.A major concern with unlicensed prescriptions is the potential for side effects. Several studies have reported an increased incidence of oral thrush in patients with asthma associated with ICS dose.39 The short duration of clinical trials and the stringent inclusion criteria often limit the quality and quantity of data on adverse events.41 Similarly, patient-perceived ICS-associated adverse events may not be detected during routine clinical practice as patients are often reluctant to discuss their concerns about medication with their physicians.42 Discordance and lack of patient–prescriber communication may cause patients to titrate their medication or self-medicate, reducing disease control.12 This existing disparity between doctors and patients, with respect to their approach to drug-related adverse events, can be tackled via better patient understanding of their treatment benefits and of potential adverse effects, and with prescribers trying to better understand the concerns of patients.43 Previous reports have suggested differences in patient- versus doctor-reported adverse events,44 and it is therefore important to integrate self-reported patient questionnaires as a key tool for investigating adverse events. The use of both patient questionnaires and physician-recorded adverse events makes this study unique.It is very likely that the range and extent of ICS-related adverse events, as experienced by patients, are underestimated.Real-world studies assess the results of therapy under conditions of usual care that are not subjected to the selection of patients through restrictive eligibility criteria as occurs in clinical trials. Although the Optimum Patient Care Research Database (OPCRD) is a well-maintained and validated database, we cannot rule out the possibility of inaccurate or missing data. The outcomes were studied over 3 full years for the cohort study to balance seasonal influences on outcome measures. However, the real-life nature of this study also means that although spacer prescriptions were identified, it is not guaranteed that the prescriptions were filled or that the spacers were used. A limitation inherent to observational studies is the possibility of unrecognised confounding factors or influences in prescribing that were not accounted for such as inhaler technique. Lastly, only read-coded adverse events would have been detected in the EMR-based study. This is however unlikely to be unbalanced between either spacer arms and thus is not expected to significantly affect the finding of this study.45 Further studies will be required to extend the finding of this study to spacer use with ICS delivered as extrafine particles.The current study focused on the adverse events of spacer co-prescription with non-extrafine beclometasone prescription for asthma. More recent devices are able to generate ICS aerosol as extrafine particles which has been previously reported by various studies to have comparable to superior efficacy and safety compared to non-extrafine formulation.In conclusion, this study found that co-prescription of the unlicensed Aerochamber spacer with non-extrafine beclometasone dipropionate therapy for asthma did not increase the risk of developing patient-reported or EMR-recorded ICS-related adverse events, as compared to co-prescription of the licensed Volumatic device.www.opcrd.co.uk).46 The OPCRD currently comprises fully anonymous, longitudinal medical records for over 4.5 million patients from over 600 primary care practices across the United Kingdom. The OPCRD contains two types of data: (1) routinely recorded clinical data and (2) questionnaire data (collected as part of routine patient data collection) from over 55,700 patients with respiratory conditions. This enables real-life studies to draw on information from both perspectives, ensuring a more complete answer to the questions posed. The OPCRD is approved by the Health Research Authority of the UK NHS for clinical research use (Research Ethics Committee (REC) reference: 15/EM/0150). Records contain complete prescribing, coded diagnostic, and clinical information, as well as information on tests requested, laboratory results, and referrals made at or following on from each consultation.47The study utilised a large UK primary care database, the OPCRD .The study protocol was overseen by an independent steering committee and registered with the European Network of Centers for Pharmacoepidemiology and Pharmacovigilance  and the Anonymous Data Ethics Protocols and Transparency (ADEPT) committee (Ref: ADEPT0517) prior to data extraction.For the questionnaire-based study, eligible patients were aged ≤65 years, with a Read code  confirmed asthma diagnosis. They received ≥2 separate non-EF BDP (Clenil Modulite) prescriptions with one prescription for a spacer (Volumatic or Aerochamber) during the baseline year prior to the date of the questionnaire and had 2 years of continuous practice data (comprising ≥1 year of data prior to the questionnaire).Eligible patients of the EMR-based study were aged ≤65 years, with a Read code confirmed asthma diagnosis. They received ≥2 separate non-EF BDP (Clenil Modulite) prescriptions in the baseline year and another ≥2 prescriptions in 1 year after index. They were prescribed either Volumatic or Aerochamber spacer at the index date and had 4 years of continuous practice data (comprising ≥1 year of baseline data and 3 years of outcome data).Patients were excluded from both studies if they received prescriptions for different ICS or fixed-dose combination) ICS/LABA (long-acting β-agonist) therapy or were ever prescribed both Volumatic and Aerochamber spacers  over a 3-year period were extracted from the OPCRD.The secondary objective was to compare EMR outcomes for non-EF BDP co-prescribed with either the Volumatic or the Aerochamber spacer in the EMR-based study. Read codes for adverse events to