Hydrocodone is one of the most prescribed oral analgesic drugs and it is one of the most abused drugs in general population. It is a mu-opioid agonist predominantly metabolized to the O-demethylated product hydromorphone and to the N-demethylated product norhydrocodone. The purpose of the study is to summarize the preclinical and clinical characteristics of hydrocodone. Pharmacokinetic aspect  of hydrocodone and the influence of metabolic genetic polymorphism in analgesic response to hydrocodone are also illustrated and commented. Literature on experimental preclinical pharmacology investigating analgesic activity in laboratory animals is furtherly discussed. Moreover, the authors discuss and comment on the updated data regarding safety profile and effectiveness of hydrocodone in the treatment of chronic pain. A bibliographic research was carried out  independently by two researchers  in the major scientific databases and research engines of peer-reviewed literature on life sciences and biomedical topics, starting from January 1990 to August 2018. Analysis of results of clinical studies suggests that abuse-deterrent extended-release (ER) hydrocodone formulations can be effective and they are well tolerated in the treatment of chronic low back pain. Weaker is the evidence of the analgesic effectiveness of ER hydrocodone on other chronic pain syndromes and non-cancer non-neuropathic chronic pain. In these conditions, hydrocodone showed to have positive effects in non-controlled open studies and needs to be further studied to assess the real strength of results. Opioids are the most potent drugs producing analgesia and their use is fundamental for the clinical pain management . The larA bibliographic research was carried out  independently by two researchers  in the major scientific databases and search engines of peer-reviewed literature on life sciences and biomedical topics  starting from January 1990 to August 2018. The investigators used the following keywords or combination of keywords: “hydrocodone,” “hydrocodone” and “chronic pain,” “hydrocodone” and “opioids.” The analysis included all articles written in English language, published in peer-reviewed scientific journals, describing preclinical findings and clinical applications of hydrocodone. All the authors reviewed all the eligible articles and resolved by discussion any uncertainty regarding the content about hydrocodone to be discussed.Hydrocodone is a semi-synthetic phenanthrene opiate derivative with analgesic and antitussive effects. The chemical name of hydrocodone is -9-methoxy-3-methyl-1,2,4,4a,5,6,7a,13-octahydro-4,12-methanobenzofuroisoquinoline-7-one, the drug name dihydrocodeinone was given when it was first marketed in Germany . Since tIt was originally marketed as a single drug as immediate-release (IR) dosage forms indicated for the short management of acute pain and it was successively released in association with non-opioid drugs . OpioidsAnalgesic products containing hydrocodone in combination with the anti-inflammatory drug ibuprofen (hydrocodone bitartrate/ibuprofen 2.5–7.5 mg/200 mg) to be taken by oral administration and a long-acting formulation of hydrocodone not containing acetaminophen were also released .In February 2018, the FDA approved the association between the prodrug benzhydrocodone and acetaminophen . HoweverChanging hydrocodone from schedule III to schedule II has been associated with an increase in the total amount of opioids filled in the initial prescription following surgery . HoweverOther novel synthetic opioids, such as U-47700, U-49900, AH-7921, or MT-45 have no recognized therapeutic use but emerged as non-illegal drugs diffused to circumvent prohibition laws, resulting in numerous abuse reports and overdose cases, especially across the United States and Europe .Abuse of hydrocodone seems to be lower than the oxycodone abuse. This is true for previously dependent opioid abusers, for non-dependent opioid abusers  and for Hydrocodone is the second drug of abuse in the United States but the first preferred by women. Female preference could be due to the fake perception of a better safety profile deriving by the minor rate of overdose associated with hydrocodone . This miER opioid formulations are considered more suitable for appropriate management of pain in chronic patients. Oral intake of ER medicinal products produces higher plasmatic concentrations and lower peak-to-trough changes over the dosing interval, in comparison with IR products . The firMetabolism of hydrocodone was studied in laboratory, animals and species differences have been observed. In rats, metabolic conversion of hydrocodone to hydromorphone is performed by the enzyme CYP2D1, homolog of the human CYP2D6. While hydrocodone mainly underwent O-demethylation and ketone reduction in rats to form hydromorphone and hydromorphone in the reduced form, in dogs it is metabolized prevalently by N-demethylation and N-oxidation .Rewarding and euphoric effects of hydrocodone, investigated by using the conditioned place preference (CPP) paradigm, have been compared in rats to those of morphine. In laboratory animals, hydrocodone is self-administered and produces an opiate-like subjective discriminative generalization profile and a withdrawal syndrome after sudden treatment cessation that was similar to morphine and/or oxycodone .Hydrocodone and morphine injected intraperitoneally produce a CPP at the 5 mg/kg dose, but not the lower 1 mg/kg dose, suggesting similar rewarding properties, furthermore hydrocodone and morphine equally reduced phosphorylation levels of extracellular signal-regulated kinase (ERK) and cAMP response element-binding (CREB) proteins in the nucleus accumbens, thus indicating that these drugs cause their effects through signal transduction pathways involved in rewarding and reinforcing effects .in vivo in rats by using the pain models “tail withdrawal test” and “formalin test” on opioids administered subcutaneously, shown that analgesia caused by hydrocodone is greater than codeine and lower than, in decreasing order, fentanyl, buprenorphine, oxycodone, and morphine . Pain relief correlates with plasma hydromorphone but not with hydrocodone concentration, thus confirming that the ability to convert hydrocodone to its active drug is essential , only through the bioconversion to its active metabolite hydromorphone it induces analgesia , causing a slower rate of conversion of hydrocodone to hydromorphone. Urinary hydromorphone after a single dose of hydrocodone was found at relatively small amounts in both extensive metabolizers (EMs) and PMs but PMs were equally responsive to oral hydrocodone as EMs. The study demonstrated that although hydrocodone is less potent than hydromorphone, it clearly has its own agonist actions .Hydrocodone is also metabolized by CYP3A4, but the product of transformation is the inactive metabolite norhydrocodone . IsoenzyApproximately 3% of Blacks, 1% of Asians are PMs of CYP2D6. The remainder of individuals in these populations produce functional levels of CYP2D6 and are labeled EMs .Patients who are ultra-rapid metabolizers may produce more hydromorphone, while subjects who are PMs of CYP2D6 may experience little to no analgesia from hydrocodone since they lack or have not sufficient activity of the enzyme to metabolize it . PMs areOther products of the hydrocodone metabolism are the glucuronate conjugated products to hydrocodone-3β-glucuronide and hydrocodone-6β-glucuronide. The metabolite hydromorphone is also glucuronidated to hydromorphone-3β-glucuronide and hydromorphone-6β-glucuronide . The 6β-Renal excretion is the principal way of elimination for hydrocodone and its metabolism products. Renal hydrocodone elimination in healthy subjects account for 6.5% and it reduces in values with the severity of the disease . Severe Blood concentrations of hydrocodone and its metabolite dihydrocodeine are widely used to determine the cause of death. While concentrations in postmortem samples may not necessarily reflect the original drug concentration at the time of death, a study of liver to peripheral blood hydrocodone ratio suggests that hydrocodone is unlikely to undergo substantial postmortem distribution changes .in vitro experiments, hydrocodone itself is a low efficacy agonist , it is a μ-opioid receptor agonist analgesic, even though when higher concentrations are reached it can bind with different opioid receptors. As the dose of opioids increases beyond typical starting doses, delta-opioid receptors and kappa-opioid receptors are activated. MORs are G-protein coupled receptors that inhibit cAMP production and activate G-protein mediated inwardly rectifying potassium channels. The analgesic effect appears to be associated with the latter signaling pathway. As the dose of hydrocodone increases over the starting doses, delta-opioid receptors and kappa-opioid receptors are also activated. In  agonist .The affinity measured using a single binding assay in a cell membrane preparation expressing recombinant human MOR of the product of conversion hydromorphone for the MOR has been reported to be over 100 times greater than that of hydrocodone, with Ki values of 0.36 nM for hydromorphone versus 41.58 nM for hydrocodone .Hydromorphone, but not hydrocodone, exerts analgesic effects  and it pHydromorphone had a similar effect on patient-perceived cancer pain intensity as described for oxycodone and morphine  and therIt has also been shown that hydrocodone, as well as morphine, is conditioning the locomotor response involved in the dopamine reward system to the D2/D3 dopamine receptor agonist quinpirole .Opioids are used for moderate to severe chronic non-cancer pain in patients that are refractory to other analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs and when other opioids are not appropriate in patients because they experience unsupportable adverse effects .In 2008, the American Society of Interventional Pain Physicians (ASIPP) released guidelines to provide guidance for opioids use for chronic non-cancer pain. According to these guidelines, hydrocodone and methadone were considered at level III of evidence, the level of evidence for transdermal fentanyl and sustained-release morphine was II-2, whereas for oxycodone the level of evidence was II-3. The level III of clinical evidence for hydrocodone is a weak level since was based on expert opinion .More recently, several studies have been performed to investigate on the effectiveness of ER hydrocodone in chronic pain. Chronic pain has been recognized as pain that persists past normal healing time and hence lacks the acute warning function of physiological nociception .The authors collected 13 clinical studies on the effects of ER hydrocodone bitartrate administered alone in the treatment of chronic pain deriving from different pathologic conditions.Five clinical studies were carried out with ER hydrocodone on chronic pain deriving from low back pain. Four of them were randomized controlled double-blinded clinical trials (RCTs), one was designed as a 22-week open study. The RCTs recruited 1246 patients; dose ranging was 15–120 mg of ER hydrocodone every 12 h, duration of treatment was 12 weeks in all the clinical trials. Similarly, conclusions were that ER hydrocodone is significantly more effective than