To evaluate the 12-month total direct costs  of delivering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) under three strategies — facility-based administration, community-based administration and self-injection — compared to the costs of delivering intramuscular DMPA (DMPA-IM) via facility- and community-based administration.We conducted four cross-sectional microcosting studies in three countries from December 2015 to January 2017. We estimated direct medical costs  using primary data collected from 95 health facilities on the resources used for injectable contraceptive service delivery. For self-injection, we included both costs of the actual research intervention and adjusted programmatic costs reflecting a lower-cost training aid. Direct nonmedical costs  came from client interviews conducted during injectable continuation studies. All costs were estimated for one couple year of protection. One-way sensitivity analyses identified the largest cost drivers.Total costs were lowest for community-based distribution of DMPA-SC (US$7.69) and DMPA-IM ($7.71) in Uganda. Total costs for self-injection before adjustment of the training aid were $9.73 (Uganda) and $10.28 . After adjustment, costs decreased to $7.83 (Uganda) and $8.38  and were lower than the costs of facility-based administration of DMPA-IM . Costs were highest for facility-based administration of DMPA-SC ($12.14) and DMPA-IM ($11.60) in Burkina Faso. Across all studies, direct nonmedical costs were lowest for self-injecting women.Community-based distribution and self-injection may be promising channels for reducing injectable contraception delivery costs. We observed no major differences in costs when administering DMPA-SC and DMPA-IM under the same strategy.Designing interventions to bring contraceptive service delivery closer to women may reduce barriers to contraceptive access. Community-based distribution of injectable contraception reduces direct costs of service delivery. Compared to facility-based health worker administration, self-injection brings economic benefits for women and health systems, especially with a lower-cost client training aid. The DMPA-SC product available to Family Planning 2020 countries is Pfizer’s Sayana® Press, which delivers the contraceptive drug through the BD Uniject™ injection system, allowing for easier administration by lay health workers with minimal training and for women to self-inject. Recent studies demonstrated the operational feasibility of these administration modalities and acceptability to women and health workers Evidence on the costs of contraceptive service delivery in LMIC is generally scarce. Only a few studies have estimated the costs of delivering injectable contraceptives — mainly DMPA-IM Therefore, we sought to investigate whether the costs to administer DMPA-SC differed from the costs to administer DMPA-IM and whether these costs differed by delivery strategy. We conducted these costing studies in parallel with studies evaluating the method continuation rates of DMPA-SC under facility-based administration in Burkina Faso, community-based distribution via Village Health Teams in Uganda, and self-injection in Senegal and Uganda, all compared to DMPA-IM The main objective of this study was to assess the costs of delivering DMPA-SC and DMPA-IM using different strategies in three sub-Saharan African countries: Burkina Faso, Uganda and Senegal. We reported costs from a health system perspective and also accounted for women’s travel and time costs to travel to, wait for and receive services. Specifically, we sought to understand the total direct costs of delivering DMPA-SC and DMPA-IM, including commodity costs; costs of provider time, medical supplies and drugs for the treatment of side effects; and travel and time costs to women. We did not seek to directly compare results across countries. However, we can draw some lessons by looking at the costs by delivery strategy, especially in Uganda where we assessed three delivery approaches  in two studies conducted in a very similar setting .We then used the cost estimates as input in a follow-up cost-effectiveness study 2We received in-country approval for conducting the costing studies from the Comité d’Ethique pour la Recherche en Santé in Burkina Faso, Mulago Research Ethics Committee of Uganda and Comité National d’Ethique pour la Recherche en Santé of Senegal. We obtained consent to participate in this study from each health worker interviewed.2.1Burkina Faso introduced DMPA-SC through the facility-based delivery strategy in place for DMPA-IM 2.2We conducted four microcosting studies across the three countries. Microcosting is a cost estimation method that involves collecting detailed data on the resources used (input quantities) and the value of those resources (input prices) in the delivery of a health service The direct medical costs for service delivery included the costs of contraceptive commodities, health worker time to deliver family planning services , medical supplies and drugs for the treatment of side effects. For self-injection, we also included the resources used for training women to self-inject: health worker time to train the client and necessary supplies .In addition, we estimated the direct nonmedical costs (women’s travel costs and time) by interviewing women enrolled in the continuation studies . To thisWe estimated the economic costs of contraceptive service delivery to account for donated health commodities as well as for the time of volunteers involved in contraceptive service delivery . We estimated annual costs per couple years of protection (CYP) — equivalent to receiving four injections of these 3-month injectable contraceptives 2.3We estimated health workers’ time costs by multiplying the self-reported time spent with a client for each family planning service by the average salary per minute of the health workers. We included facility-based health worker time costs, valued at the average government salary pay by grade. We valued volunteers’ time using the salary of a nursing assistant. For the Uganda Village Health Teams study, in addition to health workers’ time, we also included time and travel costs for Village Health Teams to reach the communities where they met with women and the travel costs to reach their facility for replenishment of supplies or data reporting.To estimate costs of medical supplies and tests, we asked health workers to list all medical supplies and tests used in the delivery of each contraceptive method and the percentage of women on whom these were used. We calculated the costs by multiplying the quantity of supplies and pregnancy tests used per client with the corresponding unit price Costs of treatment of side effects included the costs of health worker time spent on counseling and/or treating a client experiencing side effects, and the drugs they typically prescribed for treating these side effects. We used similar approaches as described above to calculate the costs for health workers’ time. To calculate drug costs, we multiplied each unit price by the total quantity prescribed for each side effect and by the probability of experiencing the side effect over the first 12 months of use based on data from the continuation studies . We calcTo estimate the costs of medical equipment related to safe disposal of injectable contraceptives, we divided the cost of a safety box by the number of DMPA-SC and DMPA-IM units that could fit in one safety box We estimated costs of training women to self-inject DMPA-SC under a research study design. These costs included the time spent by study health workers to train clients to self-inject and the costs of training material calculated by multiplying the quantity of each supply by the respective unit cost. We estimated costs for retraining women by multiplying the training costs by the percentage of women who were retrained.We adjusted costs of training supplies to better reflect current programmatic implementation in Uganda. Namely, we replaced the self-injection training booklet given to women under the research study with a lower-cost, one-page (front-and-back) training instruction sheet with the same information.We derived travel and time costs for women to receive injectable contraceptives using client-level data collected during method continuation studies We calculated roundtrip transport costs per visit to the facility or Village Health Team using the self-reported data. We calculated annual costs for DMPA-SC or DMPA-IM users by multiplying the costs per visit by four when women went to a facility/Village Health Team for all injections. Instead, for self-injecting women, we included the costs of the first visit and the (minor) costs for subsequent visits in case women sought help at the health facility for side effects.2.4We performed data analysis in Microsoft Excel . We converted costs in local currency to 2016 US$ using annual average exchange rates by country; US$1 corresponded to 3419 Ugandan shillings and 595 West African Francs  3We estimated supplies for self-injection training at $3.60 for Uganda and $3.58 for Senegal before adjustment, with the training booklet ($2.00) accounting for the largest share of the costs. The adjusted training aid costs reflect the replacement of the booklet with the one-page instruction sheet ($0.07), and the estimated self-injection training costs for Uganda and Senegal were $1.70 and $1.68, respectively .Total direct medical costs were lowest for community-based distribution by Village Health Teams in Uganda  because of lower Village Health Teams time costs. Community-based distribution also saved costs for tests and supplies typically used during the first facility visit. In Uganda, the costs were similar for DMPA-IM and DMPA-SC delivered under the same strategy (community-based). We attributed the $0.54 higher cost for four DMPA-SC injections in Burkina Faso relative to DMPA-IM to differences in reported side effects and the associated costs of treatment Women’s time and travel costs estimates ranged from $0.97 to $4.66 across countries and delivery strategies . The lowWhen we included both direct medical costs and direct nonmedical costs, the adjusted total direct costs of self-injection in Uganda and Senegal were lower than the total direct costs of DMPA-IM delivered by facility-based health workers .Fig. 1On4Research studies on DMPA-SC delivery alongside DMPA-IM provided a unique opportunity to analyze the costs of this new contraceptive technology across different delivery strategies. In both Uganda and Burkina Faso, the costs for DMPA-SC were similar to the costs for DMPA-IM when delivered under the same strategy; hence, there is no clear cost advantage of one product over the other. In Uganda, community-based distribution of DMPA injectable contraception resulted in lower costs for both service delivery  and for women  when compared to facility-based DMPA-IM delivery. Bringing contraceptive services closer to women by leveraging and allowing community health workers to provide short-term contraceptives may help increase access to and uptake of contraceptives — especially in rural areas, where women may face higher financial barriers that limit their ability to travel to a facility to receive services The option to self-inject may further reduce financial and logistical barriers for women. Women’s travel and time costs accounted for 32% to 46% of total costs when health workers administered the injections compared to 9% to 20% of total costs when self-administering. As the one-way sensitivity analysis for these Senegal and Uganda self-injection studies showed, there was a much wider range in women’s travel costs over the four injections for women who were receiving DMPA-IM injections from providers than for women who were self-injecting; the relative cost savings for women who self-inject will also vary widely depending on the distance between their home and the facility and, hence, their travel costs.The upfront costs to train women to self-inject can be high, as observed under the research study. As the sensitivity analysis showed, the training aid was an important driver of costs. Simple modifications to the training aid used can reduce client training costs, likely without affecting the quality and effectiveness of the training. As self-injection is offered and scaled up in more settings, these cost drivers can be reduced to make self-injection training more affordable and sustainable.Our cost estimates are comparable with previous study results, which found facility-based delivery of DMPA-IM to cost between $8.50 and $20 per CYP This study had several limitations. First, the study sites that we used for the costing analysis were not representative of their districts or of the country in which the study was set, and the sample sizes were small. The need to select facilities from those involved in the pilot introduction of DMPA-SC or the research study of self-injection drove this limitation. Second, self-reported estimates of health worker and client resources may be inaccurate due to recall bias. In addition, this analysis looked at the annual costs of DMPA (four injections); however, women’s 12-month use of injectable contraception across methods and delivery modalities may differ. Finally, we did not include some delivery or programmatic costs in this study, such as costs for training and supervising health workers to deliver injectables, facility operational and management costs, and supply chain costs.One-way sensitivity analysis for the costs for facility-based delivery of DMPA-SC and DMPA-IM in Burkina Faso.Fig. A1One-way sensitivity analysis for the costs for self-injection of DMPA-SC and facility-based delivery of DMPA-IM in Senegal.Fig. A2The following are the supplementary data related to this article.