non-EF BDP, as defined in the product information sheetFor the questionnaire-based study, patients in each spacer group were compared following adjustment for variables selected from those with the highest relative change in coefficient. The final variables used for adjustment were gender, ICS average dose, and smoking status, selected based on clinical judgement and baseline balance. Matching was not conducted for the questionnaire-based study to preserve statistical power due to sample size.For the EMR-based study, exact matching for categorical variables and matching within a maximum calliper for numeric variables were used to match patients using 1:1 nearest neighbour matching, without replacement. Matching variables such as demographic data, disease co-morbidity, and indicators of disease severity were considered for selection using a combination of baseline data analysis and predictive modelling of the baseline data in relation to the outcome variable (independent of treatment group). The final criteria settled on a mix of direct and propensity score matching .The study was powered using the occurrence of oral thrush as the representative adverse event. The occurrence of adverse events (34%) was based on the oropharyngeal adverse events in users of ICS in a real-life setting reported in the literature.All analyses were carried out using IBM SPSS Statistics version 21 , SAS version 9.3 , and Microsoft Office Excel 2013 . Forest Plot was generated with DistillerSR Forest Plot Generator from Evidence Partners.p value of <0.05 was considered statistically significant.MEE of spacer type (Aerochamber or Volumatic) on the reported oral thrush/hoarse voice incidence was calculated to determine non-inferiority in the primary outcome analysis. The MEE was calculated from predictions of the model at fixed values of the covariates and averaging over the remaining covariates to obtain an interval where the result was likely to lie. Chi-square test was utilised to obtain the odds ratio of adverse events identified from the EMR (EMR-recorder adverse events). Poisson regression was utilised to calculate the rate ratio of EMR-recorded adverse events, adjusted for osteoporosis and anxiety/depression diagnosis. The Further information on experimental design is available in the Supplementary InformationReporting Summary


Although limited data are available in the veterinary literature, human studies have demonstrated benefit with the addition of PET both for assessment of the primary tumor and for detection of metastatic disease. 18F-FDG PET appears to be more accurate at detecting the margin of oral neoplasia, in particular for tumors arising from highly vascularized tissue, such as the lingual and laryngeal areas. 18F-FDG PET has a high sensitivity for the detection of lymph node metastasis, however the specificity is variable between studies. Tracers beyond 18F-FDG can also be used for oncology imaging. 18F-Fluoride (18F-NaF) is an excellent osseous tracer, useful in assessing bone involvement of primary tumors or osseous metastasis. Other specific tracers can be used to assess cell proliferation or hypoxia for tumor characterization. 18F-FDG is also an excellent tracer for detection of inflammation. Human studies have demonstrated its value for the assessment of periodontitis and dental implant infection. 18F-NaF has been used to assess disorders of the temporomandibular joint in the human literature, demonstrating good correlation with arthralgia and therapeutic outcome. Both 18F-NaF and 18F-FDG had good concordance with localization of cervical pain in people. PET will likely have a growing role in veterinary medicine not only for oncologic imaging but also for assessment of inflammation and pain.Positron Emission Tomography (PET) is an imaging technique that provides functional information, in addition to structural information obtained with computed tomography (CT). The most common application is cancer staging, using  Positron Emission Tomography (PET) is a nuclear medicine imaging technique, which provides cross-sectional data based on the 3-dimensional localization of positrons emitted by radiotracers. When compared with scintigraphy, in addition to its cross-sectional nature, PET has the advantages of higher detection efficiency and spatial resolution . PET dat18F-FDG), which is a radioactive analog of glucose. Similar to glucose, FDG is actively transported into cells by a group of structurally related glucose transport proteins. For this reason, 18F-FDG is an excellent marker of metabolic activity and is particularly useful for the detection of neoplasia, as tumor cells often preferentially utilize glucose for glycolysis and subsequently display increased numbers of glucose transporters . 18F-NaF is an excellent marker of bone remodeling as it gets integrated into the exposed hydroxyapatite matrix at sites of bone turnover. 18F-NaF has a higher sensitivity than the larger and more complex 99mTc-Bisphosphonates used for scintigraphic imaging. 18F-NaF has been commonly used in oncology for the detection of primary osseous tumors or metastasis but can also be used for non-oncologic imaging  and 61Cu-diacetylmethylthiosemicarbazone (61Cu-ATSM), are markers of tumor proliferation and hypoxia, respectively, which are useful indicators of tumor sensitivity to radiation  is another marker of hypoxia used in human studies (In addition to n cancer . A compaadiation . Twenty orrelate . 