placebo in alleviating chronic low back pain and shows a safety profile without the risk of liver toxicity associated with acetaminophen . The opeThree studies reported the effects of ER hydrocodone on non-cancer non-neuropathic moderate-to-severe chronic pain. They were long-term open-label designed studies recruiting a total number of 542 patients. Ranging dose of ER hydrocodone was 20–120 mg administered once daily for an elapsed period of 12–18 months. Adverse events reported were those normally associated to opioids: nausea, vomiting, constipation, dry mouth, hematemesis, abdominal pain, dizziness, dysgeusia, headache, myalgia, paresthesias, scratch, fatigue, sleep disorders, and hyperhidrosis .Another open-label, long-term trial (1-year maintenance treatment) investigated on long-term safety and effectiveness of hydrocodone 20–120 mg tablets taken by 269 patients with moderate to severe chronic, non-malignant and non-neuropathic pain. Supplemental non-opioid pain medications were permitted. A total of 226 patients (84%) completed the 1-year maintenance period. Results showed a reduction in pain intensity consistently maintained during the entire treatment period .One study evaluated safety and effectiveness of a once-daily, single-entity, ER hydrocodone over a 52-week period in 97 patients with chronic non-cancer and non-neuropathic pain who required opioid rotation from IR oxycodone. Hydrocodone was well tolerated and produced effective analgesia; furthermore, use of opioids decreased .Other three open studies investigated on the effectiveness of hydrocodone on chronic pain deriving from any origin. Dose ranging was 15–300 mg divided into two daily doses for a period of 3–13 months. Results showed moderate to substantial levels of pain relief associated with functional improvements in patients treated with ER hydrocodone ,b,c.Finally, Data from this overview of clinical studies with ER hydrocodone suggest that this formulation can be used to relieve chronic pain. However, more relevant results were showed in RCTs conducted in patients with low back pain. On a lower step of importance are open studies on chronic non-cancer and non-neuropathic pain. All the studies showed a good tolerability of ER hydrocodone and the one long-term open study  indicateHydrocodone use can trigger the occurring of adverse reactions. Abuse, addiction, and adverse effects related to opioid drugs have been detected . At highThere have been cases of self-reported severe to profound sensorineural hearing loss in people using hydrocodone-acetaminophen association. Sensorineural hearing loss is an ototoxic condition resulting in permanent, severe to profound auditory damage and it has been associated with the use of these combination products . HearingIt has been suggested that opioids such as transdermal fentanyl, methadone, and oxycodone can be associated with increased odds of androgen deficiency. However, this kind of risk is lesser with hydrocodone use .Hydrocodone is one of the most prescribed and effective opioid analgesic drugs, however, the rate of its abuse raised a new health problem. In particular, medicinal products based on association hydrocodone-acetaminophen released with the aim to enhance analgesic effects and at the same time to reduce the dose of hydrocodone caused abuse and addiction prevalently in young people. To fight this phenomenon, abuse-deterrent formulations ER long-acting opioid products were authorized, however, these deterrent forms remain abused orally. Analysis of results of clinical studies considered for this review suggests that abuse-deterrent ER hydrocodone formulations can be effective and they are well tolerated in the treatment of chronic low back pain. However, guidelines for the management of chronic pain still report for hydrocodone the level III of clinical evidence, corresponding only to expert opinion. Although it is important to keep in mind that several studies are from corporate sponsored articles, on the basis of the assessed effectiveness of RCTs investigating on long-term therapy with ER hydrocodone in patients affected by low back chronic pain. About the evidence of the analgesic effectiveness of ER hydrocodone on other chronic pain syndromes and non-cancer non-neuropathic chronic pain, hydrocodone showed to have positive effects in open non-controlled studies and needs to be further studied to assess the real strength of results.GC and EM developed the project of the study, performed the analysis, and discussed preclinical and clinical data. LC, CrM, and DQ collected and discussed clinical data. VA, CaM, and FC collected and discussed data on pharmacokinetics and pharmacodynamics.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.


Many studies have used position-specific scoring matrices (PSSM) profiles to characterize residues in protein structures and to predict a broad range of protein features. Moreover, PSSM profiles of Protein Data Bank (PDB) entries have been recalculated in many works for different purposes. Although the computational cost of calculating a single PSSM profile is affordable, many statistical studies or machine learning-based methods used thousands of profiles to achieve their goals, thereby leading to a substantial increase of the computational cost. In this work we present a new database compiling PSSM profiles for the proteins of the PDB. Currently, the database contains 333,532 protein chain profiles involving 123,135 different PDB entries. Position-specific scoring matrices (PSSMs) have been used in many works to compute and predict a broad range of protein features. For example, PSSM profiles have been used to predict residue solvent accessibility , proteinSeveral resources compiling PSSM profiles are currently available. The Conserved Domain Database (CDD)  annotatehttp://3dcons.cnb.csic.es.In this work we present 3DCONS-DB, a database of PSSM profiles computed over protein sequences collected from the Protein Data Bank (PDB) . The maiCurrently, 3DCONS-DB database compiles PSSM profiles for 123,135 PDB entries, involving 333,532 protein chains and 83,297 non-redundant protein sequences. The database is freely available and accessible either through a browser or using a web service designed for programmatic access. In this section we also present the analysis and comparison of PSSM profiles in protein domain and non-domain regions and show how 3DCONS-DB data can be used to predict secondary structure and residue contact numbers.One of the aims of this work is to show that non-domains regions of proteins are functionally relevant and, therefore, having profiles characterizing non-domain residues (in addition to profiles of domain residues) will benefit the calculation and prediction of biological features in these regions. To that end, we have measured the occurrence of different biological features in protein domain and non-domain regions. Protein domains were determined in terms of the Pfam classification  for eachAnother important comparison is the quality and amount of information of PSSM profiles in domain and non-domain residues. To estimate these values, we analyzed the multiple sequence alignments (MSAs) that can be obtained by stacking the aligned sequences computed by PSIBLAST. For each PDB chain, PSIBLAST recovered an average number of 243 protein sequences that were used to generate a MSA. Pfam domains are computed from MSAs collected from non-redundant sets of protein sequences and, thus, the number of gaps is expected to be smaller in domain than non-domain positions. In our analysis we observed that the gap frequency was 1.8% in domain and 10.5% in non-domain positions, in agreement with the expected results. However, the gap frequency was 10 times greater in non-domain regions, we obtained an average number of 217 protein sequences that were aligned in these positions with no gaps. Then, to measure whether these aligned sequences contained more information than random alignments we computed the Williamson entropy  see Sec for the As a concrete example of how 3DCONS-DB has a clear impact in the agile development of new bioinformatics tools, we used 3DCONS-DB data to train a neural network classifier for protein secondary structure prediction. The selected neural network architecture was the same as the one described in PSIPRED , consistAs a second example of how 3DCONS-DB can simplify and facilitate the development of algorithms for the prediction of protein structural features, we have trained a support vector regression (SVR) model for predicting residue contact number (CN) using the same procedure as described in Yuan et al. . In theiThe evaluation consisted in a threefold cross-validation using different distance thresholds to define contacts between C-beta atoms. 3DCONS-DB is a new database that compiles PSSM profiles for PDB protein sequences with the aim set at facilitating the development and testing of prediction methods that use PSSMs. Currently, the database contains 123,135 PDB entries, involving 333,532 protein chains and 83,297 non-redundant protein sequences. The main difference with similar resources is that 3DCONS-DB annotates residues over whole protein sequences and not only on domain regions. However, the comparison of different biological features on domain and non-domain residues indicates that both types of protein regions seem functionally relevant. Indeed, non-domain residues are most often affected by post-translational modifications that domain ones and short linear motifs can be found more frequently in them as well, indicating that non-domain regions might be more involved in protein signaling than domain regions.Several biological features to characterize and compare protein domain and non-domain regions were collected from different sources. Secondary structure was calculated using the dssp software  for all k = 20) in order to ensure that the computed entropy value was not magnified due the class amino acid reduction.To measure the amount of information encoded behind PSSM profiles, we have calculated the Williamson entropy  values ohttps://www.sqlite.org) and a web server was built to dispatch the data. The web server was developed using the Ruby on Rails framework (http://rubyonrails.org) and was designed to collect and deliver PSSM profiles of PDB entries. 3DCONS-DB data can be accessed in three different ways: through a REST web service to retrieve PSSM profiles in JSON format, submitting a list of desired PDB ids and retrieving their PSSM scores in a ZIP file and, finally, using 3DCONS-DB web application to explore specific PSSM profiles through a browser.3DCONS-DB data was compiled computing the iterative BLAST algorithm (PSIBLAST)  with defhttp://d3js.org) and it summarizes PSSM scores for the entire selected sequence. Finally, the residue level PSSM table contains the exhaustive PSSM score list for each residue of the selected protein. 3DCONS-DB client can display the different levels of PSIBLAST information; thus, the scores of the different iterations, swapping between PSSM scores and position-specific frequency matrix scores, or exploring the PSSM scores for the different chains of a PDB entry.The web client was designed to display 3DCONS-DB data on a browser and to provide an interactive environment to explore PSSM profiles at sequential and structural level. The information is divided in three major panels see : the str