Left ventricular pseudoaneurysm is a very rare complication following acute myocardial infarction, which results from a free wall rupture. Hemopericardium and cardiac tamponade caused by rupture of the free wall after acute myocardial infarction are often fatal. It is difficult to fully document the evolution of left ventricular pseudoaneurysm resulted from acute myocardial infarction with conservative treatment.Herein, we followed a 75-year-old female patient for 3 years. Recorded the evolution of the disease: acute lateral myocardial infarction - emergency reperfusion therapy - cardiac rupture - positive successful rescue - the pseudoaneurysm formation - maintaining conservative treatment - gradual enlargement of the pseudoaneurysm - thrombosis in pseudoaneurysm - thrombus filling with pseudoaneurysm - finally stabilized condition - the treatment of coronary revascularization.This case is reported here because of its scarcity, which provides provides us with a complete record of the entire evolution and an astonishing indication of the long-term prognosis of non-surgical treatment for pseudoventricular. Left ventricular pseudoaneurysm is a very rare complication of acute myocardial infarction. Hemopericardium and cardiac tamponade caused by a free wall rupture following the acute myocardial infarction is often fatal. Only a few patients survive and develope left ventricular pseudoaneurysm. Owing to the possibility of death caused by subsequent complete rupture, surgical repair is usually recommended when a left ventricular pseudoaneurysm has been detected. However, we followed a 75-year-old female patient who had a left ventricular pseudoaneurysm for 3 years due to a ruptured left ventricular free wall after an acute myocardial infarction. We recorded the evolution of left ventricular pseudoaneurysm with conservative treatment.A 75-year-old woman was admitted to our hospital for 1 h of persistent severe chest pain. Apart from smoking, she had no cardiac risk factors. At the time of admission, the electrocardiogram showed ST-segment elevation in leads I,avl. Laboratory data showed that the serum creatine kinase and troponin I had elevated. According to the results of electrocardiogram and laboratory data, STEMI was definitly diagnosed. Primary percutaneous coronary intervention (PCI) was indicated immediately. The coronary agiography (CAG) revealed triple vessel disease with left circumflex as the culprit which was occluded in the proximal segment . During the first 2 months of follow-up, the volume of pesudoaneurysm increased to 65 × 55 mm(Fig. 6 months.The symptoms of angina were significantly improved after operation. Our patient continued outpatient follow-up after discharge, and was symptom free. There was no significant change in medication during the 3 years of treatment. Dual antiplatelet therapy was continued for 3 years.Left ventricular free wall rupture is a very serious mechanical complication after AMI with high mortality rate. Myocardial rupture that directly causes death reportedly occurs in 4 to 10% of patients after acute myocardial infarction . CardiacIn this case, the process of left ventricular pseudoaneurysm caused by rupture of left ventricular wall after myocardial infarction was clear. After a long time of follow-up, we were surprised to find that despite the high mortality, the disease could still be self-limiting for a period of time. Thrombus could form in the chamber of the aneurysm and increase gradually. However, it reduced the sustained impact of blood flow on the wall of the pseudoaneurysm. Eventually, the thrombus filled the aneurysm and prevented blood from flowing into the aneurysm from the left ventricular. The patient turned the corner. The dynamic evolution of this case demonstrated the feasibility and long-term benign prognosis of conservative treatment for left ventricular pseudoaneurysm.In one study, 13% of the patients with a left ventricular pseudoaneurysm had systemic embolism as the clinical presentation . In anotThis is a rare case. First of all, timely and accurate treatment in the acute phase saved the life of this patient. Second, after a long period of follow-up, we have obtained the complete evolution of a left ventricular pseudoaneurysm: acute myocardial infarction - cardiac rupture - left ventricular pseudoaneurysm formation - gradual enlargement of the pseudoaneurysm - thrombosis in pseudoaneurysm - thrombus filling with pseudoaneurysm - condition recovery and stability. These data suggest that the evolution process and the long term outcome of the left ventricular pseudoaneurysm may be relatively benign after severe acute pericardial tamponade. Secondary thrombosis in the aneurysm, while increasing the risk of thromboembolism, might be a solution for the aneurysm to repair itself and reduce the risk of fatal rupture in the long term. Therefore, these suggest a possible benign endpoint for long-term prognosis after conservative treatment of left ventricular pseudoaneurysm.


Large bone defects from trauma or cancer are difficult to treat. Current treatment options include the use of external fixation with bone transport, bone grafting, or amputation. These modes of therapy continue to pose challenges as they are associated with high cost, failure, and complication rates. In this study, we report a successful case of bone defect treatment using personalized 3D-printed implant. This is the longest known follow-up using a 3D-printed custom implant for this specific application. Ultimately, this report adds to existing literature as it demonstrates successful and maintained incorporation of bone into the titanium implant. The use of patient-specific 3D-printed implants adds to the available arsenal to treat complex pathologies of the foot and ankle. Moreover, the technology's flexibility and ease of customization makes it conducive to tailor to specific patient needs. Despite advances in modern orthopaedic traumatology, bone loss following high-energy trauma remains a challenge to treat. Traditional treatment modalities include bone transport using an external fixator , cancell3D printing, also called additive manufacturing, is the process of creating digitally designed objects by deposition of materials in sequential layers . This raPreviously, we reported early follow-up on a case of limb salvage using a 3D-printed patient-specific titanium cage in a 46-year-old female who sustained traumatic distal tibia segmental bone loss and multiple additional foot fractures [The 46-year-old female was the driver of a car that rolled over. She sustained an open distal tibia fracture with substantial distal-third tibia bone loss . Other bAmputation and multiple limb salvage options were discussed with the patient and primary surgeon (SBA) via the shared decision-making process. The patient opted to proceed with limb salvage via arthrodesis of the tibia to the hindfoot using a custom 3D-printed titanium cage  and an intramedullary rod. The patient was non-weight bearing for six weeks after surgery. This period was followed by a six-week period of limited weight bearing in a cast. She was then transitioned to full weight bearing in a boot brace over the last six weeks.She was followed closely with routine plain radiographs approximately every 6 to 12 weeks and CT scans every 6 months. By six months after surgery, the patient had returned to special needs elementary school teaching without any ambulatory aids and with regular shoe wear as tolerated. Her only pain was transient heel pad pain from the intramedullary rod insertion site. The patient's most recent follow-up was at 60 months after surgery. Plain radiographs and CT scan  demonstrThe FAAM has two subscales and asks patients to rate their level of functionality. Her responses were as follows. Her FAAM activities of daily living subscale score was 79 , and she rated her functionality during activities of daily living as 85% of her baseline function prior to her injury. Her FAAM sports subscale score was 46 , and she also rated her current level of function during sports-related activities as 85% of what it was prior to her injury. She also responded with a rating of “nearly normal” regarding her current level of function.Her AOFAS ankle-hindfoot scale score was 71 out of 100. She reported “mild, occasional” pain. Most of the reduction in this score came from the loss of sagittal and hindfoot motion.Treating segmental bone loss of the lower extremity has been a major challenge for orthopaedic surgeons. Reconstruction methods with autografts or allografts have had variable success –3, 7, 8.This five-year follow-up report describes successful limb salvage with the use of a FDA-approved and custom-designed 3D-printed titanium implant following segmental bone loss of the foot and ankle. The present decade has seen rapid advancement in 3D printing technologies and increases in applications for medicine, contributing to the growth in available patient-specific and customizable avenues of care. Current applications include patient-specific instrumentation, 3D models for surgery planning, navigational templates, total knee implants, and customizable talar implants –21. 3D pLiterature has demonstrated that the cost of amputations over a lifetime serves as more of a deterrent than previously thought. This discrepancy in cost can be attributed to the use of prosthetics . Costs o3D printing has several disadvantages as well that may preclude custom implants from widespread adoption. First, 3D-printed implants are expensive. However, these technologies have the ability to significantly decrease turnaround times, thus decreasing the need for large inventory stocking and the associated space used to house the unused implants, driving down overhead and healthcare costs. As the technology is more broadly accepted with multiple device companies adopting its usage, its costs will subsequently decrease. Another disadvantage is unknown capacity for bone ingrowth and stress shielding. However, one of the main purposes of this case report was to detail the ability for bone ingrowth and the lack of stress shielding that occurred in this patient . As withAs additive manufacturing technology continues to expand and spreads more widely and as technical experiences are shared, reports of successful use of 3D-printed implants in surgical care are increasing. Hsu and Ellington first reported the use of a 3D-printed titanium cage truss for use in a persistent tibial nonunion with excellent results at one year . LikewisSeveral aspects of this case portended a successful outcome. First, despite severe trauma, the limb was sensate and well perfused. Second, there was no infection. The authors do not encourage the use of this kind of reconstruction in limbs with neurovascular compromise or in the setting of active infection or a history of infection. Finally, the patient was well informed about the potential risks and complications of the procedure and maintained a high compliance with the postoperative protocol.Here, we reported the longest known follow-up of successful implantation and bony incorporation of a 3D-printed patient-specific titanium cage. Large lower extremity bony defects, complex foot and ankle deformities, and high-risk arthrodesis situations can be difficult to treat. These challenging pathologies often require a critical-sized and/or shaped structural bone void filler which may not be available with autograft or allograft bone. The use of patient-specific 3D-printed titanium implants offers a new technology that can address a variety of bone defects and deformities to successfully treat a variety of difficult to treat pathologies in foot and ankle and lower extremity surgery. Furthermore, the flexibility and ease of customization of implants allow for patient-specific needs to be met and planned for preoperatively. The case presented herein is the first published observation of long-term success for the treatment of large bone defect using a 3D-printed implant. Thus, the techniques used in this case were not based on prior established evidence. The surgical interventions utilized here are not mainstream and, as such, should be used with caution when considered in the treatment of other patients.