18F-flu studies  with pot studies .PET/CT has been used extensively in the detection of local and distant metastasis. In the feline oral squamous cell carcinoma study, only limited cytologic confirmation of metastasis was available, however out of three cytologically confirmed lymph node metastasis, two were identified based on PET findings, but were not apparent on contrast CT . To our 18F-FDG PET was also useful in a case of Blastomyces dermatitis, as well as cases with a fever of unknown origin (18F-FDG has been proposed for lameness evaluation in a dog (18F-NaF PET for assessment of active bone remodeling (There are limited reports evaluating the use of PET in non-oncologic applications in the veterinary literature. The most common use of PET for the detection of inflammation relates to neurologic disease , but 18Fn origin , 21. Ortin a dog . Recentlmodeling –25.18F-FDG PET for identification of periodontal disease or apical periodontitis (18F-FDG PET had not been performed for the primary purpose of periodontal assessment, these studies demonstrated that useful information regarding the oral cavity can be obtained when patients are imaged with PET for other indications. Similar observations exist in canine patient. 18F-FDG could become a new tool for the assessment of peri-implant diseases (In the human literature, there are various interesting applications for non-oncologic PET imaging of the head and neck. A few reports have assessed the value of dontitis –28. Althdiseases .18F-NaF PET has been suggested for assessment of temporomandibular joint disorders (18F-NaF PET imaging has also been used for assessment of neck pain. Although the high background vertebral uptake can be a limitation, PET was still considered beneficial in a study for 84.5% of the 58 patients with neck pain (18F-FDG PET also appeared useful as guidance for therapy in patients with cervical facet syndrome. In a study involving 140 facet joints, 100% concordance was found between location of focal 18F-FDG uptake and painful area in the neck (isorders , 31. Preisorders . Furtherisorders . 18F-NaFeck pain . 18F-FDGthe neck .In conclusion, PET is best known for its use in oncologic staging, however the array of radiotracers available provide a diverse set of applications. The functional properties of the technique apply to not only the metabolic activity of tumors but also the assessment of bone remodeling, inflammation, and pain. With changes in technology, including the decreased cost and the availability of high resolution PET scanners, it is likely that the use of PET in veterinary medicine will experience continued growth in the future.The images presented in this manuscript were obtained as part of clinical trial projects approved by the animal care and use committee and the clinical trial review board of the University of California Davis.MS redaction of the manuscript. JW and WC contribution to redaction of the manuscript. MS, JW, and WC approval of 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.


We report a male premature baby who was born at 24 weeks gestation weighing 600 grams. There was bilateral stage 2, zone 2 retinopathy of prematurity (ROP) without plus disease at 38 weeks postmenstrual age. Ultra-wide-field Optomap images obtained 1 week later showed no change in ROP stage. At 40 weeks postmenstrual age, stage 3, zone 2 ROP was detected using binocular indirect ophthalmoscopy and documented using Optos. Minor tortuosity and dilation of vessels was interpreted as pre-plus disease. One week later, at 41 weeks postmenstrual age, Optomap images identified progressive extraretinal fibroproliferation in the nasal quadrant. As a result, the baby was treated with fundus laser photocoagulation. ROP occurs because the retinal vessels and neural retina of a preterm newborn are incompletely developed at birth and do not grow normally. It is one of the leading preventable causes of childhood blindness, especially in high- and middle-income countries.4Retinopathy of prematurity (ROP) was first described by Terry5 The Optos uses a non-contact ultra-wide-field dual wavelength laser camera that is able to capture high-quality images from infants with ROP.6 The Optomap is a panoramic digital image generated by Optos scanning laser technology which shows approximately 82% of the retina.At the present time, ROP screening is generally performed by binocular indirect ophthalmoscopy and/or wide-field digital imaging systems. There are 2 kinds of wide-field viewing systems in use for the pediatric age group: contact  and non-contact systems.In this report, we present a case of ROP managed using the Optos ultra-wide-field imaging system.A male baby was born at 24 weeks of gestation and birth weight of 600 g. Maternal history included no clear reason for prematurity such as preeclampsia or maternal chorioamnionitis. The baby needed oxygen therapy in the first weeks of life due to chronic lung disease. ®  imaging system demonstrated progression of the extraretinal fibroproliferation in the nasal quadrant. Binocular indirect ophthalmoscopy supported the decision to treat with laser therapy, as the neovascular areas were beginning to exert traction on the vitreous, suggesting a high risk of retinal detachment  with suspected abusive head trauma. It is indisputable that to document and record any abnormalities in patients is a medicolegal obligation. It is also possible to acquire fluorescein angiograms in premature infants with ROP using the Optos system. Fung et al.11 reported the fluorescein angiograms of 3 premature infants with ROP using oral fluorescein, at a dose of 25 mg/kg of body weight. The 2% fluorescein was mixed with infant formula milk and/or bottle-fed to the infants 30 minutes before the imaging process.The non-contact high-resolution ultra-wide-field system has other advantages for pediatricians, neonatologists, and ophthalmologists in the evaluation of premature or full-term babies. Yusuf et al.Although indirect ophthalmoscopy is still the gold standard method for ROP screening, non-contact ultra-wide-field fundus imaging offers new opportunities in the evaluation of pediatric retinal diseases. These 2 methods can be used together in the evaluation of ROP. In the present case, high-quality Optomap retinal images assisted us in effectively managing ROP.