EUS-guided rendezvous technique (EUS-RV) is an effective salvage technique for failed biliary cannulation during ERCP. However, it is still difficult to achieve cannulation in some cases, especially using the intrahepatic bile duct (IHBD) approach, which requires complicated guidewire manipulation. EUS-hybrid rendezvous technique (HRV) has been applied as a salvage technique for difficult guidewire placement during EUS-RV with IHBD approach. The aims of this study were to evaluate the efficacy and safety of EUS-HRV using a retrospective study. Database analysis revealed 29 patients who underwent EUS-RV for difficult biliary cannulation. Among them, 8 patients underwent EUS-HRV as a salvage technique for difficult guidewire placement during EUS-RV with the IHBD approach. In EUS-HRV, a 6-French dilator was advanced into the biliary system for better guidewire manipulation. After successful guidewire placement, the EUS scope was exchanged for a duodenoscope, keeping the guidewire and dilator in place. The EUS-placed guidewire was retrieved through the duodenoscope, followed by cannulation over the guidewire. The dilator remained at the fistula until completion of the procedure. The analysis showed that the guidewire placement and the subsequent scope exchange and deep biliary cannulation after the retrieval of the EUS-placed guidewire were successfully conducted for all 8 patients. Mild pancreatitis was recognized as an adverse event in 1 patient. The overall success rate of EUS-RV combined with EUS-HRV was improved up to 90% (26/29). Our results suggested that EUS-HRV can be an effective and safe salvage technique in cases wherein guidewire placement is difficult during EUS-RV with IHBD approach. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for biliary disorders has been widely accepted as a safe, minimally invasive, and efficient procedure. During ERCP, deep biliary cannulation is an inevitable primary step, and its high success rates have been reported. However, an achievement of deep biliary cannulation is occasionally difficult even with the application of advanced cannulation techniques, such as double guidewire or precutting techniques. EUS-guided rendezvous technique (EUS-RV) has also been reported as an effective salvage technique for failed biliary cannulation during ERCP.–6 In EUSFig 1.[In EUS-RV, the accessed route to the bile duct can be divided into 3 categories based on the biliary ducts accessed and the position of the scope: the intrahepatic bile duct (IHBD) from the stomach, extrahepatic bile duct (EHBD) from the first portion of the duodenum (D1), and EHBD from the second portion of the duodenum (D2) as shown in Fig 1. At our iFig 1. In a preFig 1. As for tFig 1., 6 EUS-gFig 1.–12A novel EUS-hybrid rendezvous technique (EUS-HRV), wherein a dilator was temporally inserted into the biliary system to maintain guidewire maneuverability like EUS-AG, has been applied as a salvage technique in cases where the guidewire placement was considered difficult or impossible during the EUS-RV with IHBD approach. We therefore conducted this retrospective study to evaluate the efficacy and safety of EUS-HRV.This was a retrospective study conducted in a single academic center, Gifu University Hospital. Retrospective database analysis of all ERCP and EUS-guided procedures was performed between April 2012 and March 2017. We included patients who underwent EUS-RV or HRV for failed biliary cannulation, but excluded patients with the following conditions: surgically altered upper intestinal anatomy (except for Billroth I) or management with combination of percutaneous or surgical approach. During the study period, 1398 patients with normal upper intestinal anatomy underwent ERCP for biliary diseases. Among them, achievement of deep biliary cannulation was failed in 33 patients. Four patients who were managed by percutaneous approach were excluded from the analysis. Finally, 29 patients underwent EUS-RV or EUS-HRV as a salvage technique for difficult biliary cannulation were included and analyzed in this study. No patients were managed by a surgical approach in the study period. Written informed consent for ERCP and EUS-guided procedures was obtained from all patients.Fig 2A). EUS-HRV was utilized if the guidewire placement into the duodenum was difficult or impossible because of downstream resistance during the IHBD approach from the stomach. A 6-French bougie dilator  with well-tapered tip for smooth dilation but without any attachment at the end, such as a nasobiliary drainage tube, was inserted into the biliary system during the EUS-HRV procedure . The guidewire was manipulated again with improved torqueability and pushability due to the support from the dilator, similar to the PTB approach or EUS-AG. Once the guidewire was inserted into the duodenum, the EUS scope was retrieved, keeping both the guidewire and the dilator in place . The ERCP scope was inserted into the duodenum next to the dilator.  After identification of the dilator and the guidewire coming out from the ampulla in the duodenum, the guidewire was grasped by a snare or loop cutter. At this point, the EUS placed guidewire could be freely manipulated through the dilator, since the dilator worked like a catheter. The guidewire was retrieved through the accessory channel of the duodenoscope. Deep biliary cannulation was performed using the ERCP catheter over the EUS-placed guidewire . After deep biliary cannulation, the EUS-placed guidewire was removed through the dilator, and another guidewire was inserted into the biliary system through the ERCP catheter. At this stage, the dilator was pulled back slightly within the biliary system but was not removed until the completion of the whole procedure to reduce possible bile leak through the fistula . Subsequently, the originally-planned endoscopic therapy was performed  during the study period. EUS-RV was attempted after failed deep biliary cannulation. Once the decision to perform EUS-RV was made, the ERCP scope  was exchanged with the EUS scope . The biliary system was evaluated from the stomach, D1, and D2 with EUS before the puncture. At our institution, the EHBD from D2 approach was chosen as the primary approach if it was technically and anatomically possible, followed by the IHBD from the stomach and the EHBD from D1 approaches. The bile duct was subsequently punctured using a 19-gauge FNA needle  primed with a contrast agent, and proper puncture was confirmed with a cholangiogram through the needle. A 0.025 guidewire  was inserted into the biliary system through the needle and manipulated into the duodenum via the ampulla .Among 29 patients who underwent EUS-RV for failed biliary cannulation after the median number of 15 attempts (range 4–35) of cannulation with the median time of 15 minutes (range 5–47) during the study period, 13 patients underwent EUS-RV with IHBD approach. EUS-HRV was attempted in 8 patients  because of the difficulty in guidewire placement during EUS-RV with IHBD approach from the stomach. ERCP was performed to manage malignant biliary obstruction in 7 patients and common bile stone in 1 patient. The reasons for difficult biliary cannulation were cancer invasion in 4 patients, periampullary diverticulum in 1 patient, and other technical difficulties in 3 patients. During EUS-RV, the median diameter of punctured IHBD was 4 mm with a range of 3–5 mm (Table 1). The procedure time and adverse event rates in EUS-RV were 32.5 minutes (14–89) and 14%  and did not show significant differences in comparison with EUS-HRV (p = 0.78 and p = 1.00), respectively. The overall success rate of EUS-RV combined with EUS-HRV was improved up to 90% (26/29) .Dilator insertion into the duodenum and guidewire manipulation was successfully performed in all patients who underwent EUS-HRV. The subsequent scope exchange and deep biliary cannulation after retrieval of the EUS-placed guidewire was also successfully conducted in all 8 patients. After deep biliary cannulation was achieved, bile disorders were managed through metallic stent placement in 3 patients, plastic stent placement in 3 patients, nasobiliary drainage tube placement in 1 patient, and endoscopic papillary large balloon dilation with stone removal in 1 patient. The median procedure time for EUS-HRV was 35 minutes (17–47 minutes). Mild pancreatitis was recognized in 1 patient and was successfully managed conservatively; however, no other adverse events were observed in the remaining 7 patients . The adverse event rate was 12.5% (1/8), which was similar to the overall adverse event rate in the previous pooled analysis . EUS-RV combined with EUS-HRV improved the success rate of biliary cannulation up to 90%.In EUS-RV, there are 3 technically challenging steps: biliary puncture, guidewire placement, and biliary cannulation using the EUS placed guidewire. GuidewirWe noticed an additional advantage of EUS-HRV in obtaining biliary cannulation using the EUS-placed guidewire. In this step, there are 2 methods to obtain biliary cannulation, the “along the wire” or “over the wire” methods. In the “The possible disadvantage of EUS-HRV is that the fistula dilation using a bougie dilator might increase the risk of bile leakage into the abdominal cavity. However, we believe this risk is minimal because the dilator is maintained at the site of the fistula until completion of the originally planned procedures, such as stone removal or stent placement. This can potentially seal the fistula, thus preventing bile leakage into the abdominal cavity. After the procedure, the dilated fistula should close shortly and spontaneously, as the internal pressure of the bile duct should be well controlled by the proper endoscopic management of the underlying biliary diseases and tamponade effect of liver parenchyma. No bile peritonitis was recognized in this study. Presently, however, we are unsure whether EUS-HRV can be safely applied for EUS-RV with EHBD approach route that do not have liver parenchyma at the puncture site. Another possible disadvantage of EUS-HRV is the increased risk of bleeding due to the dilation of the fistula, although we also believe this risk is minimal because the fistula is dilated using a 6-French mechanical bougie dilator without any diathermic or balloon dilation.PTB-RV is another option to salvage failed biliary deep cannulation during ERCP. PTB-RV has several potential advantages and disadvantage over EUS-RV. PTB-RV can reduce the distance between the operator’s hand and the ampulla and allows the use of flexible percutaneous guiding devices, which enhances support for guidewire manipulation.  FurthermThis study has several limitations. Patient selection might have been biased because of the retrospective nature of the study design. Internal and external validity also might be low, as this was a single-center study with a small sample size.In conclusion, EUS-HRV can be an effective and safe salvage technique in cases where guidewire placement is considered difficult during EUS-RV with IHBD approach to improve the success rate of EUS-RV. Further prospective studies involving a larger cohort are warranted to confirm the findings of this study.S1 Video(3GP)Click here for additional data file.