Cardiopulmonary arrest may result in high mortality rate in hospitals where the rapid response team is not implemented. A rapid response system can recognize patients at high risk of cardiopulmonary arrest and provide the needed medical management to prevent further deterioration. The rapid response system has shown a dramatic reduction in mortality rate and cardiopulmonary arrest.To evaluate the effectiveness of the rapid response team (RRT) implementation in reducing the mortality rate, number of cardiopulmonary arrests, and number of ICU admission.A pre- and post-rapid response team system implementation.Four tertiary private hospitals in Saudi Arabia.A total of 154,869 patients in the 3-year before rapid response system period (January 2010 to December 2012) and a total of 466,161 during the 2.5-year post-RRT implementation period (January 2014 to June 2016).Results indicated that ward nurses activated RRT more often than physicians (1104 activations [69%] vs. 499 activations [31%]), with cardiovascular and respiratory abnormalities being the most common triggers. Serious concern about the patient condition by the ward staff was the trigger for 181 (11.29%) activations. The RRT provided a variety of diagnostic and therapeutic interventions. Most patients cared for by RRT were admitted to ICU 1103 (68.81%), and the rest 500 (31.19%) were managed in the ward. After the implementation of the RRT project, the hospital mortality rate dropped from 7.8 to 2.8 per 1000 hospital admission. Hospital cardiopulmonary arrest rate has dropped from 10.53 per 1000 hospital admissions to 2.58. Rapid response team implementation also facilitated end-of-life care discussions.Implementation of the RRT project has shown a dramatic reduction in the total ICU admissions, average ICU occupancy rate, total hospital mortality, and total ICU mortality. These findings reinforce the evidence that RRT implementation is effective in reducing hospital mortality and cardiopulmonary arrest rates in addition to other outcomes related to healthcare quality. The study was conducted in four tertiary private hospitals with a relatively good sample size.The study evaluation of only adult pre- and post-ICU excluding pediatric ICU and CCU.The study lacks robustness to assumption as the study was conducted in private hospitals in Saudi Arabia where public hospitals may further add to the study findings.Rapid response team (RRT) system is implemented to identify the deteriorating hospitalized patients who show clinical warning signs –3. The rAlthough the rapid response system concept has been largely adopted and endorsed, evidence supporting its effectiveness comes mainly from non-randomized short-term studies where pre- and post-implementation of RRT are compared , 5–8. InIn a recent systematic review and meta-analysis study conducted by Mahraj, Raffaele, and Wendon, they reviewed 29 studies including randomized controlled trials and pre-post rapid response team system implementation . The resFurthermore, implementation of a rapid response team may skill the hospital ward staff. A hypothesis was approved by nurses surveyed in two studies which were conducted in Canada and Australia , 12. SevThis is a prospective cohort pre- and post-rapid response team implementation study. Data was retrieved from the pre-RRT 36-month period (January 2010 to December 2012) and was compared to post-RRT 30-month period (January 2014 to June 2016). The study was conducted in four private tertiary hospitals in total which provide general and tertiary clinical services. The 118-bed medical-surgical ICU admits approximately 1000 patients yearly and is managed as a closed unit by board-certified critical care consultants on a 24/7 in-house basis along with specialist and residents.In the pre-RRT period, the response to unstable patients in hospital wards followed a traditional hierarchy starting from the bedside nurse escalating in a stepwise approach to the “first-on-call” physician, the senior resident, and then the attending physician with several cycles of evaluation and management. The ICU team involvement was typically sought later and followed a similar hierarchy.The RRT intervention was implemented as a plan-do-study-act project with the aim of reducing unanticipated non-ICU cardiopulmonary arrests and reducing ICU morbidity and mortality. Preparation for RRT implementation started in August 2013.RRT was structured as a system of four components: (1) The system consisted of afferent component that included the process of event detection and response triggering. (2) The efferent component was led by a trained intensivist , an ICU nurse, and a respiratory therapist. (3) The quality improvement component involved the development of a database to monitor the RRT activations and their outcomes. (4) The administrative component consisting of the RRT committee oversaw the function of the intervention and reported to hospital administration.The composition of the rapid response team includes primary nurse, unit charge nurse, ICU specialist, ICU nurse, respiratory therapist, ICU on-call consultant, and an on-duty nursing supervisor. RRT is led by an intensivist, and patients will be followed up for 48 h post-ICU admission. The calling criteria are based on the presence of any abnormality and derangements in vital signs. The roles of the rapid response team involve the administration of oxygen, intravenous fluids, bronchodilators, and respiratory therapy. RRT performs CPR if needed, decides whether to manage the patient in the ward or transfer them to the ICU, and facilitate the discussion about end-of-life care.Data was obtained from the hospital information system, from the records of the cardiopulmonary resuscitation committee, and from the prospectively collected ICU and RRT databases. Outcomes to be assessed were included: we compared the pre- and post-RRT period total hospital admission, total ICU admission, average ICU occupancy rate, total hospital mortality, and total ICU mortality. We also analyzed the RRT data such as demography, RRT activation personnel (doctor or nurse), RRT triggers, RRT intervention, and mortality (patient died in the ICU and in the ward).t test and chi-square test were used to compare the differences between the groups. Relative risk (RR) and 95% confidence intervals (CIs) were reported for categorical outcomes. The p value of ≤ 0.05 was considered to be statistically significant.All statistical analyses were performed using the SAS software . The Student p < 0.0001).The primary outcomes were hospital mortality and in-patient (non-ICU) cardiopulmonary arrest activation rate. There were a total of 154,869 hospital admissions and a total of 466,161 post-hospital admissions in the pre-RRT and post-RRT implementation, respectively. After RRT implementation, there were 1603 RRT activations which lead to a decrease in ICU admission from 44.65 to 20.70 per 1000 hospital admissions  (Tables p < 0.0001). ICU cardiopulmonary arrest decreased from 115.7 to 48.8 per 1000 hospital admissions . The patients intubated in the ICU increased from 119 to 179 per 1000 ICU admissions (p < 0.0001).Non-ICU cardiopulmonary arrests decreased from 10.53 to 2. 58 per 1000 hospital admissions  in the present study got transferred to the ICU, whereas only the rest of the patients were admitted in the ward. As per the discussion, following the rapid response team implementation of the system has shown facilitation of end-of-life care discussion.p < 0.0001). Nevertheless, another study found also that the number of ICU admissions was decreased after the implementation of the RRT system [The impact of the rapid response system on ICU workflow is extremely significant. Many of the previously reviewed studies were not able to show the impact of the rapid response system activation on the number of ICU admissions –18. The T system .The present study extends the findings of other studies which investigated the reduction in the mortality rate following the implementation of the RRT system. Similarly, other studies have also shown a reduction in the mortality rate , 17–20).–20.17–20Previous studies showed that the composition of the rapid response team is uncertain –23. ThosThe findings of the current study should be interpreted taking into considerations the strengths and limitations of the investigation. The study was conducted in four tertiary private hospitals with a relatively good sample size. The limitations include the study evaluation of only adult pre- and post-ICU excluding pediatric ICU and CCU. The study lacks robustness to assumption as the study was conducted in private hospitals in Saudi Arabia where public hospitals may further add to the study findings. Additional studies are needed to confirm the effect of rapid response team system implementation utilizing multisite, cluster-randomized controlled trial designs rather than pre-post implementation designs.In conclusion, the implementation of the rapid response team system was significantly associated with a reduction in hospital-wide mortality rate, ICU mortality, and cardiopulmonary arrests. The study demonstrated that the activation of the rapid response team system was associated with the reduction of ICU admission. The findings showed also the practice was effective in improving patient outcomes and quality parameters and facilitating end-of-life care discussions. Further investigations are needed to evaluate the efficacy of the rapid response teams’ system implementation over time and study the specific factors that may diminish its effectiveness.