Cancer related cognitive impairments have been subjectively reported and objectively detected in breast cancer patients treated with chemotherapy and are known to have a profound negative impact on productivity, psychosocial well-being and overall quality of life. Moderate levels of walking are known to be of benefit to the psychosocial well-being of those affected by breast cancer and for managing cognitive impairment in healthy adults, children, and the elderly. The purpose of this study is to investigate the effects of a home-based, self-managed, moderate intensity walking intervention on subjective and objective cognitive functioning in breast cancer patients undergoing chemotherapy.A home-based, self-managed intervention that consisted of moderate levels of walking was compared to usual care among breast cancer patients treated with chemotherapy in a randomised controlled trial. Outcome measures included changes in subjective (CFQ) and objectively detected cognitive functioning . Fifty participants were randomised to either the intervention group (n = 25), who completed 12 weeks of moderate intensity walking, or to the control group (n = 25) mid-way through chemotherapy.Compared with the control group, the self-managed walking intervention had positive effects on perceived cognitive function but not on sustained attention, executive function, memory or visual spatial skills when assessed objectively using neuropsychological measures.This home-based, self-managed intervention is beneficial for protecting against perceived cognitive decline in breast cancer patients treated with chemotherapy. There is a need for further research to objectively assess cognitive decline within this population with larger sample sizes of patients.ISRCTN50709297Current Controlled Trials  Cancer related cognitive impairments (CRCI) in breast cancer patients and survivors have been subjectively reported  and objesurvivors, through the implementation of cognitive behavioural training ; c; c26]; ctraining , cognititraining , 29] an ansurvivtraining , 33], , . P. PsurvivIn contrast, evidence demonstrates promising effects of easy-moderate levels of walking as a protective strategy for managing cognitive impairment in healthy individuals, and the elderly , 41] as as41] asTo our knowledge, this is the first intervention to investigate the effects of a self-managed, home based, moderate intensity walking intervention among breast cancer patients receiving chemotherapy.The primary outcomes for the intervention were changes in subjective and objective cognitive functioning. Secondary outcome measures investigated the effects of the intervention upon the psychosocial functioning  of breast cancer patients. The results for the secondary outcomes have been published elsewhere .In the current study we hypothesise that a self-managed, home based moderate intensity walking intervention may help in managing CRCI experienced by breast cancer patients during chemotherapy.The randomised controlled parallel trial compared 12 weeks of self-managed moderate intensity walking plus usual care (n = 25) to usual care alone (n = 25). Subjective and objective assessments of cognitive functioning and psychosocial measures were completed pre-intervention and 12 weeks later at post-intervention . Ethical approval for the study was obtained from both Loughborough University and the NHS Research Ethics Committee in East Midlands and Northampton . All participants provided written consent. Research was conducted according to the principles expressed in the Declaration of Helsinki. At the time of initial participant enrolment, the researchers were unaware of trial registration resulting in a delay in registering the current study. The authors confirm that all ongoing and related trials for this intervention are registered.Participants were recruited over a 16-month period from three outpatient clinics at the Leicester Royal Infirmary, UK between 01/06/12 and 01/10/2013. Patients with a diagnosis of breast cancer waiting to begin adjuvant or neo-adjuvant chemotherapy who were considered fit to participate in moderate intensity exercise by their oncologist were invited to take part in the study. The researcher met the participants following their initial consultations with their oncologist, provided them with a participant information sheet and explained the nature of the study. Those who showed an interest were followed up 5–7 days later. Women aged between 18 and 75 years were eligible for the study if they: had a primary diagnosis of stage I to III breast cancer; were waiting to begin chemotherapy; were able to read and speak English; were able to walk unassisted; and were relatively inactive . They were excluded if they had previously been diagnosed with cancer or if they had a current psychiatric illness that could hinder participation in the intervention.Cognitive functioning was measured objectively using neuropsychological assessments and subjectively using self-report measures of cognitive difficulties. Measures of Psychosocial well-being and both objective and subjective measures of physical activity were also collected. Experimental assessments took place at two-time points: pre-intervention (after two cycles of chemotherapy) and post-intervention (after the completion of six cycles of chemotherapy). All participants had been prescribed eight cycles of FEC or FEC-T chemotherapy. Participants were randomised to either the intervention (n = 25) or control (n = 25) group after completing the pre-intervention assessment. Following guidance from oncologists, the same measures were also completed pre-chemotherapy to enable