The CRASH-2 trial demonstrated that tranexamic acid (TXA) reduced mortality with no increase in adverse events in severely injured adults. TXA has since been widely used in injured adults worldwide. Our objective was to estimate mortality and adverse events in adults with trauma receiving TXA in studies published after the CRASH-2 trial.ClinicalTrials.gov for studies that included injured adults who received TXA and reported mortality and/or adverse events. Two reviewers independently assessed study eligibility, abstracted data, and assessed the risk of bias. We conducted meta-analyses using random effects models to estimate the incidence of mortality at 28 or 30 days and in-hospital thrombotic events.We systematically searched PubMed, Embase, MicroMedex, and We included 19 studies and 13 studies in the systematic review and meta-analyses, respectively. The pooled incidence of mortality at 28 or 30 days  was 10.1%  , and the pooled incidence of in-hospital thrombotic events  was 5.9%  .Compared to the CRASH-2 trial, adult trauma patients receiving TXA identified in our systematic review had a lower incidence of mortality at 28 or 30 days, but a higher incidence of in-hospital thrombotic events. Our findings neither support nor refute the findings of the CRASH-2 trial but suggest that incidence rates in adults with trauma in settings outside of the CRASH-2 trial may be different than those observed in the CRASH-2 trial. Hemorrhage is the primary cause of death in the first 24 hours after trauma and is responsible for 40% of all trauma-related deaths.6Administering TXA is now considered standard treatment in adults with traumatic bleeding and its use has been implemented worldwide.ClinicalTrials.gov for studies that included adult trauma patients who received TXA and reported mortality and/or adverse events  and studies that reported only mortality or adverse events. We excluded case reports and review articles, studies that were not trauma-related or that included primarily children, and studies that did not report mortality or adverse events. We also excluded studies that were secondary analyses of the CRASH-2 trial.We screened studies for inclusion initially by titles, abstracts, and then full texts. Each study title and abstract was reviewed independently by two authors. When consensus could not be reached on screened titles and abstracts, a third reviewer independently adjudicated the discrepancies. Full-text discrepancies were resolved by group consensus during in-person meetings. Prior to independent author screening, we piloted the study selection procedures as a group for several studies to enhance standardization of the selection protocol. Our study selection procedure is reported for in Two authors independently abstracted data from each of the included studies. We abstracted study characteristics that included the following: year, country, setting , design, inclusion criteria, TXA dosing, and outcomes measured. We abstracted outcome measures including mortality during any time frame, thrombotic events, and other adverse events reported, as well as adverse event definitions provided by the authors of the included study. Extraction was piloted as a group on several studies. We resolved disagreements in extracted data by group discussion and by consensus of all authors.We assessed the quality of included studies using a quality assessment instrument previously developed by the National Heart, Lung, and Blood Institute.Our primary outcomes were mortality at 28 days and in-hospital thrombotic events, as these were outcomes reported in the CRASH-2 trial.2 where a value >75% represents considerable heterogeneity.Prior to pooling the data, we assessed studies for clinical heterogeneity based on study population, setting, design, intervention, and outcome assessment. All authors participated in group discussions to determine which studies should be excluded from the meta-analyses due to significant clinical heterogeneity compared to the other studies. We performed meta-analyses using the random effects model to report incidence with 95% confidence intervals (CI). Statistical heterogeneity was assessed with IClinicalTrials.gov, 10 of which met our inclusion criteria; however, all were ongoing or have not yet published results.15The search strategy yielded a total of 4100 articles. After duplicates were removed and abstracts screened, we assessed 52 full-text articles for eligibility. Of these full-text articles, 33 were excluded. Reasons for exclusion can be found in the PRISMA diagram . Table 1Six studies were conducted in military hospitalsWe did not include six studies in the meta-analyses due to significant clinical heterogeneity compared to the other studies. Reasons for exclusion of these studies were as follows: only included patients with injury by firearm or explosive;34We included 13 studies2 = 42.7%) (2 = 87.6%)  . This wa= 87.6%) . This waOur quality assessment suggested concerns regarding non-consecutive patient enrollment (six studies)Our study demonstrated some interesting findings, particularly in comparison to the CRASH-2 trial. In our study, trauma centers demonstrated a wide variation of TXA administration including dosing (bolus vs bolus + maintenance), total bolus dose (1 g vs 2 g), and timing (within three hours vs eight hours from injury). The CRASH-2 trial administered TXA as a 1 g IV bolus infusion over 10 minutes and a 1 g maintenance infusion over eight hours within eight hours from the time of injury. The varying timing of TXA adminstration noted in our study is likely a result of an exploratory analysis that demonstrated increased benefit in preventing hemorrhagic death with earlier TXA administration given within one hour.15Compared to the CRASH-2 trial, our pooled results demonstrated a lower incidence of mortality at 28 or 30 days and a higher incidence of in-hospital thrombotic events. We do not conclude from our findings that the effectiveness and harm of TXA is different than what was demonstrated in the CRASH-2 trial, as our study included primarily observational studies. Our results instead suggest that the incidence rates observed in settings outside of the CRASH-2 trial might be different than what was observed in the CRASH-2 trial. This is particularly true for the incidence of thrombotic events, where our pooled results demonstrated a higher incidence of thrombotic events than what was observed in the CRASH-2 trial. The incidence rates reported in our included studies are likely biased towards under-reporting thrombotic events due to the high proportion of retrospective studies (more difficult to identify thrombotic events) and less-comprehensive definition of thrombotic event  compared to the CRASH-2 trial.It is unclear why there are differences in thrombotic events seen in the CRASH-2 trial and our study. It is possible that the injury severity of the two study populations is different. We were unable to compare overall patient characteristics of our included studies with those of the CRASH-2 trial. It is also possible that sites included in the CRASH-2 trial screened less for thrombotic events compared to sites included in our study. Other large trauma clinical trials enrolling similarly injured populations have also reported higher thrombotic event rates compared to the CRASH-2 trial.15Future studies evaluating TXA use in patients with hemorrhagic injuries may consider work to identify patients where the potential efficacy of TXA use is maximized and exposure to harm is minimized. Identification may be based on clinical characteristics, transport time or modality, or laboratory measurements such as thromboelastography.39Our results should be interpreted in the context of some limitations. First, the included studies demonstrated clinical heterogeneity, limiting the numbers of studies that could be included in the meta-analyses. Second, studies had varying definitions of in-hospital thrombosis, which may lead to differences in reported incidence rates. Third, the majority of the studies were retrospective, and this may result in less accurate data abstraction compared to prospective studies.Compared to the CRASH-2 trial, adult trauma patients receiving TXA identified in our systematic review had a lower incidence of mortality at 28 or 30 days, but a higher incidence of in-hospital thrombotic events. Our findings neither support nor refute the findings of the CRASH-2 trial. They merely suggest that incidence rates observed in settings outside of the CRASH-2 trial may be different than those observed in the CRASH-2 trial.


Drosophila melanogaster larva, the detection of positive odor gradients extends runs while negative gradients promote stops and turns. This algorithm represents a foundation for the control of sensory navigation across phyla. In the present work, we identified an olfactory descending neuron, PDM-DN, which plays a pivotal role in the organization of stops and turns in response to the detection of graded changes in odor concentrations. Artificial activation of this descending neuron induces deterministic stops followed by the initiation of turning maneuvers through head casts. Using electron microscopy, we reconstructed the main pathway that connects the PDM-DN neuron to the peripheral olfactory system and to the pre-motor circuit responsible for the actuation of forward peristalsis. Our results set the stage for a detailed mechanistic analysis of the sensorimotor conversion of graded olfactory inputs into action selection to perform goal-oriented navigation.Sensory navigation results from coordinated transitions between distinct behavioral programs. During chemotaxis in the  C. elegans and the D. melanogaster larva suppress turning during up-gradient runs, but turning is facilitated during down-gradient runs  . The axof the LH . Distincf the LH . Aside fehaviors .At the other end of the central nervous system of the larva, pre-motor circuits located in the ventral nerve cord (VNC) are responsible for generating patterns of rhythmic motor activities that create peristaltic motion through stereotyped sequences of muscle contractions . CentralDrosophila, activation of distinct descending neurons can elicit stereotypic behaviors such as backward walking  reconstruction of its synaptic partners, we report that PDM-DN receives olfactory input from a set of lateral horn interneurons and that it provides outputs to a set of interneurons in the SEZ. We showed that PDM-DN blocks forward peristalsis by activating an inhibitory descending neuron in the SEZ, SEZ-DN1. By monitoring the propagation of waves of segmental contractions and motor neuron activity, we demonstrated that both PDM-DN and SEZ-DN1 cease forward locomotion by inhibiting the initiation of new peristaltic waves at the posterior segments. Using EM reconstruction, we described that SEZ-DN1 synapses onto a network of excitatory premotor neuron A27h  whose artificial activation triggers run-to-turn transitions during ron A27h , which iTo identify neurons in the larval brain involved in chemotaxis behavior, we conducted a loss-of-function (LoF) screen on a large collection of Split-Gal4 driver lines . Acute LUsing Split-Gal4 driver lines, we achieved a more specific phenotypic characterization of the functional impairments induced by small neuronal subsets . We screst instar larva  triUsing infrared spectroscopy, the stability and geometry of the gradient was established as described in earlier work . Consist-/-w) showed a significant reduction in turning performances compared of PDM-DN>TNT and the other parental control  during the middle of the experiment. We selected this time window since the distance of PDM-DN-silenced larvae to the odor source increased during this period while the distance of the wild-type larvae remained stationary , we meas control , which m control .2 to minimize artefactual stops due to startle responses elicited by sudden exposure to intense red light  and down-gradient (away from the source) runs. While the sensory experience did not appear to affect the dynamics underlying switches from running to stopping modes elicited by optogenetic activation of PDM-DN  of PDM-DN promotes stopping , we hypoTo refine our analysis of the role of PDM-DN activation on the control of peristalsis, we tracked the position of individual body-wall segments, which can be visualized by the pigmented denticle bands on the ventral cuticle of the larva . Larvae F in Motor neurons and abdominal muscles form a myotopic map: motor neuron dendrites are organized into distinct domains in the VNC mirrored by the segmental organization of their target muscles at the periphery . We turnUsing calcium imaging to monitor the rhythmic propagation of motor-neuron activity, we assessed the effect of optogenetic activation of the PDM-DN neuron. When the onset of the PDM-DN activation coincided with the beginning of a wave, the wave