Paper-based lateral flow devices (LFDs) are regarded as ideal low-cost diagnostic solutions for point-of-care (POC) scenarios that allow rapid detection of a single analyte within a fluidic sample, and have been in common use for a decade. In recent years, there has been an increasing need for rapid and simultaneous detection of multiple analytes present within a single sample and to facilitate this, we report here a novel solution—detection using a multi-path LFD created via the precise partitioning of the single flow-path of a standard LFD using our previously reported laser direct-write (LDW) technique. The multiple flow-paths allow the simultaneous detection of the different analytes individually within each of the parallel channels without any cross-reactivity. The appearance of coloured test lines in individual channels indicates the presence of the different analytes within a sample. We successfully present the use of a LDW-patterned multi-path LFD for multiplexed detection of a biomarker panel comprising C-reactive protein (CRP) and Serum amyloid A-1 (SAA1), used for the diagnosis of bacterial infections. Overall, we demonstrate the use of our LDW technique in the creation of a novel LFD that enables multiplexed detection of two inflammation markers within a single LFD providing a detection protocol that is comparatively more efficient than the standard sequential multiplexing procedure. Across a wide range of fields that include not just clinical diagnostics but also areas such as food safety testing and environmental assessment etc., the need for simple point-of-care (POC) testing solutions has become increasingly evident in recent years ,2,3. TheSignificant effort has therefore been made to develop such biosensors and one such example is paper-based microfluidic devices, which promise to satisfy these requirements. Their inherent advantages such as low-cost, ease of use, portability, requiring small sample volumes and no additional need for laboratory equipment and trained personnel have attracted attention within the diagnostics research domain as a low-cost alternative to conventional POC diagnostic tools ,6,7.Rapid Diagnostic Test (RDT) strips, also known as lateral flow devices (LFDs) are one of the simplest and most established formats of paper-based devices that allow the detection of an analyte through the testing of a complex bodily fluid such as urine, blood, saliva or even sweat ,9,10,11.Multiplexing, which is defined as simultaneous analysis of multiple analytes under the same set of conditions, is a critical parameter for increasing diagnostic efficiency . An obviCurrently, LFDs that provide such multiplexing are constructed either by laminating or shaping together different individual LFDs ,23 or alIn this article, we propose a novel solution to overcome both of these limitations—a multi-path LFD created via the precise partitioning of the flow-path of a single LFD using a laser direct-write (LDW) technique. The multiple flow-paths allow individual detection of different analytes in each of the separated channels. We successfully demonstrate the use of these LDW-fabricated multi-path LFDs for simultaneous detection of a biomarker panel comprising C-reactive protein (CRP) and Serum amyloid A-1 (SAA1), commonly used for the diagnosis of bacterial infections. Unlike other multiplexing methods, our approach that is presented here, allows the creation of multiple individual flow-paths inside a ‘single’ LFD without increasing its original size. These multiplexed tests do not require multiple inlets and an increased sample volume, and, most importantly, eliminate the interference between individual detection sites positioned within the same channel. Overall, we believe that our LDW approach provides a novel and easy-implementable solution for enabling multiplexed detection via LFDs that hugely improves the detection efficiency and will therefore lead to an increase in the current market-size of LFD-based testing within in-vitro diagnostics.As shown in the schematic in The boundaries that separate these individual channels were created using our previously reported local-deposition-assisted LDW technique ,27,28. T® 3471-3-14 from DSM Desotech, Inc., Elgin, IL, USA. The dispenser platform used for the local deposition of the photopolymer onto the various substrates was a PICO® Pµlse™ dispensing system from Nordson EFD, UK. A different reagent-dispensing system was used for local deposition of antibodies onto the reaction pad for creation of test lines and control line and that was the XYZ3210 dispense platform from Biodot, Irvine, CA, USA.The laser used for this LDW process was a 405 nm continuous wave (c.w.) diode laser  with a maximum output power of 110 mW). The photopolymer used for creating the boundary walls between individual channels was DeSoliteE. coli (Sigma Aldrich C1617). For the SAA1 assay, both the capture and detection antibodies and also the protein standard used were from a DuoSet ELISA kit (DY3019) from R&D Systems. The control line antibody was anti-mouse Goat IgG (AF007) from R&D Systems. The streptavidin-conjugated gold nanoparticles  were obtained from BBI solutions (BA.STP40). The diluent used for preparing all the antibody and sample solutions was 1% BSA in PBS. The bovine serum albumin (BSA) (A2058) and phosphate buffered saline (PBS) (P3831) used were obtained from Sigma Aldrich, Gillingham, UK.The nitrocellulose membrane used as the reaction pad was UniSart CN95 purchased from Sartorius and the absorbent pad was cellulose filter papers (CF1) from GE Healthcare. For the CRP assay, the capture and detection antibodies used were mouse anti-human CRP antibody (MAB17071) and biotinylated mouse anti-human CRP antibody (BAM17072) from R&D Systems, Abingdon, UK. The protein standard was recombinant human CRP expressed in Prior to developing the multiplexed LFD, we first demonstrated the successful implementation of single assays on a standard LFD using a sandwich ELISA for the two identified biomarkers (CRP and SAA1) commonly used as indicators of an inflammation. The protocol for the sandwich-ELISA we have used is described in The arrangement of a simplified standard lateral-flow strip that we used for these single detections is as shown in The operation of this LFD is described in We first studied the detection of CRP using single LFDs. The capture antibody (mouse anti-human CRP at 1 mg/mL) was locally deposited onto the reaction pad as a line using the BioDot dispenser and left to dry and immobilise overnight. A mixture of the sample , the detection antibody (biotinylated mouse anti-human CRP at 1.6 μg/mL), and the streptavidin-modified 40 nm Au-nanoparticles in a volumetric ratio of 3:2:4  was first prepared immediately prior to the testing with the single LFDs.To perform the test, 15 μL of the mixture was added into a well of a 96-well microtiter plate and then the LFD was dipped into the sample solution. The device was left to run for 3 min to allow all of the solution in the well to be wicked into the strip. The device was subsequently dipped in a chase buffer of PBS solution for another 5 min to allow the entire reagent to be pushed through to the reaction pad. The result was then immediately captured using a scanner (Epson Perfection V800 Photo A4 Flatbed Scanner). The resultant, appearance of the red-coloured test lines are as shown in The images captured using the scanner were processed with the ImageJ software  to extract the respective colour intensities of the red colour produced at the test lines. The resultant plot in The results above show the successful detection of CRP using a standard single flow-path LFD. From the plot in Following the experiments for the CRP detection using standard single-channel LFDs, in a similar manner, we then tested their use for detection of SAA1. These LFDs had the same device geometry as those used previously for the CRP testing. The capture antibody used was mouse anti-human SAA1 at 1 mg/mL. The sample mixture was prepared by mixing of the sample , the detection antibody (biotinylated mouse anti-human SAA1 at 12 μg/mL) and the Au-nanoparticles (streptavidin-modified 40 nm gold nanoparticles) in a volumetric ratio of 3:2:4.The tests were performed in the same way as described for CRP testing by dipping the LFDs into the sample-containing well followed by dipping in a chase buffer. The results are shown in the scanned image in From both the images in The clinically relevant ranges for CRP and SAA1 are 50 ng/mL to 500 µg/mL  and 1 µgAfter demonstrating the successful detection of the above two analytes in separate LFDs, we then attempted their combined detection using a single-channel multiplexed LFD via the introduction of multiple detection lines within the common reaction zone of a standard single LFD.As shown in Based on the results from our previous section, for these experiments we chose to test for concentrations of 100 ng/mL and 1 µg/mL for CRP and SAA1 respectively, which as shown in To perform the tests, we have use an identical volume of 15 µL for the sample-reagent mixture and the results are shown in the scanned image in Based on these results we can infer that the second test line is affected by the presence of a first test line positioned prior to it in the flow-path. To further confirm this hypothesis, we then used the same devices and reversed the position of the two test lines, as shown in These results clearly confirmed here the problem of undesired interference between sequential detection sites positioned within a common flow-path, namely, the influence of a test-line on subsequent lines positioned further along the flow-path. This represents a key barrier to the use of such a single-channel LFD with sequentially positioned test lines as an appropriate tool for multiplexed detection. An alternative, as proposed by others to achieve multiplexed LFDs is to laminate or shape together different individual LFDs. However, this leads to an increased device footprint and therefore requires larger sample volumes, which is also undesirable, especially when working with samples such as blood or saliva etc. that normally are available in limited volumes.To solve this problem of interference, we propose herein the use of our LDW method for creation of multiple flow-paths in a standard single LFD that allows isolation of each of those different detection sites, without increasing the overall dimension of the original device.As shown in the schematic in The tests were performed in the same way as for the previous multiplexed test single-channel LFD by dipping the strip into a 15 µL sample-reagent mixture and the results are shown in To further confirm the above observations, the colour intensities of the test lines in these LDW-patterned dual-channel LFDs were measured and then compared with those acquired for both the standard single LFDs and single-channel multiplexed LFDs. The three concentrations used for these comparisons were 50 ng/mL, 100 ng/mL and 1 µg/mL for both CRP and SAA1. These results are shown in the plots in Overall, as anticipated, these results conclusively confirm that there is no interference between two test lines placed within the individual channels of the dual-channel LFD, because both detections are implemented independently in parallel channels rather than in series within a single channel. Additionally, by patterning more than a single barrier in the reaction pad more flow-paths can be created hence allowing multiplexing of more than this proof-of-principle dual assay. In the current dual-channel LFDs, the laser-patterned barrier walls have dimensions of ~500 µm, however, this can be reduced to have dimensions of ~200 µm if desired. It is therefore then possible to pattern a greater number of fluidic flow-paths while maintaining the widths of our LFDs to be similar to that of a standard single LFD (that has a width of ~5mm)―allowing detection of not two, but a greater number of analytes from within the same sample.In conclusion, we have proposed a novel solution to achieve multiplexed diagnosis in LFDs that overcomes the limitations of current techniques including either interference of multiple test sites positioned in the same flow-path or increased device dimensions that require larger sample volumes. We have developed a LDW technique that allows creation of multiple flow-paths in a single LFD simply via the precise partition of the flow-path of a single LFD. The multiple isolated parallel flow-paths then allow individual detection of the different analytes in each of the separated channels without interference or cross-reaction. As a proof of principle, we have shown the successful use of a dual-channel LFD for multiplexed detection of a biomarker panel comprising CRP and SAA1, used commonly for the diagnosis of bacterial infections. The results show that our laser-patterned LFDs performed equally well as the single LFDs and do not need increased device dimensions or additional sample volumes. Overall, we believe that when compared to the current multiplexed detection procedures our technique offers a better solution for multiplexed detection within LFDs.