familiarisation with the researcher and research methods see . MeasureParticipants began the walking intervention after two cycles of treatment, as discussions with oncologists suggested that the intervention would be better received after patients had begun chemotherapy and understood what they were facing. Therefore, assessments of cognitive and psychosocial functioning were compared at time two and time three (pre- and post-intervention) in line with oncologist recommendations. Those who were randomised into the physical activity group were provided with the intervention materials and those in the control group continued with usual medical care alone provided by oncology nurses and doctors. At the time of data collection, patients receiving treatment at the Leicester Royal Infirmary were not routinely advised of the benefits of physical activity during chemotherapy and therefore the control group did not receive any information from either the researcher or their medical team encouraging them to be more active.The intervention consisted of 12 weeks of home-based, self-managed, moderate intensity walking compared with usual care alone. The design of the walking intervention was based on the Theory of Planned Behaviour (TPB) . Full deThe intervention group was provided with a Yamax Digi-Walker SW-200 pedometer for the duration of the intervention to measure daily step count, to provide patients with immediate feedback, and with the aim of enhancing motivation for the 12-week period. They were also asked to keep a daily exercise diary including the number of steps taken, duration of walking bouts and perceived exertion rates. Those randomised to the control group continued to receive usual care alone.Demographic information was gathered via a recruitment questionnaire and disease or treatment related data was gathered via medical records. Assessments of psychosocial well-being included anxiety and depression  , mood  . The tasVisuospatial skills were measured using the WAIS Block Design as used in the Wechsler Adult Intelligence Scale-III . This taThe Cognitive Failures Questionnaire (CFQ)  measuredAll participants were provided with ActiGraph GT3X+ accelerometers and were instructed to wear the device for 10 hours a day for seven days at baseline and after the completion of chemotherapy. In line with previous findings, seven days of continuous monitoring is recommended to assess habitual physical activity in adults and provides a trade-off between feasibility, reliability and acceptable participant burden . AccelerThe Yamax Digi-walker SW-200 pedometer was worn by participants randomised to the intervention group for 10 hours a day for the duration of the 12-week intervention. The devices were attached to participants’ clothing above the hip and recorded the number of steps taken per day. Participants were asked to make a daily note of steps taken before resetting the device.The Borg Rating of Perceived Exertion Scale  was compThe Talk Test  was usedThe General Practice Physical Activity Questionnaire is a validated tool published by the Department of Health in 2002 to assess physical activity levels in 16–74 year olds. The questionnaire rates physical activity on four levels: active, moderately active, moderately inactive, and inactive. The measure was used to gain subjective measures of physical activity levels pre and post intervention.Block randomisation using four blocks was used to allocate patients into one of two groups. Within each group of four patients, two were allocated to the intervention group and two to the control group, and the allocation of groups within each block was random. This method was used rather than simple random allocation, to ensure equal numbers of consecutive patients in both groups, as recruitment was staggered .Sample size calculations were based previous research with this population , 26]. T. T26]. TAll analyses were carried out using IBM SPSS version 21.0 for Windows. All between-group differences in categorical variables were analysed using Pearson’s chi-square. Initial analyses compared baseline ratings of subjective and objective outcomes of cognitive function.Intention to treat (ITT)  analysisOf the 96 eligible participants 33 (34%) declined participation due to high levels of distress following their diagnosis. In total, 63 breast cancer patients due to begin adjuvant and neo adjuvant chemotherapy met the inclusion criteria, consented to take part, and completed recruitment measures (recruitment rate of 69%). A further 13 participants were lost to attrition, due to changes in treatment as a result of chemotherapy related side effects, after providing consent. Therefore, 50 participants receiving chemotherapy were randomised to the intervention (n = 25) or control group (n = 25) see The age of participants in the intervention group ranged from 27–74 years  and 29–66 years in the control group . The majority of participants received adjuvant chemotherapy: 20 (80%) in the intervention group and 21 (84%) in the control group see .2x  = 0.12, p = 0.94 . Sixty There was no significant difference in age between those who completed the study  and those who withdrew  following familiarisation. Those who withdrew from the study had lower educational qualifications and were less likely to be in employment. Participants did not differ on any other demographic or cancer-related characteristics - please refer to .Adherence for the intervention group was calculated based upon the completion of the 12-week physical activity intervention, completion of intervention diaries, and goal setting. Although adherence was not calculated based on total amount