terminated at the hinge point (A4) . The iniThe circuitry involved in the control of the propagation of forward peristaltic waves include a network of segmentally repeated excitatory premotor neurons called A27h . A27h exEM reconstruction revealed that PDM-DN is connected to the A27h premotor network through a descending neuron named SEZ-DN1. SEZ-DN1 has its dendritic arbors in the SEZ region. This neuron projects its axon to the posterior abdominal segments of the VNC . By screImmunostaining for GABA and glutamate together with the labeling of PDM-DN (PDM-DN>CsChrimson::mVenus) showed that PDM-DN is unlikely to express GABA or glutamate . By contPDM-DN has two additional post-synaptic partners in the SEZ that innervate known elements of the premotor system. First, SEZ-LN1  is a locUsing the same preparation as Drosophila melanogaster larva has a numerically simple nervous system that comprises ~10,000 neurons  . While t42b OSNs . Given t42b OSNs , we specOr42a and Or42b OSNs (Or42a OSN encodes the time derivative (slope) of ramps of odor concentrations  region: LH-LN1 and LH-LN2 . These naneuvers . Future aneuvers .Optogenetically-controlled activation of PDM-DN produces two distinct motor responses: (1) a cessation of forward peristalsis inducing a switch from running to stopping  and (2) th abdominal segment (A4) appears to be the ‘hinge’ region beyond which PDM-DN fails to inhibit the wave propagation. Third, similar observations were made by using calcium imaging to monitor fictive patterns of locomotion in isolated CNS preparations in response to PDM-DN activation . We concluded that PDM-DN might specifically target the pre-motor circuit responsible for the initiation of forward locomotion in the most posterior segments, while enabling asymmetrical contractions of the thoracic and anterior abdominal segments to scan the local odor gradient through head casts and to implement turning maneuvers  to the anterior end (head) of the body segments . This cytivation . In agretivation , we founaneuvers .What are the neural mechanisms underlying the inhibitory action of PDM-DN on the pre-motor system of the larva? The EM reconstruction of the downstream partners of PDM-DN revealed that that PDM-DN synapses onto a set of local and descending interneurons in the SEZ region . We haveHaving identified SEZ-DN1 as the main actuator of pauses upon PDM-DN gain-of-function, we turned to the second phenotype triggered by PDM-DN activation: the release of head casting behavior in preparation of turning maneuvers. By reviewing the downstream partners of PDM-DN, we discovered that at least two pathways might be implicated in the release of head-casting behavior: SEZ-LN1 and SEZ-DN2 . The SEZIn summary, the present study describes the reconstruction of a sensorimotor pathway from the peripheral sensory system down to the motor system . We ideny--w; R23E07-p65.AD; VT002081-GAL4.DBD (PDM-DN-GAL4). SEZ-DN1 is targeted by using R75C02-GAL4. Wild-type background for Split-GAL4 lines is y--w flies with empty attP40 and attP2 landing sites . Wild-type background for GAL4 lines is -w flies with empty attP2 landing site. For control experiments, we used -w flies as wild-type background crossed to the UAS-TNTE effector line.Fly strains used in this study are listed in Key resources table. Flies were raised on standard cornmeal medium at 22–23˚C on 12 hr-day: 12-hr-night cycle. PDM-DN is targeted by using the Split-GAL4 combination: http://fiji.sc/). Background correction, brightness and contrast adjustments, 3D rendering and maximum projections were performed by using Fiji. Antibodies and dilutions used in this study are listed in Key resources table. In order to detect CsChrimson::mVenus, we used conventional GFP antibodies . For MCFO experiments, we used an antibody against HA-tag . To label the neuropil, we used a combination of anti-brp  and anti-synorf1  antibodies.Larval CNS were dissected and fixed in 4% formaldehyde  in PBS  for 1 hr at room temperature. After 3 times 15 min washes in PBS + 1% Triton X-100 , the tissues were blocked for 1 hr at room temperature with 3% normal goat serum  in 1% PBS-TX. The tissues were incubated with primary antibodies overnight at 4 ˚C. After 4 times 20 min washes in 1% PBS-TX, the samples were incubated with secondary antibodies for 4 hr at room temperature. Tissues were washed 4 times for 20 min with 1% PBS-TX followed by a short wash with PBS. The CNS were mounted in Vectashield mounting medium  on lysine-coated  coverslips and kept at 4 ˚C until imaged. Imaging was performed by using either a Leica SP5 or a Leica SP8 confocal microscope . Image rendering was performed with Fiji . Prior to tracking, 3rd instar larvae were kept in 15% sucrose  for 20 min. After a quick wash in distilled water, twenty larvae were gently placed on 4% agar  slabs in 245 mm x 245 mm square Petri dishes using a small paint brush. Four odor droplets of 8 µl of 15mM ethyl butyrate  diluted in paraffin oil (Sigma-Aldrich) were pipetted inside the lid of the Petri dish . Shortly after the lid was closed on the Petri dish, larvae were tracked for 6 min using Multi Worm Tracker software (http://sourceforge.net/projects/mwt). Behavioral data were analyzed using custom-written MATLAB scripts . The odor gradient was numerically simulated by using the analytical solution of an idealized diffusion problem from four point-odor sources in an environment with absorbing boundary conditions. At any given position in the assay . 5 µl of odor (100 µM ETB or 1 mM EtA) was placed in one of the condensation rings in the middle of the 96 well plate lid with condensation rings . The lid with the odor droplet was inverted on the agarose slab. The distance between the top of the lid and the agarose layer was sufficient to prevent any contact between the larva and the odor source .In these experiments, UAS-TNTE was used to silence neural activity . Single r source . A singlr source . Behavior source  (updatedBDSC_55136). For the gain-of-function experiments with ChAT-RNAi, 20XUAS-IVS-CsChrimson::mVenus in attP18 landing site was used . Flies were kept in complete darkness on food supplemented with 0.5 mM all trans-retinal . For optogenetic stimulation experiments, we used a red LED with peak emission at 625 nm . Single larvae were placed on a 2.5% agarose slab and tracked for 5 min using a closed-loop tracker Chrimson::mVenus attP2 was crossed to (PDM-DN-GAL4). Flp2::PEST is a low activity flippase that allowed us to produce unilateral patterns of stochastic expression of CsChrimson::mVenus on one side of the brain . The larrd instar developmental stage were pinned down on a PDMS slab  using stainless steel pins . The pins were placed at the anterior end of the animal between the mouth hooks and at the posterior end of the animal between the tail spiracles. The segmental contractions were tracked by visualizing the denticle bands on the ventral side of the larva. Videos were recorded at a resolution of 1280 × 720 pixels and a rate of 20 Hz by using a USB3.0 CMOS camera . The movements of the denticle bands were analyzed by using Fiji and custom-written scripts in MATLAB. For optogenetic stimulations, we used a red LED with peak emission at 625 nm . We applied 6 s long flashes interspaced by 20 s. The camera and the LED were triggered with a NI-DAQ  and a custom written LabVIEW software .Larvae at the 3rd instar developmental state were dissected in cold saline composed of 135 mM NaCl , 5 mM KCl , 2 mM CaCl2 , 4 mM MgCl2 , 5 mM TES  and 36 mM sucrose . Isolated CNS were mounted on lysine-coated coverslips and covered with the saline solution. Imaging of motor neuron activity was performed with a Leica SP5 upright microscope using a 25X water immersion objective  or 20X multi-immersion objective with a correction collar . Optogenetic activation of PDM-DN or SEZ-DN1 was performed by using a red LED with peak emission at 625 nm . The microscope and the LED were triggered with NIDAQs  using custom written MATLAB scripts. Very low powers of Argon laser (488 nm) were used to excite GCaMP6f while avoiding the activation of CsChrimson at this wavelength. In the absence of 625 nm LED stimulus, waves of motor-neuron activity were observed . Changes in the fluorescence signal were quantified as follows: region of interests (ROIs) were chosen for each segment on both sides of the VNC /F0 attP8; 12XlexAop2-IVS-GCaMP6f-p10 su(Hw)attP5 (gift from Stefan Pulver). CG9887-LexA (gift from Julie Simpson) targets GCaMP6f expression to glutamatergic neurons including all motor neurons. The central nervous system (CNS) of larvae at the 3observed  and 6 sui-F0)/F0 . The ΔF/rd instar developmental stage were dissected in cold saline  and placed dorsal side down on a lysine-coated coverslip. We used an Ultima II two-photon scanning microscope  and a Vision II laser . For imaging we used two-photon excitation wavelength of 920 nm with the power at the sample never exceeding 10 mW. CsChrimson was activated with a LED  with peak wavelength at 590 nm and a 605/55 bandpass filter. To feed the CsChrimson excitation light into the light path, we used a custom dichroic dichroic . The power of the LED from the objective was ~30 µW/mm2. Optogenetic activation stimuli were delivered in 30 Hz pulse trains  lasting for 1 s. For trial the neuron was observed for approximately 20 s. Each trial was repeated 5 times. Functional imaging was analyzed by using custom written Python scripts . A ROI was chosen to contain only the axonal branching of the neuron of interest /F0. Baseline fluorescence F0 was defined as the mean pixel intensity of a 2 s time window preceding the optogenetic stimulus.Imaging experiments were performed with the following cross: 75C02-LexA/Cyo-Dfd::YFP; 13xLexAop2-IVS-GCaMP6f-p10 50.693 in VK00005, 20xUAS-CsChrimson-mCherry-trafficked in su(Hw)attp1 was crossed to PDM-DN-GAL4. The CNS of larvae at the 3interest . The siginterest . No noisEM reconstruction of neurons and annotations of synapses were performed as described previously  using wecorrcoef function of MATLAB_R2015b. To compare proportions in Normality was tested using Lilliefors test. If distributed normally, data were analyzed with ANOVA test. When the Lilliefors test rejected normality, we used Wilcoxon ranksum test followed by Bonferroni correction. For paired data in  In the interests of transparency, eLife includes the editorial decision letter and accompanying author responses. A lightly edited version of the letter sent to the authors after peer review is shown, indicating the most substantive concerns; minor comments are not usually included.Drosophila melanogaster larva" for consideration by eLife. Your article has been reviewed by three peer reviewers, including Ronald L Calabrese as the Reviewing Editor and Reviewer #1, and the evaluation has been overseen by K VijayRaghavan as the Senior Editor. The following individual involved in review of your submission has agreed to reveal their identity: Jimena Berni (Reviewer #3).Thank you for submitting your article "Sensorimotor pathway controlling stopping behavior during chemotaxis in the The reviewers have discussed the reviews with one another and the Reviewing Editor has drafted this decision to help you prepare a revised submission.Summary:Drosophila larvae. In particular they concentrate on the role of a newly identified olfactory descending neuron, PDM-DN , originating in the Lateral Horn region of the Brain Lobes and descending to the Ventral Nerve Cord. They use previous em reconstructions of the larval nervous system to identify upstream circuitry leading from olfactory receptor neurons, through specific olfactory Projection Neurons, through specific LH neurons to the PDM-DNs. They use the same reconstructions to further trace downstream circuitry focusing mainly on a path from the PDM-DNs onto the SubEsophageal Zone DN1 which then projects onto the previously characterized segmentally repeated  excitatory premotor interneurons A27h to which they connect in the posterior segments. The manuscript makes full use of current behavioral, intersectional genetics and optogenetic techniques available for circuit analyses of behavior in Drosophila and is guided by an em reconstruction of upstream and downstream synaptic targets. They perform critical necessity and sufficiency tests for the PDM-DNs and some downstream elements. The level of circuit analyses is impressive and it clearly shows that the PDN DNs play a critical role in the halts and head casts that accompany down-gradient runs in attractive chemotaxis. They also present a very convincing analysis of how PDM DN (and SEZ DN1) activation halts locomotory waves of contraction and fictive locomotory activity recorded with Ca indicator in the posterior abdominal segments of the VNC. The work is truly elegant and pushes the technology available. The elegance of both the analysis and the circuitry uncovered for