Assess the Five Times Sit-to-Stand Test safety and clinimetric properties inolder patients hospitalized in an intensive care unit.Test safety was assessed according to the incidence of adverse events andthrough hemodynamic and respiratory data. Additionally, reliabilityproperties were investigated using the intraclass correlation coefficients,standard error of measurement, standard error percentage change,Altman-Bland plot and a survival agreement plot.The overall suitability of the Five Times Sit-to-Stand Test was found to below, with 29.8% meeting the inclusion criteria. Only 44% of the hospitalizedpatients who met the inclusion criteria performed the test, with no need fordiscontinuation in any patient. Heart rate  and systolic blood pressure  were the only variables thatpresented a significant statistical increase, with no evidence ofexacerbated response to the test. Additionally, no adverse events werereported from participating and both test-retest and interrater reliabilitywere high (intraclass correlation coefficient ≥ 0.99).The Five Times Sit-to-Stand Test was proven to be safe and to have excellentreliability. Its clinical use, however, may be restricted tohigh-functioning older adults in hospital settings. Accordingly, the Five Times Sit-to-Stand Test (FTSST) is considered to bea useful, consistent and low-cost tool to assess sit-to-standability.(3) The FTSST measures the time taken to stand fivetimes from a sitting position as quickly as possible. Researchers have described itsuse as a measure of lower limb strength,(4) balance control,(5) fallrisk(6) and exercise capacity.(7) Slower sit-to-standtimes have been linked to an increased risk for recurrentfalls,(8) slow gait speed(9) and deficits in otherADL living in community-dwelling older people.(10) Furthermore, reduced exercise capacityand muscle force in the quadriceps have been found in chronic obstructivepulmonary disease patients who were unable to complete theFTSST.(7)A sit-to-stand (STS) movement is considered a fundamental prerequisite for mobilityand functional independence, since the movement is part of the various Activities ofDaily Living (ADL).(11) stroke,(13) Parkinson's disease(14) and backpain,(15) as well as in older hospitalizedsubjects,(16) an evaluation of the safety, reliability andvalidity of the FTSST in older subjects within the intensive care unit (ICU) settinghas not yet been conducted. Moreover, few studies have assessed the hemodynamic,respiratory and metabolic functioning of patients performing the FTSST.Although past research has produced normative values and data on predictive andconcurrent validity and test reliability when used for patients withosteoarthritis,The FTSST has potential to be a valuable tool for clinicians seeking a bedside toolto assess sit-to-stand ability for older hospitalized patients. Such a tool mightcomplement other resources when identifying walking capacity, fall risk, andfunctional independence recovery in this setting. Thus, this study had a twofoldpurpose: (a) to establish the safety of applying the FTSST on discharge from acritical care unit within a hospital setting, and (b) to determine FTSST test-retestand interrater reliability when used with older patients being discharged from acritical care hospital unit.Hospital Teresa Lisieux, in Salvador, Brazil. We recruited aconvenience sample of 96 patients, of both genders, who were greater than or equalto age 60 years, discharged from the general ICU to the hospital ward at studyentry. The study was approved by the Human Research Ethics Committee of theUniversidade Salvador (UNIFACS) - Salvador, Brazil, underprotocol no. 1.047.232, and all participants provided informed written consent toparticipate.This cross-sectional study was conducted between July and December 2015 at2) at rest ≥ 92% without oxygen supplementation andreceived medical authorization to perform the FTSST.All participants were aged ≥ 60 years, were able to sit and stand withoutassistance, had clinical and hemodynamic stability - resting heart rate (HR) from 60to 100bpm, had systolic blood pressure (SBP) < 160mmHg/diastolic < 100mmHgwithout using vasoactive drugs, had oxyhemoglobin saturation by pulse oximetry > 22 incursions per minute(ipm), HR > 120 beats per minute (BPM), systolic blood pressure (SBP) >180mmHg and/or diastolic blood pressure (DBP) > 100mmHg and subjective perceptionof exertion > 13 evaluated by the Borg Scale of perceivedexertion.(17)Patients were excluded if they had any (a) substantial pain that might affectparticipation, (b) cognitive impairment that led them to be unable to understand thetest instructions, or (c) presence of fever, unstable angina, cardiac arrhythmias,cardiac resynchronization therapy, myocardial infarction within the last 2 months,unstable heart or respiratory disease. Clinical staff were instructed to discontinuethe test if patients presented a SpOTwo trained senior physiotherapists administered the test when patients were beingdischarged from the intensive care unit and transferred into the hospital ward. Weassessed the safety of the FTSST as defined by an absence of exacerbated hemodynamicand respiratory response or adverse events such as dizziness, fall, dyspnea, chestpain or musculoskeletal pain.® multiparameter monitor  wasused to record demographic, clinical and vital signs data , as well as a printed version of the Borg Scale ofperceived exertion in a traditional version.A Dixtal(18) In this study, tests were administered threetimes on the same day, with a minimum interval of 30 minutes for recoverybetween each test run, yielding an average result between tests. An untimedtrial was given with the objective of reducing the risk of learning effects forall patients.The FTSST reproduces the act of sitting and standing for five repetitions asrapidly as possible.(19) Each participant was instructed to cross theirarms over their chest and sit with their back against the upright backrest ofthe chair. The rater then demonstrated the correct technique to perform thetest, including coming to a full stand, defined as an upright trunk with hipsand knees extended. Timing began when the rater spoke the word "go" and stoppedwhen the participant's buttocks reached the seat following the fifthstand.(14) The raters required the patients to stand andsit five times "as quickly as possible" without physical assistance. Words ofencouragement or body language to speed up were not used so that the patientscould choose their own intensity of exercise. If the participants stopped duringthe test to rest, the raters would say, "You can stay seated if you would likeand then continue standing whenever you feel able" and would not stop the timer.If the patient stopped before the 5 times and refused to continue, we registeredthe reason for stopping prematurely and excluded the participant's score fromanalysis.The participants began the FTSST test sitting in an armless chair with a seatheight of 43cm.The test performance was based on its duration; consequently, the shorter timetaken by the patient, the better their functional condition would be. Vitalsigns were measured at the beginning and end of test, and the frequency ofadverse events was recorded in a specific instrument.® SPSS®, v.22.0, Armonk, NY, USA) and Microsoft Excel 2011 . The Kolmogorov-Smirnov test was used to evaluate the normality of thedata. Student's t-test for paired samples was used to test whether hemodynamicand respiratory variable responses before and after the test were significantlydifferent. We performed a one-way ANOVA to analyze possible differences betweentrials. We determined test-retest and interexaminer reliability by using theintraclass correlation coefficients (ICCs), Altman-Bland plot and survivalagreement plot. Intraclass correlation coefficients were calculated using atwo-way random effects consistency model.Statistical analyses were conducted with Statistical Package for Social Science(SPSS) software version 22.0 (IBM(20) 2003, proposed a new graphic approach tocomplement the Altman-Bland method for agreement analysis. It allows a simpleinterpretation of agreement that takes into account the limits of tolerancebased on clinical importance. This new approach uses the Kaplan-Meier method,which is normally used for the analysis of survival data, and thus, the authorshave named this approach a survival-agreement plot. The data analyzed wereconsidered statistically significant when p ≤ 0.05.Luiz et al.,Clinical and demographic data of the studied population are presented in We performed 288 measurements of the FTSST, with no reports for discontinuationneeded. Hemodynamic and respiratory variables were investigated to determine thesafety of the test .The only variables that were significantly higher after the test were HR  and SBP ; however these modifications did notlead to any adverse events.The mean of the FTSST times for each trial, as well as reliability and standarderror of the measurements (SEMs), are presented in The means of the FTSST times for each trial were similar, and one-way ANOVArevealed no significant difference between them (p = 0.43). The test-retestreliability  and interrater reliability  of theFTSST were shown to be excellent. The SEMs for the test-retest and interratermeasures were computed to be 0.68 and 0.69 seconds, with SEM percentage change(SEM%) of 4.6% and 4.5%, respectively.Furthermore, a visual inspection of the Altman-Bland plot  revealedThe purpose of this study was to determine safety, test-retest and interraterreliability of the FTSST in older hospitalized patients being discharged from ageneral critical care unit to hospital wards. Initially, we observed a low overallrate of patients suitable for the test (29.8%), as well as a low number of patientsenrolled in the study (43.8%), considering all patients who met the inclusioncriteria. Although current literature information concerning FTSST suitability ratesin populations previously investigated is insufficient, a low suitability rate couldpossibly reflect that the use of FTSST was restricted to a very specific population.Interestingly, 123 patients (57.2%) physically able to perform tests were notenrolled, mainly due to the failure to obtain informed consent for the study.Factors related to refusal were not investigated, however, concern for their currenthealth status and hospitalization could be linked to this finding.(21) also reported the absence of adverse events,including falls in individuals with mild to moderate Alzheimer's disease.Additionally, as seen in (22) which compared 3sit-to-stand test  modalities and found that markedchanges in SPO2, HR, blood pressure, dyspnea and leg fatigue were onlyfound after the 1 minute type.The results showed the test to be safe, as analyzed by hemodynamic and respiratoryvariable responses (pre- and posttest) and the absence of adverse events. A studypublished by Suttanon et al.,(24) The high interraterand test-retest reliability is possibly related to straightforward testinstructions, the researchers' experience and the objective nature of the testassessment as stated by Teo et al.