of physical activity completed , the duration, intensity and frequency of physical activity completed across the 12-week intervention is reported below. Twenty (80%) out of the twenty-five participants who were randomised to the physical activity group adhered to the intervention and completed walking diaries through recording of goal setting, duration, intensity and frequency of their walking. Five participants discontinued participation within the first few weeks of the 12-week intervention, did not complete diaries, but completed all follow up measures post-intervention. Reasons for discontinuing participation in the intervention included hospitalisation or medical complications.F  = 0.14, p = 0.71 or the number of sessions completed F  = 0.03, p = 0.85. Findings indicate that patients were able to complete the recommended dose of physical activity throughout the course of the intervention and their chemotherapy treatment.Of the 20 participants that continued with the intervention, 16 completed walking diaries on a weekly basis and four had one or more weeks of missing data due to hospitalisation but continued with the intervention after they were discharged. Walking schedules were self-prescribed, but it was recommended that participants should aim to walk for 30 minutes, five times a week at moderate intensity. Analysis of weekly walking diaries revealed that the 20 participants who completed the intervention walked at moderate intensity (as recorded using the RPE) for an average of 157.4 minutes per week across the 12-week intervention. On average, patients participated in 4.85 walking sessions per week for an average of 30.49 minutes. Findings suggest that the 20 participants who adhered to the intervention met the recommended guidelines of 30 minutes of moderate intensity walking 5 times a week. There was no significant difference between week one and week 12 of the intervention in the number of minutes walked F  = 2.13, p = 0.16, suggesting that levels of walking remained consistent across the 12-week period.Findings revealed that participants walked an average of 36,217 steps per week as gathered using the Yamax Digi-walker SW-200. There was no significant difference in the number of steps recorded between week one and week 12 of the intervention 2x  = 17.15, p = 0.001. When looking at groups separately, the majority of the intervention group (36%) classed themselves as ‘active’ compared with 0% in the control group  out of the 63 who completed the familiarisation session at baseline (pre-chemotherapy), returned accelerometers. A total of 32 patients were lost due to non-compliance. The most common reasons for missing data were forgetting to wear the device and forgetting to return the device to the researcher. Out of the 31 participants who returned data, six participants complied with recommended wear time with an average of five days, and average wear per day ranged from 39 minutes to 7 hours. Wear time for the 25 participants that did not comply ranged from 7 hours to 3 days.2  = 2.41, p = 0.49.Participants were asked to wear the device for a further 7 days post-intervention, after the completion of their chemotherapy. Of the 50 participants randomised, seven participants in the intervention arm and three in the control group returned accelerometers at post-intervention. The most common reasons for missing data at post-intervention were forgetting to wear the device, wearing the device incorrectly preventing valid data collection, declining to wear the device, or not returning the device. Due to low numbers and non-compliance, wear time analysis between groups across the intervention period were not possible. At post-intervention, Chi-square analyses showed no significant differences between the intervention and control group in the proportion of patients forgetting to wear the accelerometer, wearing the device incorrectly preventing valid data collection, declining to wear the device, or not returning the device, xF  = 8.27, p < 0.01, 2 =ƞp 0.147 and within groups, F  = 4.55, p = 0.03, 2 =ƞp 0.087. Inspection of the means indicated that digit span was slightly, though significantly, greater in the intervention group  than the control group  and at post-intervention  compared with pre-intervention .Analysis of objectively measured cognitive performance revealed no significant main effects for between or within group, or a significant interaction between the two for Stroop interference, sustained attention, visuospatial skills, or memory as assessed by the digit backwards task. There was also no significant interaction for the digit span forwards task. Additional analyses were conducted to examine the main effects whilst removing the interaction as this can mask a significant main effect. There were small effect sizes for the non-significant interactions effects for all measures of objective cognitive functioning. Therefore, these non-significant findings could be due to an inadequate sample size. However, there were significant main effects between groups F  = 3.90; p = 0.05, 2 =ƞp 0.075. As seen in p = 0.9, they increased significantly in the control group, t (24) = -2.39, p = 0.02, suggesting that the walking intervention protected against self-reported cognitive decline. Inspection of the means indicated that self-reported cognitive failures were significantly higher in the control group  than the intervention group  post-intervention.Analysis of self-reported cognitive failures revealed a significant interaction, Further exploratory analysis was conducted in order to examine if any psychosocial wellbeing variables contributed towards self-reported cognitive