mediating down-gradient run associated halts and head casts will be of wide interest.In this manuscript, the authors present a thorough analysis of circuit elements that mediate in olfactory guided stops and head casts associated with chemotaxis to an attractive odor in The writing is clear and the figures are well organized, and clear.Essential revisions:1) Fundamental for the interpretation of all the results presented in the paper is the demonstration that the PDM-DNs plays a role in chemotaxis and not in crawling itself. The authors should show that when there is no odor and PDM-DNs are blocked, the larvae behave as their parental genetic controls. The experiment in Figure 3—figure supplement 1 no odor, should be performed with the same number of animals (30) required to see a significant difference in the chemotaxis experiment. If the behavior is not as the controls, then the entire paper will have to be reinterpreted and rewritten.2) The sufficiency and necessity tests performed and the associated analyses are very impressive, and the data are convincing; however, they do not show necessity for halts or for head casts. Rather, they show that the PDN DNs play a critical role in halts and head casts associated with down-gradient runs but are not essential for such halts and head casts. Similarly, the sufficiency tests do not present an absolute result indicating that activation of the neuron produces a halt. It is not important to claim necessity or sufficiency but rather to present the impressive circuit analysis. Trying to fit these neurons in the Kupfermann and Weiss box of a command neuron may be the problem. It is not necessary to call these neurons command neurons for this work to be important. The experiments show that the PDN DNs are critically involved in the halt phase of chemotaxis, and PDN DNs provide a nexus for further circuit analysis and dissection of the behavioral mechanisms. Please re-frame your claims so that they are more nuanced and reflect the actual complexity of the whole system.3) A synthesizing diagram in the manuscript that can tie in all of the observations  is missing. Even just a cartoon schematic would go a long way in making this work more easily digestible by all readers, including non-experts. This schematic could also effectively raise clearly the outstanding information for further experiments to determine the circuit mechanisms whereby PDM-DN and its downstream partners control halting and head-casting behaviors. What are the take-home messages to neuroscientists interested in behavioral control? We encourage the authors to provide such a synthesis in the final, published manuscript. Essential revisions:1) Fundamental for the interpretation of all the results presented in the paper is the demonstration that the PDM-DNs plays a role in chemotaxis and not in crawling itself. The authors should show that when there is no odor and PDM-DNs are blocked, the larvae behave as their parental genetic controls. The experiment in Figure 3—figure supplement 1 no odor, should be performed with the same number of animals (30) required to see a significant difference in the chemotaxis experiment. If the behavior is not as the controls, then the entire paper will have to be reinterpreted and rewritten.We have conducted the additional experiments requested by the reviewers. In a new dataset, statistical comparisons of no-odor controls shown in Figure 3—figure supplement 1 are based on a sample size of 31. The difference between the median of the test and control conditions is not statistically significant . These results strengthen our conclusion that silencing the activity of PDM-DN does not result in locomotor defects that would make larvae crawl slower or turn less frequently.2) The sufficiency and necessity tests performed and the associated analyses are very impressive, and the data are convincing; however, they do not show necessity for halts or for head casts. Rather, they show that the PDN DNs play a critical role in halts and head casts associated with down-gradient runs but are not essential for such halts and head casts. Similarly, the sufficiency tests do not present an absolute result indicating that activation of the neuron produces a halt. It is not important to claim necessity or sufficiency but rather to present the impressive circuit analysis. Trying to fit these neurons in the Kupfermann and Weiss box of a command neuron may be the problem. It is not necessary to call these neurons command neurons for this work to be important. The experiments show that the PDN DNs are critically involved in the halt phase of chemotaxis, and PDN DNs provide a nexus for further circuit analysis and dissection of the behavioral mechanisms. Please re-frame your claims so that they are more nuanced and reflect the actual complexity of the whole system.We are thankful to the editor and reviewers for encouraging us to reevaluate the appropriateness of the concept of command neuron as proposed by Kuperfmann and Weiss (1978). We agree that this framework is so restrictive that it might lead to unfortunate conclusions, as has been argued by Yoshihara and Yoshihara (2018). We reformulated our conclusions accordingly.3) A synthesizing diagram in the manuscript that can tie in all of the observations  is missing. Even just a cartoon schematic would go a long way in making this work more easily digestible by all readers, including non-experts. This schematic could also effectively raise clearly the outstanding information for further experiments to determine the circuit mechanisms whereby PDM-DN and its downstream partners control halting and head-casting behaviors. What are the take-home messages to neuroscientists interested in behavioral control? We encourage the authors to provide such a synthesis in the final, published manuscript.We thank the reviewers for this suggestion. In the new Figure 7, we added a schematic diagram that illustrates the sensorimotor pathway anchored to the PDM-DN neuron. We summarized the results of our study about the function of the pathway and we highlighted the points that were left to speculation.


Background. This in vitro study compared the fracture resistance of roots instrumented either with ProTaper or One Shape rotary systems and filled with one of the silicate, epoxy resin or silicone-based sealers. Methods. Sixty single-rooted extracted mandibular premolars were decoronated to a length of 13 mm and then randomly divided into two main groups (n=30) in terms of the rotary system used for preparation. Group 1 samples were instrumented with the ProTaper Universal system up to a master apical file of #F2, while samples in group 2 were enlarged with One Shape system. The two main groups were then divided into 3 subgroups in terms of the sealer used (n=10) and filled with guttapercha (either F2 or MM-GP points) of the rotary system used and one of the sealers as follows: group 1, BioRoot RCS + ProTaper F2 gutta-percha; group 2, AH Plus + ProTaper F2 gutta-percha; group 3, GuttaFlow + ProTaper F2 gutta-percha; group 4, BioRoot RCS+ MM-GP points; group 5, AH Plus + MM-GP points; and group 6, GuttaFlow + MM-GP points. Each specimen then underwent fracture testing by using a universal testing machine at a crosshead speed of 1.0 mm/min until the root fractured. Data were statistically analyzed. Results. Two-way ANOVA showed no significant differences between the groups. One Shape instruments showed significantly better fracture resistance compared to ProTaper instruments. Statistically, no significant difference was found between AHPlus, GuttaFlow and BioRoot RCS sealers. Conclusion. It can be concluded that the rotary system used for the instrumentation of teeth has some influence on the fracture resistance, while the root canal sealers do not have such an effect. During root canal treatment, the possibility of vertical root fracture is higher in over-instrumented teeth.2Endodontically treated teeth are more susceptible to vertical fractures than vital teeth. Endodontic therapy includes caries removal, access cavity preparation and root canal preparation procedures. These procedures weaken the tooth structure during endodontic therapy, dehydrate the dentin after endodontic therapy and exert excessive pressure during obturation.3 ProTaper Universal (PTU)  is a conventionally used NiTi rotary system that operates rotationally.4 The instrument has a variable taper along its length and a convex triangular cross-section.5 Another system, One Shape , is a single-file shaping system, and it is recommended that it should not be sterilized. It has two cutting edges and triple helical construction. Two cutting edges provide bending resistance, while triple helical construction is torsion-resistant. One Shape offers three different cross-sectional areas along its length for added flexibility, and the region closest to the shaft has an "S" cross-section with two cutting angles.6Nickel-titanium (NiTi) instruments have been generally used in endodontic practice because of their relatively higher reliability and better flexibility and efficiency than stainless steel files.7 Root canal sealers are needed to fill the voids between the gutta-percha cones and the voids between the gutta-percha cones and root canal walls.8 Lateral compaction is the most common root canal filling technique. Also, this technique prepares the ground for vertical root fracture due to the application of force to the root, and it is time-consuming.9 As a result of using NiTi rotary systems and with the advent of tapered gutta-percha cones, the single-cone technique has become more useful.10Gutta-percha is used as the most popular root canal filling material because it has many advantages, such as easy removal from the root canal, and it is biocompatible, non-toxic and non-allergic. For hermetic seal, gutta-percha is not sufficient alone because it has no adhesion to root canal walls.11 Another silicone-based root canal sealer is GuttaFlow . GuttaFlow is a liquid filling system that combines root canal sealer and gutta-percha (GP) in a single material. GuttaFlow is biocompatible, has excellent fluidity and features a thin sealing layer.12 Another root canal sealer is tricalcium silicate-based BioRoot RCS ; it consists of tricalcium silicate, zirconium dioxide and povidone, water and calcium chloride.13 In addition, the manufacturer claims that BioRoot RCS can obturate the root canal with and without gutta-percha cones because of the excellent bonding by penetrating into the dentin structure.Resin-based AH Plus root canal sealer  is widely used today due to its many advantages.This study aimed to evaluate the fracture resistance of roots instrumented either with ProTaper or One Shape rotary systems and filled with one of the silicate, epoxy resin or silicon-based sealers while the teeth were obturated either with the laterally condensed gutta-percha or the single-cone technique.Sixty extracted caries-free and single-rooted mandibular premolar teeth were decoronated to a length of 13 mm. The teeth were stored in saline solution before the experiments. The tooth lengths were determined by placing a #15 K-file  in the root canal until the apical foramen was observed and reducing the file length by 1 mm.The teeth were randomly divided into two main groups (n=30) in terms of the instrumentation system. The samples in group 1 were instrumented with ProTaper Universal system  according to the manufacturer’s instructions; SX, S1, S2, F1 and F2 instruments were used, while the samples in group 2 were enlarged with One Shape system . During the instrumentation, the root canals were irrigated with 2.5 mL of 5.25% NaOCl between each change of file. After instrumentation, the specimens were irrigated with 5 mL of 17% EDTA to remove the smear layer. The root canals were dried with sterile paper points .Two main groups were then subdivided into three subgroups in terms of the sealer used (n=10) and filled with gutta-percha (either F2 or MM-GP points) of the rotary system used. The experimental groups were treated as follows:Group 1: BioRoot RCS  and ProTaper F2 gutta-perchaGroup 2: AH Plus  and ProTaper F2 gutta-perchaGroup 3: GuttaFlow  and ProTaper F2 gutta-perchaA ProTaper F2 master gutta-percha, corresponding to the final instrument, was used as a single cone. The root canal walls were covered with sealer  using paper points, and then the apical portion of the gutta-percha was coated with sealer and inserted into the root canal.Group 4: BioRoot RCS, MM-GP pointsGroup 5: AH Plus, MM-GP pointsGro up 6: GuttaFlow, MM-GP pointsAn MM-GP point was used as a master cone, and the root canal walls were covered with sealer  using paper points; then the apical portion of gutta-percha was coated with sealer and inserted into the root canal, followed by the placement of lateral cones for lateral condensation.The root canal orifices were sealed with Cavit temporary