(25)Regarding test reliability, the results revealed excellent test-retest and interraterreliability, with low percentages of error measurement, as demonstrated by severalreliability methods, including ICCs, visual inspection of the Altman-Bland plot anda survival agreement plot. This finding is in accordance with other studies thathave investigated FTSST test-retest and interraterreliability.(26) In comparison with these results, in thecurrent research, the mean time of the test was higher (14.98 ± 9.6 s) thanfor community-based individuals of a similar age group.(22) Several factors suchas chair height, muscle force, use of footwear and trunk, knee and foot position areconsidered determinants of the sit-to-stand movement and thus influenceperformance.(27) Moreover, factors including bed rest duringhospitalization, malnutrition, isolation, decrease in muscle mass and otherphysiologic changes related to bed rest, contributed to overallweakness(28) and hence, poorer performance. Therefore, originalstudies are essential to broadly investigate an association between performanceduring the test, hospitalization process and clinical features.To date, no data have been referenced in respect to older hospitalized individuals.In a meta-analysis, reference values were established depending on the age group asperforming "worse than the average": 11.4 s (60 - 69 years), 12.6 s (70 - 79 years)and 14.8 s (80 - 89 years).(29) previously reported that the sit-to-stand test hasbeen administered in the ICU when performing the Short Physical Performance Battery(SPPB). However, there have been no published studies specifically examining theclinimetric properties of either the SPPB test or the FTSST within an ICU setting.The study of the FTSST's clinical applicability through the safety and reliabilityof measurements is essential to allow a more accurate analysis of functionalrecovery in older individuals with critical illness.The present study is a pioneer investigation of FTSST applicability in olderBrazilian individuals in a hospital scenario admitted to an intensive care unit.Files et al.,This test may therefore be helpful as a tool for the risk management of falls andfunctional decline in hospitalized patients. Innovative studies are necessary todetermine its validity and responsiveness in order to establish the fall risk andfunctional status in this population. Some limitations of the study include the useof a convenience sample and the absence of a power analysis for sample sizedetermination.Based on the consolidated findings presented, it appears that the Five TimesSit-to-Stand Test is a safe test to be applied to high functioning older individualsat the time of intensive care unit discharge. The Five Times Sit-to-Stand Testpresented high interrater and test-retest reliability, and patients recentlydischarged from intensive care presented a higher score than other previouslyanalyzed populations.


This therefore suggests that small bandgap polymers can suffer from short exciton lifetimes, which may limit their performance in organic solar cell devices. In addition, the impact of film crystallinity on the exciton lifetime was assessed for a small bandgap diketopyrrolopyrrole co-polymer. It is observed that the increase of polymer film crystallinity leads to reduction in exciton lifetime and optical bandgap again in agreement with the Energy Gap Law.The lifetime of singlet excitons in conjugated polymer films is a key factor taken into account during organic solar cell device optimization. It determines the singlet exciton diffusion lengths in polymer films and has a direct impact on the photocurrent generation by organic solar cell devices. However, very little is known about the material properties controlling the lifetimes of singlet excitons, with most of our knowledge originating from studies of small organic molecules. Herein, we provide a brief summary of the nature of the excited states in conjugated polymer films and then present an analysis of the singlet exciton lifetimes of 16 semiconducting polymers. The exciton lifetimes of seven of the studied polymers were measured using ultrafast transient absorption spectroscopy and compared to the lifetimes of seven of the most common photoactive polymers found in the literature. A plot of the logarithm of the rate of exciton decay  Organic solar cells (OSC) have power conversion efficiencies that are now surpassing 11% which is a five-fold increase from the efficiency of the first reported OSC device 30 years ago ,3. Howevalt-co--2,5-dihydro-2,5-di(2-octyldodecyl)pyrrolopyrrolo-1,4-dione-5,5′-diyl)]) with different molecular weights were characterized to assess the impact of film crystallinity on the exciton lifetime.Polymer singlet excitons are the precursors for charge photogeneration taking place at the D-A interface and despite of their importance for OSC performance, relatively little is known about their properties and how we can control them. In particular, there are not clear strategies for the optimization of the exciton lifetime in conjugated polymer films. Therefore, the aim of this work is to provide an analysis of the singlet exciton lifetimes of 16 different conjugated polymers and to test the validity of the Energy Gap Law in thin polymer films ,10. The The excited states of conjugated polymers are coulombically-bound electron-hole pairs that resemble molecular excited states . They arSinglet excitons can be broadly classified as intrachain and interchain ,16,17. IIn addition to intrachain excited states, many conjugated polymers including co-polymers form interchain excited states that can be thought of as the excitons generated in molecular crystals, where the excitation can be shared between neighboring chromophores . These oet al. have also pointed out that in addition to excimers and excitons, polymer films generate a low yield of long-lived polaron states pyrrolo-1,4-dione-5,5′-diyl)];BTT-DPP : Polythiophen]-5,5′-diyl]];DPP-TT-T : Poly[[2alt-];SiIDT-BT : Poly;SiIDT-2FBT : Poly;SiIDT-TPD synthesis is provided in the SI : Poly;PCDTBT: poly;PCPDTBT: Polydithiophene)-PFO: Poly;PTB7: Polyoxy]benzodithiophene-2,6-diyl}{3-fluoro-2-[(2-ethylhexyl)carbonyl]thienothiophenediyl});MEH-PPV: Poly.The thin polymer films were fabricated via spin-coating from chlorobenzene or di-chlorobenzene solutions on glass substrates. The absorption spectra of the films were measured with a PerkinElmer Lambda 25 spectrometer in air. The optical bandgaps of the films were estimated from the onset of the lowest absorption peak.Femtosecond transient absorption spectroscopy was carried out using a commercially available transient absorption spectrometer, HELIOS . Samples were excited with light pulses with a wavelength matching the lowest energy absorption maxima of the polymers. The excitation was generated by an optical parametric amplifier, TOPAS  seeded with the output of an 800 nm, ~100 fs, 1kHz Solstice Ti:sapphire regenerative amplifier . The probe pulses were generated in a sapphire plate and detected with an InGaAs CMOS camera.vs. the optical bandgap of all thin polymer films presented in 1 to S0 transition in the polymers examined here. The exciton lifetime of PFO is corrected using Equation (2) for the high QY of this polymer (53%); it, therefore, represents the non-radiative recombination decay of the PFO singlet exciton. A similar correction was carried out for PCPDTBT (QY of 6%) [Y of 6%) ,67, alth−1) is extracted [According to the Energy Gap Law, the slope of the linear fit (γ) depends on the geometrical rearrangements experienced by the polymers during their non-radiative decay from the excited to the ground state. It also includes the maximum energy vibration involved in the decay. Considering the relatively low confidence in the fit in xtracted ; thus, s−1 which is in a good agreement with previously published values for molecules and polymers [To test the importance of film crystallinity on the exciton lifetime, three BTT-DPP polymers with differing molecular weights were studied using transient absorption spectroscopy . Previoupolymers . This inThe results presented herein have a particular significance for the development of materials for OSC, especially in lights of the extensive number of small bandgap materials with absorption up to and beyond 900 nanometres reported over the past five years. They suggest that smaller bandgap polymers should generally exhibit shorter exciton lifetimes than higher bandgap polymers because of an increase in their rate of non-radiative exciton decay that follows the Energy Gap Law. This reveals a fundamental limitation of small bandgap polymers for their use in OSC devices as light harvesting materials. Indeed, recent reports of small bandgap materials have shown that incomplete exciton dissociation is a key limiting factor for their device photocurrent generation properties ,72.Our analyses of the exciton lifetimes generate high variance plots with medium confidence fits which suggest that in addition to the bandgap there are other material parameters that control the exciton lifetimes. There are multiple possibilities, of which the most obvious ones are the diversity of chemical structures between the polymers used, the presence of different heteroatoms in their structures and the differences in film order/crystallinity. These factors may lead to the population of very different in nature excited states that may result in different exciton lifetimes, as discussed in