failures. Change scores from pre- to post-intervention were calculated, and correlations conducted for each group between change in reported cognitive failures and change in depression, anxiety, self-esteem, fatigue, and mood; however no significant associations were observed. Similarly, correlations conducted for each group between change in reported cognitive function and objectively detected cognitive function were non-significant.rs = -0.40, p = 0.05, suggesting that as physical activity increased, self-reported cognitive failures decreased.Exploratory analyses were conducted using Pearson’s two-tailed correlations to explore the relationship between the amount of self-reported physical activity completed by the intervention group and subjective cognitive function. These revealed a significant negative correlation between mean duration of walking (in minutes) and self-reported cognitive failures, This randomised controlled trial is the first to investigate moderate levels of a self-managed, home-based walking intervention on cognitive functioning of patients during chemotherapy treatment for their breast cancer. The aim of the study was to assess the effectiveness of a self-managed, home-based walking intervention on subjectively reported and objectively assessed cognitive function during chemotherapy. There was no effect of the intervention on neuropsychological measures of cognitive function. However, small effect sizes for all non-significant interactions for objective measures of cognitive function suggest that these could be explained by the small sample size. We found that perceived cognitive impairment (as measured by self-reported cognitive failures) remained stable in the intervention group whereas it declined in the control group, indicating that moderate levels of walking may help to protect against decline in self-reported cognitive functioning. The maintenance of subjectively perceived cognitive function in the intervention group provides further support for previous literature reporting the benefits of physical activity such as Tai Chi  and QigoExploratory correlations between change in reported cognitive failures and change in depression, anxiety, self-esteem, fatigue, and mood were non-significant. Contrary to predictions, maintenance of perceived cognitive function was not due to improvements in psychosocial well-being following the completion of the home-based moderate intensity walking intervention but may be due to a direct effect of participating in the self-managed walking intervention.Furthermore, duration of walking completed by patients was negatively associated with self-reported cognitive function, suggesting that as physical activity increased, self-reported cognitive failures decreased, and that improvements in subjectively detected cognitive function might be dose-dependent. The dose-dependent relationship between duration of physical activity and perceived cognitive function make vital contributions to limited literature within this area of research, leading to crucial implications for the healthcare of breast cancer patients treated with chemotherapy.As previously reported , breast during chemotherapy for breast cancer and makes vital contributions to current evidence and clinical practice. This self-managed intervention requires very little input from health professionals and therefore has the potential to mitigate impairments in perceived cognitive function for a large number of breast cancer patients’ receiving chemotherapy. However, as it is the first intervention of its kind and has a relatively small sample size, as highlighted by small effect sizes for all non-significant measures of objective cognitive function, further research with larger sample size is required to confirm findings. Future interventions could examine the dose and intensity of physical activity required for effective maintenance of self-reported cognitive function.To the authors’ knowledge, this is the first intervention to investigate the effects of a self-managed, home-based, walking intervention Contrary to previous research, there was no effect of the intervention on neuropsychological measures assessing sustained attention, executive function, memory and visuospatial skills. However, as the effect sizes for non-significant interactions were small, this suggests that further research with larger sample sizes would help to clarify these findings. Moderate levels of exercise have demonstrated positive effects on cognitive function among breast cancer patients , 42], h, h42], hA possible explanation for null findings of objective cognitive function in the current study may be the intensity and dose of physical activity completed in our small sample of patients. As discussed above, evidence suggest that moderate levels of physical activity can help to improve cognitive functioning , 31], , , 42]. H. H42]. HA further possible explanation for not detecting an effect of the intervention on objectively measured cognitive function may be due to the selection of neuropsychological measures and the subtle nature of cognitive difficulties experienced by breast cancer patients. Evidence suggests that many standard neuropsychological tests do not detect subtle change experienced by cancer patients . The neuIn the present study there were no significant effects relating to the backwards digit span task, whilst there was a small but significant improvement in recall on the forwards task from pre- to post-intervention, and superior performance overall for the intervention group compared with the control. It is unclear why our findings differed for the forwards and backwards