filling material . The obturated teeth were stored at 37ºC at 100% humidity for one week for complete setting of the sealers.After one week, 3 mm of the roots were embedded in self-cured acrylic resin  by using cylindrical molds measuring 15 mm in diameter and 13 mm in height, leaving 9 mm of the root length exposed. The temporary filling material was removed with an excavator. The specimens were mounted on the lower plate of a universal testing machine  . A comprThe means and standard deviations of push-out bond strengths (MPa ± SD) of the experimental groups are presented in In this study, we compared the fracture resistance of roots instrumented with either ProTaper or One Shape rotary system and filled with one of the silicate, epoxy resin or silicone-based sealers.14 This is one of the limitations of such experiments.In this study, no additional silicone was used as an artificial periodontal ligament to counteract the vertical force. To perfectly simulate the periodontal ligament, it is still difficult to apply a force parallel to the long axis of the tooth for proper simulation of the clinical situation.15 Stresses generated through the root canal were transmitted along the root surface where the interfacial adhesion failed.15 In this study, a single load was applied to the fracture parallel to the long axis of the teeth, which produced more uniform stress distributions by using a universal test machine .The strength test is a method that has been used to examine the effect of fracture resistance of obturation materials on the root canal-filled teeth.16 Several studies have shown that decreased fracture resistance of roots after preparation with different rotary systems.18 A round cross-sectioned root canal results in more homogeneous stress distribution during root canals obturation, increasing the fracture resistance.19 Accordingly, ProTaper NiTi and One Shape rotary systems were used in this study to produce round-shaped root canals. One Shape instruments showed significantly better fracture resistance compared to ProTaper instruments in the present study. This could be attributed to the fact that One Shape files permit more round cross-sectional root canals during preparation because of their “S” cross-section with two cutting angles. During the root canal preparation, a relatively low concentration of NaOCl (2.5%) was used as an irrigant to minimize any adverse effects on the dentin mechanical properties.20Chemomechanical preparation of the root canal system is performed during root canal treatment to remove the infected pulp tissues; mechanical preparation should also be performed. Excessive tooth structure removal during mechanical preparation and excessive forces applied during obturation reduce the fracture resistance of root-filled teeth.21 However, the lateral condensation technique was used in this study because it is a widely recommended classic technique.21 In another study, Ersoy and Evcil22 investigated root canal sealers and obturation techniques.22 The single-cone technique showed significantly higher resistance to fracture than the lateral condensation technique. However, in this study, there were no significant differences between the root canals filled with lateral condensation technique and the other groups, which might be explained by the use of NiTi files.The primary goal of root canal filling is to strengthen a weakened root against fracture. To achieve an ideal and three-dimensional root canal obturation, gutta-percha cones should be used with a root canal sealer. However, root canal obturation has been known as the major reason for vertical root fracture. In the lateral condensation technique, the spreader laterally compacts the gutta-percha and adapts it to the root canal wall under consistent vertical load.23 It has been shown that retention of the filling material can be mechanically improved, thereby strengthening the root canal dentin to increase the fracture resistance. The fracture resistance of AH Plus root canal sealer has already been investigated in numerous studies.25 In a previous study, AH Plus and MTA Fillapex showed significantly higher resistance to fracture than other conventional root canal sealers.25 With great attention to the adhesive properties and sealing ability of epoxy resin-based root canal sealers, the effect of AH Plus on the fracture resistance of root-filled teeth was compared with other types of root canal sealers in this study. In our study, there were no significant differences between AH Plus and other root canal sealers.Many studies have shown that epoxy resin-based sealers exhibit better adaptation with the root canal dentin compared to glass-ionomer and ZOE-based sealers.27 Siboni et al28 showed that BioRoot RCS has high calcium ion releasing ability. A recent study showed that BioRoot RCS has a higher bioactivity than the ZOE sealer on human PDL cells.29 According to the manufacturer, this sealer has an integration similar to Biodentine (Septodont), trying to integrate the ideal properties of Biodentine in a root canal sealer.30 Also, a silicon-based sealer, GuttaFlow, has calcium ion releasing ability. In a previous study, BioRoot RCS and IRootSP resulted in higher resistance to fracture compared to MTA-Fillapex. In the present study, no significant differences were found between BioRoot RCS and the other conventional sealers. Also, in that study, the authors observed that the LTC techniques resulted in more resistance to fracture than the SC techniques, but we observed no significant differences. The differences between the results of studies might be explained by the type of the sealer used, the brand of the sealer and the experience of the practitioner.BioRoot RCS, commonly known as an MTA-based sealer, is a powder/liquid hydraulic tricalcium silicate-based cement recommended for the single-cone technique or cold lateral condensation root filling. It has a lower cytotoxicity than other conventional root canal sealers and might induce hard tissue deposition.In the present study, no differences were found in fracture resistance between the roots filled with AH Plus, BioRoot RCS and Gutta Flow and the obturation techniques. Furthermore, all the fracture patterns observed in the study after failure were irreparable.While One Shape instruments resulted in significantly better fracture resistance compared to ProTaper instruments, all the three root canal sealers examined in this study strengthened the prepared root canals with increased fracture resistance.SİY analyzed and interpreted the data and drafted and critically revised the manuscript. MA and MBA were responsible for acquisition, analysis and interpretation of data. AÜE was responsible for the study concept and design and critical revision.No acknowledgements.Not applicable.The authors declare no competing interests with regards to the authorship and/or publication of this article.This study was approved by the Institutional review Board (reference no. 2018-330).


The Federal Maternal, Infant, and Early Childhood Home Visiting Program is a national child abuse prevention strategy that serves families at risk for child maltreatment throughout the United States. Significant portions of the clients are young mothers who screen positive for clinically significant perinatal depressive symptoms and experience relational discord that worsens their symptoms. Although home visitors refer those who screen positive for depression to community-based treatment, they infrequently obtain treatment because of multiple barriers. These barriers are compounded for home visited families in rural areas.This pilot study aimed to explore the feasibility, acceptability, and effectiveness of a video-delivered family therapy intervention on reducing maternal depressive symptoms and improving family functioning and emotion regulation.A total of 13 home visited families received the video-delivered family therapy intervention. This study included a historical comparison group of mothers (N=13) who were previously enrolled in home visiting and screened positive for clinically significant perinatal depressive symptoms but refused treatment. A licensed marriage and family therapist delivered the family therapy intervention using Health Insurance Portability and Accountability Act–compliant videoconferencing technology on a computer from an office. Families participated in sessions in their homes using cell phones, tablets, and computers equipped with microphones and video cameras. Outcomes were measured following the final therapy session (post intervention) and 2 months later (follow-up). Depressive symptom scores of mothers who received the video-delivered family therapy intervention were compared with those of mothers in the historical comparison group over a 6-month period. Univariate statistics and correlations were calculated to assess measures of feasibility. Percentages and qualitative thematic analysis were used to assess acceptability. Wilcoxon signed-rank tests were used to assess changes in maternal and family outcomes.P=.001). When compared with mothers in the historical comparison group, those in the family therapy intervention showed a significant reduction in depressive symptoms (P=.001). Families demonstrated statistically significant improvements in family functioning (P=.02) and cognitive reappraisal (P=.004).No families dropped out of the study. All families reported that the technology was convenient and easy to use. All families reported high satisfaction with the video-delivered intervention. Nearly all families reported that they preferred video-delivered family therapy instead of clinic-based therapy. Therapeutic alliance was strong. Mothers demonstrated a statistically significant reduction in depressive symptoms . The Federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program serves over 100,000 vulnerable families at risk for child abuse throughout the United States and aims to improve several outcomes, including maternal mental health . DepressHome visitors refer depressed mothers for treatment but they infrequently obtain it or complete it -12. BetwIntegrating mental health services in home visiting has been shown to reduce logistical barriers experienced by some families -10. TherFurthermore, these existing interventions do not include family members in the mother’s treatment to address family dynamics that result in family conflict. Family conflict is a risk factor for and a consequence of perinatal depression -32. FamiTechnology permits convenient access to treatment for mothers and their families in rural areas. Given that 60% of low-income families and nearly 68% of those in rural areas own handheld devices with internet access in the United States , technolThis 1-year pilot study had the following 2 aims: (1) to explore the feasibility and acceptability of the video-delivered family therapy intervention among home visited families and (2) to explore preliminary impacts of the video-delivered family therapy intervention on maternal depressive symptoms, family functioning, and emotion regulation from baseline to 2 months after the final family therapy session (follow-up). We hypothesize that mothers will show a clinically meaningful reduction in depressive symptoms at the 2-month follow-up . When coAs described in our published study protocol , our resThis study is a quasi-experimental, implementation-effectiveness hybrid trial. Although participants were not randomized, our study included a historical comparison group of mothers (n=13) who were previously enrolled in the home visiting programs at the 2 MIECHV agencies. The mothers in the historical comparison group were matched on baseline depression scores, age, and number of children. This study is registered at ClinicalTrials.gov (ID: NCT03282448).Families were recruited from 2 MIECHV agencies in New England. These 2 agencies serve families in 3 rural counties in New England. Home visitors presented an institutional review board (IRB)–approved study information sheet to eligible families in their caseloads that included a brief overview of the study goals, intervention, study measures, potential benefits, and risks. Home visitors provided each interested family’s contact information to research assistants, who scheduled a meeting with each family to review the IRB consent forms, and obtained written informed consent from all willing participants. During the consent process, families were informed that study participation was voluntary and they could receive home visiting regardless of whether or not they decided to participate in the study.Of the 28 potentially eligible families, 13 were excluded from the study because of the severity of psychiatric illnesses , maternal age that exceeded the age cut-off, domestic violence, and recent completion of standard dialectical behavior therapy (DBT) treatment. Overall, 2 families were excluded