Cell-cell adhesion molecules (cadherins) and cell-extracellular matrix adhesion proteins (integrins) play a critical role in the regulation of cancer invasion and metastasis. Although significant progress has been made in the characterization of multiple members of the cadherin superfamily, most of the published work continues to focus in the switch E-/N-cadherin and its role in the epithelial–mesenchymal transition. Here, we will discuss the structural and functional properties of a subset of cadherins  that have an RGD motif in the extracellular domains. This RGD motif is critical for the interaction with α2β1 integrin and posterior integrin pathway activation in cancer metastatic cells. However, other signaling pathways seem to be affected by RGD cadherin interactions, as will be discussed. The range of solid tumors with overexpression or “de novo” expression of one or more of these three cadherins is very wide , underscoring the relevance of these cadherins in cancer metastasis. Finally, we will discuss different evidences that support the therapeutic use of these cadherins by blocking their capacity to work as integrin ligands in order to develop new cures for metastatic patients. Metastasis initiation is enabled by cellular plasticity, including the mesenchymal-to-epithelial transition (MET) and the gain of stem-cell-like properties by cells in the metastatic organ site . Organ-sDespite the increasing number of publications describing the association of other cadherins which are different to E- and N-cadherin in terms of cancer development and progression, the characterization of these alternative cadherins remains poorly investigated. In this review, we will discuss the structural and functional properties of cadherin 5 (CDH5), cadherin 6 (CDH6) and cadherin 17 (CDH17), as well as their pathological implications in cancer progression and metastasis. These cadherins have, in common, the presence of RGD motifs within their sequence. Although another two cadherins, CDH16 and CDH20, contain RGD motifs, they will not be reviewed here as their relationship with cancer metastasis is not well established. In addition, we will discuss the implication of these three RGD cadherins in cancer signalling pathways and how this signalling might be regulated by the interaction network of each cadherin. Finally, we will address their emerging value as therapeutic targets for the treatment of cancer metastasis.CDH17 , together with CDH16, belongs to the 7D cadherin family, characterized by having seven extracellular (EC) domains . CDH17 hEC domains of cadherins are usually cleaved near the plasma membrane by different proteases, including matrix metalloproteinases (MMPs)  or Disintegrin and Metalloproteinase Domain-Containing Protein 10 (ADAM10)) and kallikrein 6 in the case of E-cadherin  or Disin. A similCDH17 gene was identified in zebrafish kidney development that can be considered the precursor of the mammalian genes CDH17 and CDH16 . MaThe interactome of VE-cadherin was quite similar to the CDH17 network, including matrix–cell adhesion proteins, actin cytoskeleton and Rho-GTPase associated proteins . As expeAn overview of the reported participation of RGD cadherins in cancer progression and metastasis indicate a wide number of cancer types and subtypes as indicated in the previous sections. This list is probably not exhaustive and is likely to expand in the next years, making these cadherins interesting targets for therapy.Since E-cadherin expression declines during metastatic progression, it has not typically been considered as a direct therapeutic objective but used as an indirect target for epigenetic regulation. Alternatively, since N-cadherin has been implicated in cancer metastasis endowing tumor cells with enhanced migratory and invasive capacity, a variety of N-cadherin antagonists have been developed and tested. A monoclonal antibody called GC-4, which binds to the EC1 domain of N-cadherin is able to block N-cadherin-mediated adhesion and might be relevant to limit metastatic dissemination . GC-4 blThe interaction of CDH17 and other cadherins with α2β1 integrin mediated by an RGD motif enables the development of new therapeutic opportunities based on the inhibition of the cadherin RGD binding. Peptides containing the cadherin RGD motif were used to prepare specific monoclonal antibodies. These monoclonal antibodies blocked the cadherin-mediated β1 integrin activation in colorectal, pancreatic, breast and melanoma cancer cell lines  Figure . TherefoCDH6 has also been identified as a target for biotherapeutics development. The recent discovery and optimization of an antibody-drug conjugate (ADC) directed against this protein has yielded effective results and provided beneficial effects in the treatment of ovarian and renal carcinomas . HoweverTargeting of cadherins for cancer treatment raises some questions about the potential complications of targeting proteins with multiple relevant physiological roles. In this regard, although GC-4 antibody or ADH-1 peptide affect the N-cadherin-mediated cell adhesion, ADH-1 seems to be well tolerated in humans . RegardiThe three cadherins discussed here share some common features, such as the presence of RGD motifs in the extracellular domains. This RGD motif in CDH17 and VE-cadherin enables the activation of α2β1 integrin in different cancers and the activation of αIIbβ3 integrin in CDH6-expressing tumors (manuscript in preparation). In addition, they are usually re-expressed in advanced metastatic stages of cancer associated to a more epithelial phenotype. They are usually associated with cellular plasticity, including the mesenchymal-to-epithelial transition (MET) and the gain of stem-cell-like properties in metastatic cells, as revealed by the increased expression of CD44, EPCAM and ALCAM, among other markers. The upregulation in late-stage tumors in association with key integrins promotes different pro-metastatic properties in different cancers that support the use of these cadherins as therapeutic targets.Still, some critical questions remain to be answered such as the potential correlation between the expression of N-cadherin and the RGD cadherins. The potential interaction between N-cadherin and other cadherins has never been explored to the best of our knowledge. The simultaneous co-expression of several cadherins and potential synergies in some tumors deserves further exploration. The involvement of other integrins, such as αIIbβ3, in the pro-metastatic mechanisms of CDH6 is currently the subject of research. The presence of soluble fragments of CDH17 and VE-cadherin released by cancer cells may facilitate the signaling capacity with integrins and the formation of trans-interactions between cadherins. Soluble fragments may compete with homotypic interactions to reduce the intercellular adhesion. The proteases involved in this shedding still need to be identified for CDH17. It is also unclear if CDH6 ectodomains are released as soluble fragments to participate in cell signaling. The different position of the RGD motifs in different extracellular domains might be related with a different signaling capacity. Undoubtedly, further exploration of N-cadherin and RGD cadherins’ role in cancer metastasis promotion is needed to develop new and more efficient therapeutic strategies.


Dear Editor,2. Many patients respond to the first-line regimens such as R-CHOP3. However, up to one-third of patients have refractory and relapse disease associated with poor outcome. DLBCL is heterogeneous with respect to morphologic, immunophenotypic, and molecular features4, and encompasses numerous variants, subgroups, and subtypes. Approximately 10–15% of DLBCL patients have bone marrow (BM) involvement7. Morphologically, lymphoma involvement in the BM of DLBCL patients can either be classified as large B-cell lymphoma  or indolent, low-grade B-cell lymphoma .Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma and accounts for 30–40% of all B-cell non-Hodgkin lymphoma (NHLs)8 based on a combination of VDJ determination, somatic hypermutation profiling, and phylogenetic analysis.Tumor clonal dynamics and evolution in the BM of patients with DLBCL have not yet been studied in detail. Questions remain whether the lymphomatous involvement in BM in DLBCL patients represents a direct dissemination of tumor cells from the dominant tumor clones in the nodal or extranodal location to the BM. It is also unknown whether tumor-related cells can be detected in the BM when there is no morphologic evidence of lymphoma, and whether detection of these cells can have prognostic utility. Deep immunoglobulin heavy-chain gene enables the study of tumor evolution in B-cell malignancies, and has been previously employed in elucidating the patterns of clonal evolution in DLBCL relapseIGH VDJ deep sequencing and phylogenetic analysis were performed  on the diagnostic DLBCL samples and their matched BM samples (n = 29). In addition, two patients (#22 and #45) had posttreatment BM only, and are included for separate case analysis (see below). The dominant rearrangements identified in the DLBCL are listed in Supplementary Table In our study, we selected 28 DLBCL cases with paired staging bone marrows (BM) (Supplementary Table Minor tumor-related clones were detected in 19 (82.6%) of the 23 BM samples which did not exhibit morphologic evidence of lymphomatous involvement. These analyzes demonstrate that these minor clones are present in the BM in minute quantity, ranging from ~0.01% to 1.98%.  Fig. . One of 8, we hypothesize that there may be an association between the presence of DA tumor clones in the BM and subsequent relapse. Among the 22 DLBCL patients with no morphologic evidence of involvement, 12 had clinical follow-up. Four of these 12 patients relapsed with DLBCL. Interestingly, DA-type minor tumor clones were detected, either solely or with I-type clones, in the staging marrow of all four patients. For the other eight patients who did not relapse, DA-type clones were detected in only two of them. None of the six patients without detectable tumor clones or I-type clone only in the BM developed relapse .As DLBCL relapses occur primarily via divergent evolutionIn our cohort, we identified three patients  who had posttransplant DLBCL relapse  between the involved or uninvolved BM samples based on analysis of a small cohort. Similar patterns of clones can be seen in both involved and uninvolved BM. These observations suggest a model of tumor progression in the BM, initiating from minute tumor-related clones not detected by morphology and expanding to overt lymphoma  could be detected based on analysis of a limited number of samples. However, a larger sample size is needed to confirm this association.There seems to be a possible association between the detection of minor DA-type clones in the staging BM of patients without evidence of lymphoma involvement, and subsequent relapse. This association is in line with the previous observation that DLBCL relapse occurs predominantly via divergent evolution12. Our assay provides a simple, feasible, and highly sensitive methodology to detect relapse precursor clones directly. Our study serves as a pilot proof-of-principle investigation that suggests serial monitoring of divergent circulating tumor clones from post-therapy bone marrow, peripheral blood or plasma at different time points to decipher clonal dynamics of these clones may be of clinical value to predict relapse. It is conceivable that emergence or rise in the abundance of one of these divergent subclones may serve as a predictive marker of impending relapse. Additional investigation on a larger cohort is necessary to examine in detail the association between the minor post-therapy tumor-related clones, chemoresistance, and subsequent DLBCL relapse.Our study of two illustrative cases suggest that identification of minor DA-type clones in the BM/circulation in a posttreatment setting may signify the presence of pre-R (relapse precursor) clones and herald increased risk of relapse. Recent studies have demonstrated the utility of monitoring clonal VDJ rearrangements and gene mutations in cell-free DNA in predicting DLBCL relapseSupplementary table 1Supplementary table 2Supplementary table 3Supplementary figuresSupplementary file and Figure legends