tasks. However, there is evidence that different strategies are employed during forwards and backwards recall. One argument suggests that, unlike forwards recall, backwards recall involves executive control and may be considered as a complex span measure of working memory . SimilarPrevious home-based studies have successfully measured objective levels of physical activity using pedometers or accelerometers, –83 and tThe 80% adherence rate to the intervention is noteworthy and a strength of the self-managed, home-based intervention in line with previous evidence which reported that over 50% of breast cancer patients prefer to exercise alone . CurrentOverall, our study reports benefits of a self-managed, home-based, moderate intensity walking intervention upon cognitive function when subjectively reported but not objectively detected. These findings further support existing evidence for the lack of associations between subjective and objective measures of cognitive decline experienced by breast cancer patients . A possiPositive findings using self-report measures are noteworthy, as patients are concerned with perceived deficits and the impact it places on their quality of life. Therefore, maintaining self-reported cognitive function is important to patients, even though perceived deficits have a limited association with objective measures. This study makes a vital contribution towards the advancement of current clinical practice to improve the quality of life of patients during treatment. Furthermore, the self-managed, home-based nature of the study requires little input from healthcare professionals and therefore can be implemented to benefit a larger population of patients.The self-managed, home-based intervention had a good adherence rate and was successful in protecting against decline in self-reported cognitive difficulties experienced by patients treated with chemotherapy for their breast cancer. Surprisingly, intervention effects were not detected for objective measures of sustained attention, executive function, memory and visual spatial skills in the current study, which could be explained by our small effect sizes. Therefore, further investigations with large sample sizes conducted over multiple sites are required in order to examine the effects of physical activity upon objectively detected cognitive impairment among breast cancer patients. These studies should optimise the use of the standardised set of neuropsychological measures recently acknowledged as suitable for detecting subtle cognitive decline experienced by breast cancer patients  and shouS1 File. Consort checklist(DOC)Click here for additional data file.S2 File. Protocol(PDF)Click here for additional data file.S3 File. Proposal(DOCX)Click here for additional data file.


We read with interest the recent letter by Ostermann et al.  about thFirst, two patients were treated with veno-venous (VV) ECMO, that is often initiated in the case of severe acute respiratory distress syndrome (ARDS). Renin-angiotensin system (RAS) has been implicated in the pathogenesis of ARDS. In particular, Ang II is a pro-inflammatory molecule able to promote capillary leak and fibroproliferation. Also, Ang II may contribute to a significant constriction of the pulmonary circulation, potentially leading to reduced blood flow and to increased ventilation/perfusion mismatch . OppositSecond, five patients were treated with veno-arterial (VA) ECMO, that is usually implemented in cases of severe cardiac failure. No information on cardiac function was provided in this series, while the safety profile of Ang II has never been tested in patients with vasodilatory shock and severe concomitant myocardial dysfunction. Indeed, Ang II could reduce the cardiac output due to its vasoconstrictive properties and provide some detrimental effects on myocardial recovery .Finally, ECMO patients need an adequate accurate anti-coagulation for the integrity of the extracorporeal system. Ang II usually exerts pro-coagulant effects, stimulating thrombin generation and potentially damaging microcirculation . For all We appreciate the comments of Professors Antunucci and Taccone who acknowledge the hemodynamic improvement associated with the use of angiotensin II (Ang II) in patients on ECMO requiring high-dose vasopressors but offer a word of caution related to ARDS and cardiogenic shock.With regard to ARDS, animal research has suggested that Ang II is detrimental in ARDS, hence the clinical development of recombinant ACE-2 (rhACE-2), an enzyme that converts Ang II into Ang 1-7. Studies in animals were promising. However, the clinical trial by Khan et al which Professors Antunucci and Taccone refer to, tested rhACE-2 in patients with ARDS and failed to show an improvement in oxygenation or any physiological parameters . Lastly,The authors’ second point is that Ang II may decrease cardiac output. Whilst this is in theory possible, previous studies have shown that administration of bovine angiotensin II successfully rescued patients with cardiogenic shock, including patients in a cardiac arrest situation . We woulFinally, Ang 1-7 is a potent vasodilator with effects opposite those of Ang II. Ang 1-7 builds up when ACE is not functional. The administration of Ang II may decrease Ang 1-7 via biofeedback resulting in an increase of blood pressure and decrease of the catecholamine dose .We fully agree that more research is needed to determine the role of Ang II in patients on ECMO. Given that the bovine form of angiotensin II was utilized safely and effectively for over 45 years to treat shock, data in the literature may help us developing thoughtful prospective trials.