before the first therapy session because the home visitor was unable to locate them after they signed the consent form. Our final sample size for the intervention group was 13 families.Inclusion criteriaHome visited mothers, ages 13-25, in the first trimester of pregnancy through 18 months postpartum;Edinburgh Postnatal Depression Scale (EPDS) [Mothers with e (EPDS)  scores oAt least one of the mother’s adult family members  must be available to participate in 8 of the 10 sessions;Mothers and family members must be fluent in English;Families with consistent internet access ; andFamily owns cell phone, tablet or computer equipped with a camera and microphone.Exclusion criteriaCurrent substance abuse in mothers;Current domestic violence;Mothers who report or exhibit current suicidal ideation, self-injurious behavior, and psychotic symptoms during a home visit or in a therapy session;Mothers experiencing a severe Major Depressive Episode;Mothers who report homicidal ideation to the home visitor or study therapist;Mothers with pervasive developmental disorders;Mothers with a diagnosis of Post-Traumatic Stress Disorder;Current family therapy;Current individual therapy for mothers or recent completion of Dialectical Behavior Therapy; and/orChild Protective Services (CPS) involvement as reported by the home visitor.This study used standard home visiting screening procedures for depression, substance abuse, and domestic violence to identify eligible families for participation. Home visitors are expected to routinely screen mothers for depression and provide mental health referrals to those who screen positive for depression on the Edinburgh Postnatal Depression Scale (EPDS). Home visitors are also expected to routinely screen mothers for substance abuse  and dom1); treatment phase (O2); and post intervention  and 2 months later . Family baseline measures were completed in O1 within 3 weeks before the first therapy session. Demographic information was collected on mothers, infants (age only), and family members. Monitoring measures were completed in O2. Postintervention measures and the 2-month follow-up were completed in O3.The study measures and time points that align with each aim are presented in The Working Alliance Inventories-Short Forms (therapist and client versions) were used to measure quality of the therapeutic alliance. The developer recommends for therapists and clients to complete this measure beginning after the third, 60-min, therapy session ,51. As eThe PI and coinvestigators developed the Satisfaction Questionnaire for this study. It includes 7 quantitative items that include 6 multiple-choice questions, with response choices that range from 1 (strongly agree) to 4 (strongly disagree), and the seventh question is rated as true or false. In total, 5 of the items assess overall satisfaction with the therapy and satisfaction with each of the 4 skills modules. The last 2 items are on the usefulness of the HIPAA-compliant video-based communication technology. The Satisfaction Questionnaire also includes 3 open-ended questions about changes families would like to see to the video-delivered family therapy intervention, the helpfulness of the skills, and a section for general comments. The Satisfaction Questionnaire was administered to families post intervention. All the quantitative items on it demonstrated good reliability  post intervention. Completion of homework assignments was based on the family report to the therapist. The percentages of families who completed homework assignments for each of the 4 skills modules were calculated.The Beck Depression Inventory-second edition (BDI-II)  was usedThe EPDS  is a depskills training sessions instead of family therapy sessions to reduce family stigma attitudes [The video-delivered family therapy intervention consisted of 10, 30-min, weekly family therapy sessions that are concurrent with ongoing home visits . The systtitudes .Home visitors were educated in how to use the HIPAA- compliant video-based communication technology (Vidyo) , and theA total of 13 families participated in the video-delivered family therapy intervention. The target sample size for the intervention group was 12 families, and it was determined in consultation with our external community stakeholders . They reFor the first aim, univariate statistics  were used to characterize family baseline characteristics and indicators of feasibility . For quality of the therapeutic alliance, average therapist scores and family scores were calculated for each subscale on the Working Alliance Inventories-Short Forms ,51 afterFor acceptability (family responsiveness), univariate statistics and qualitative data analytic methods  were useFor the second aim, basic sample statistics  were used to summarize family measures at baseline, post intervention, and at follow-up. Wilcoxon signed-rank tests were used to assess changes in maternal and family outcomes from baseline to post intervention and from baseline to follow-up.The historical comparison group included depressed mothers who were previously enrolled in home visiting at the 2 MIECHV agencies but refused treatment. The mothers in the historical comparison group were matched with mothers who received the video-delivered family therapy intervention on 3 key baseline variables: EPDS baseline score, maternal age, and number of biological children. As we were unable to find previously enrolled mothers with EPDS scores that were exactly the same as baseline EPDS scores for mothers who received the study intervention, we matched mothers based on the similarity of their EPDS scores. A total of 39% (5/13) of comparison group mothers had EPDS scores that were exactly the same as those of intervention group mothers. A total of 39% (5/13) of comparison group mothers had EPDS scores that were within 1 point of those of intervention group mothers. A total of 15% (2/13) of comparison group mothers had EPDS scores that were within 2 points of those of intervention group mothers. Only 1 comparison group mother’s EPDS score was 3 points higher than that of an intervention group mother. A Wilcoxon signed-rank test was used to assess changes in EPDS scores in the matched pairs over a 6-month period.The intervention group family baseline characteristics are presented in There were no statistically significant differences in baseline characteristics of mothers who received the video-delivered family therapy intervention and those in the historical comparison group. The therapist consistently used a computer in her office to deliver the family therapy sessions using the HIPAA-compliant video-based communication technology. Families varied in the types of devices they used to participate in the family therapy sessions. About 31% (4/13) of families used only a tablet  to participate in the family therapy sessions, and 31% (4/13) of families used only a computer to participate in these sessions. About 15% (2/13) of families used more than 1 device . Approximately 15% (2/13) of families used only a cell phone to participate in the family therapy sessions, and 1 family used an iPod Touch to participate in the sessions. Only 2 families had to reschedule family therapy sessions because of disruptions in internet service.P<.05) post intervention.For quality of the therapeutic alliance, family ratings on the 5-point subscales for the Working Alliance Inventories-Short Forms, goals , bond , and task , were very strong. As shown in All families were retained, and no families dropped out of the intervention or the study. All mothers attended all 10 therapy sessions. Family members attended an average of 8.4 therapy sessions. One family included a home visited mother, her boyfriend, and her friend . After the fourth session, the couple decided to complete the family therapy without the other home visited mother. For this reason, the other home visited mother attended the remaining 6 therapy sessions without a family member.All mothers and family members completed homework assignments from each of the 4 skills modules. Only 1 mother reported that she would prefer in-person delivered sessions, instead of video-delivered sessions, in the future. For the qualitative item on the helpfulness of the skills on the Satisfaction Questionnaire, all families reported that the mindfulness skills were most helpful for them, followed by emotion regulation , distress tolerance , and interpersonal effectiveness . Families did not report any suggestions for changes to the intervention. No families reported any complaints. The results for the remaining quantitative items on the Satisfaction Questionnaire are included in P=.001) at the 2-month follow-up. The results showed statistically significant reductions in maternal depressive symptoms (P=.02) and cognitive reappraisal (P=.004) at the 2-month follow-up. The results showed statistically significant improvements in family functioning  of mothers either enrolled in school or were employed for pay by the 2-month follow-up. Furthermore, 31% (4/13) of mothers who were in school or employed for pay at baseline maintained this status post intervention. This finding indicates that the significant reduction in maternal depressive symptoms resulted in improved functioning.This study included a historical comparison group of 13 mothers who were previously enrolled in home visiting and screened positive for depression but refused treatment. Home visiting programs routinely use the EPDS to screen for maternal depressive symptoms at different time points. The EPDS scores of mothers who received the video-delivered family therapy intervention were compared with those of previously enrolled depressed mothers who refused treatment. This study explored the feasibility, acceptability, and preliminary impacts of a video-delivered family therapy intervention for home visited young mothers with perinatal depressive symptoms and their adult family members. Our findings showed that mothers experienced a statistically significant reduction in depressive symptoms, and families experienced statistically significant improvements in family functioning and the emotion regulation strategy of cognitive reappraisal. This study demonstrated the preliminary safety of the video-delivered family therapy for home visited depressed young mothers as our results showed that maternal depressive symptoms consistently decreased from baseline to the 2-month follow-up see . We founSome technology-based interventions  have been tested in perinatal and postpartum women with depression and have been shown to be effective in reducing their depressive symptoms -63. For To date, 4 individual-level psychosocial interventions have been developed for and tested in home visited depressed mothers -24. EithThis study demonstrated the feasibility and acceptability of the video-delivered family therapy intervention. We found support for all 3 of our hypotheses. First, we hypothesized that mothers would show a clinically meaningful reduction in depressive symptoms at the 2-month follow-up . The resFinally, we hypothesized that families would show clinically meaningful improvements in family functioning and emotion regulation at the 2-month follow-up . Our resThe significant reduction in maternal depressive symptoms and significant improvements in family functioning and cognitive reappraisal hold promise for future research on this intervention. Concordantly, we plan to conduct a randomized trial of the study intervention to formally test its impacts on these outcomes.This study had several limitations. First, the results must be interpreted with caution, given the small sample size. Second, we were unable to conduct a long-term follow-up because of the short-term nature of the grant received to conduct this study. Third, this study did not include a control group. Fourth, the majority of the participants were white, and the lack of ethnic diversity limits the generalizability of our findings. Fifth, most of the participants graduated from high school, and our findings may not generalize to those with lower levels of education. Sixth, the study included heterosexual mothers, and although we did not exclude mothers who identify as lesbian from participating in the study, it is possible that the findings may not be generalizable to mothers who identify as lesbian. Finally, the findings from this type of study intervention may not be generalizable to home visited families in urban communities, given they may face fewer logistical barriers and may prefer traveling to providers’ offices for family therapy.There is a scarcity of research on the use of HIPAA-compliant video-based communication technology to deliver family therapy for treatment of perinatal depression in rural regions of the United States. The studies that have been conducted on this method of delivery focus on family therapy interventions for behavioral problems in children -44, but