Differences remained statistically significant after adjustment for potential confounders  . In conclusion, au-pairs may develop mental symptoms during their time abroad. Future prospective studies should aim at identifying potential risk factors and preventive measures.The number of au-pairs in Germany is on the rise. In 2017, about 13,500 au-pairs were living in German families, almost half of them originating from non-European Union (EU) countries and many of them from Spanish speaking countries. Knowledge about mental health among au-pairs in Germany is limited. Therefore, the main objective of this study was to assess the prevalence of Major Depressive Syndrome (MDS) and its potential association with time of residence among Spanish speaking au-pairs living in Germany via an exploratory analysis. This study included a sample of 409 Spanish speaking au-pairs living in Germany. We classified the au-pairs into those who lived less than three weeks in Germany (newcomer au-pairs) and those who lived more than three weeks (experienced au-pairs). The participants were recruited by an online survey (Facebook and Instagram) from August 2018 to June 2019. Socio-demographic characteristics, time of residence in Germany and the level of education were assessed. MDS was assessed by the Patient Health Questionnaire depression module (PHQ-9). Poisson regression models were calculated to evaluate the association between time of residence in Germany and prevalence of MDS. Most of the participants were female (91%). Almost half of them came from Colombia (48%) and were in the age range between 22–24 years (40%). Prevalence of MDS was 8% among newcomers and 19% among experienced au-pairs ( An au-pair  is “a usually young foreign person who cares for children and does domestic work for a family in return for room and board and the opportunity to learn the family’s language” . Being aThe number of au-pairs in Germany is on the rise (around 1000/year from 2012 onwards) . According to the German Federal Agency of Work, in order to be an au-pair in Germany, young foreigners should be between 18 and 28 years, should have completed secondary school education, should have basic German knowledge, and should have a contract with the hosting family minimum for six months and maximum for 12 months . UsuallyAu-pairs live in a structural dependency of the employer/host family . Some arAlso, a French study reported that Latin American au-pairs coming to Europe suffer extra challenges because they usually come from families with a middle or high socio-economic status and high levels of education (university degrees). Hence, they are not used to perform household tasks . At the Another factor that influences migrants’ mental health and well-being is the time of residence in the host country. For instance, studies suggest that experienced migrants had worse mental health and well-being than newcomer migrants due to the so-called “healthy migrant effect” ,11,12. TIn total, such cultural challenges and sometimes poor working conditions among Spanish speaking au-pairs as well as dependence and inexperience may result in poor mental health, especially symptoms of anxiety or depression . HoweverData collection for this study was carried out from August 2018 to June 2019. To be eligible for this study, participants needed to satisfy three inclusion criteria: (1) being an au-pair in Germany; (2) being born in a Spanish speaking country; (3) being aged from 18 to 28 years (age required in Germany to work as an au-pair from non-EU countries). Each participant accepted an informed consent form, which contained information about the study objectives, the methodological procedures, and the declarations on the anonymity and confidentiality principles. At the beginning of the survey, the participants created their own identification code with three letters and three numbers . This kept the participants anonymous and gave them the opportunity to resign from the study. The Ethics Committee of the Medical Faculty at the Ludwig Maximilian University of Munich approved the study protocol (project number 18-139).A total of 409 Spanish-speaking au-pairs living in Germany participated in this study. We used convenience sampling due to the unavailable sampling frame and a dispersed distribution of Spanish-speaking au-pairs in Germany, which is common among “hard-to-reach populations” such as migrants . Hence, ®) with 21 questions was used to collect the data. The questions were taken from the Spanish short version of the European Working Condition Survey [An online questionnaire in Spanish  “newcomer au-pairs”  and (2) “experienced au-pairs” (living in Germany more than three weeks). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), “the diagnosis of MDS requires five or more depressive symptoms (included either a depressed mood or anhedonia) to be present within a 2-week period” . Therefo® software version 25.0 was used to analyze the data. The descriptive analyses compared newcomers and experienced Spanish speaking au-pairs living in Germany. Nominal and ordinal variables were described as absolute and relative frequencies. Bivariate analyses with Chi-square test were conducted to assess statistical differences between exposure (time of residence in Germany) and the outcome (MDS). Moreover, Poisson regression models with robust variance estimation were performed using socio-demographic characteristics, level of education and time of residence in Germany as predictors and MDS as outcome. According to Coutinho et al., logistic regression works well for estimating the ratio of probabilities of a rare disease [SPSS disease . However disease . Therefo disease . ZochettDue to the high prevalence of the outcome (19% MDS among experienced au-pairs), we therefore performed a Poisson regression with robust variance estimation, and calculated prevalence ratios rather than odds ratios (ORs). Robust variance estimations help to adjust the overestimation of the variance and produce adequate confidence intervals ,24. Crude and adjusted PRs were calculated with 95% confidence intervals (95% CI). Missing values (4.15%) were dropped from the analysis, leaving only complete cases . Most of the participants were female (91%) and 40% were between 22–24 years old. Almost half of the participants came from Colombia (48%), followed by Mexico (23%). Regarding the level of education, 78% of the participants were highly educated. More than half of the participants were experienced au-pairs (57%). Gender, age, region of origin and level of education were not statistically significantly associated with the time of residence in Germany . p < 0.001) (p < 0.001) as compared to newcomer au-pairs   and highau-pairs . The remau-pairs , and almau-pairs .Our results show a high prevalence of MDS among Spanish-speaking au-pairs living in Germany (14%), especially among experienced au-pairs (19%). Time of residence in Germany was statistically significantly associated with MDS.The high prevalence of MDS in our study is in line with the prevalence rate of depression (20%) among migrant workers in Europe . This nuAlthough no data are available on the prevalence of depression among au-pairs, previous studies identified a high prevalence of MDS and other mental diseases among live-in caregivers. Live-in caregivers are temporal migrants living in a private household and providing child or elderly care and thus to some extend comparable to au-pairs . For exaAnother possible reason causing the decrease of psychosocial well-being among au-pairs might be poor working conditions. Even though the migrant status and the working conditions of au-pairs are clearly defined by the German law, au-pairs from non-EU countries are excluded from certain labor rights that regular employees have . Hence, Moreover, in this study, experienced au-pairs reported a higher prevalence of MDS as compared to newcomer au-pairs (19% vs. 8%). This finding is consistent with studies that expressed concerns about the continuous decline of migrants’ mental health from their arrival in the host country, which is defined as the “healthy immigrant effect”. Robert and Gilkinson concluded that newcomer migrants are significantly less likely than non-migrants to report symptoms of depression, anxiety, and other psychosocial distress, but it is unclear whether this health advantage persists over time . Also, aTime of residence can also influence mental health. Migrants’ acculturation process is a long-term source of emotional stress ,39 due tA strength of this study was the use of an internet-based sampling method , which increased the geographical scope and the sample size of a vulnerable population on a topic which has rarely been studied before . An addiThe application of the Spanish version of internationally standardized questionnaires instruments ,17,18 peOn the other hand, the study suffers from some potential limitations. First, selection bias may have occurred due to the usage of a convenience sample. For instance, participants already suffering from mental disorders may have been more likely to participate in this study than healthy participants . Second,To the extent of our knowledge, the present study is the first exploratory approach to investigate mental health among Spanish-speaking au-pairs living in Germany. This knowledge is important to create intervention strategies to prevent a deterioration of mental health among this vulnerable population. Such strategies should prepare and advise au-pairs and their host families before they start living together to have control throughout the year. Interventions could for example be carried out by the agencies or by governmental entities. Also, according to Vahabi and Wong, these interventions and mental health risks should be spread through social networks and social support organizations to reduce isolation and depression among live-in caregivers among whom au-pairs form a special group .Au-pairs may develop and suffer from poor mental health during their time in Germany. This knowledge is critical and can be used to inform policy makers as well as to find intervention strategies and adequate counseling before and during the au-pairs program. Future prospective studies should aim at identifying potential risk factors.