A great deal of research has been performed with the promise of improving such critical cognitive functions as working memory (WM), with transcranial direct current stimulation (tDCS), a well-tolerated, inexpensive, easy-to-use intervention. Under the assumption that by delivering currents through electrodes placed in suitable locations on the scalp, it is possible to increase prefrontal cortex excitability and therefore improve WM. A growing number of studies have led to mixed results, leading to the realization that such oversimplified assumptions need revision. Models spanning currents to behavior have been advocated in order to reconcile and inform neurostimulation investigations. We articulate such multilevel exploration to tDCS/WM by briefly reviewing critical aspects at each level of analysis but focusing on the circuit level and how available biophysical WM models could inform tDCS. Indeed, such models should replace vague reference to cortical excitability changes with relevant tDCS net effects affecting neural computation and behavior in a more predictable manner. We will refer to emerging WM models and explore to what extent the general concept of excitation-inhibition (E/I) balance is a meaningful intermediate level of analysis, its relationship with gamma oscillatory activity, and the extent to which it can index tDCS effects. We will highlight some predictions that appear consistent with empirical evidence – such as non-linearities and trait dependency of effects and possibly a preferential effect on WM control functions – as well as limitations that appear related to the dynamical aspects of coding by persistent activity. The key operations that support an online representation of the world in order to inform context appropriate behavior are collectively referred to as working memory (WM), encompassing both the simple maintenance of information and cognitive control and the adaptive allocation of cognitive resources . ImpairmWe will briefly review tDCS-WM studies and highlight the mixed findings as well as key mechanistic and theoretical points that could inform reconciling of these mixed results. It is clear that standard assumptions need to be considered as an oversimplification . In factThe use of multilevel modeling has been advocated to address the complexity of neurostimulation. Mathematical constructs at each level of description – current flow, cell polarization, network and information processing would provide a more informative framework and importantly, suggest relevant neurophysiological correlates. However, there is a remarkable paucity of investigations exploiting such “computational neurostimulation” strategy . Here, wFindings of the effects of tDCS on WM are mixed and a challenge to interpret due to the heterogeneity across multiple factors, all known to potentially affect outcome: tDCS parameters , protocols , individual variability , subject’s state during stimulation (resting/uncontrolled vs. active/training) and importantly, the WM task used.A quantitative review  evaluateIndeed, it has been shown that accounting for relevant factors can offer a far more informative perspective than the summary, reductive perspective of metanalysis global outcomes. The extreme variability in WM tasks dictates the need for careful consideration of potential task-dependency in tDCS effects. An intriguing perspective is that effects could be more prominent with increasing control demand. Performance in low difficulty maintenance tasks seems unaffected by tDCS , but impIt is commonly assumed that changes in excitability derive from polarization of cortical pyramidal cell somas due to radial current flow and that this can be predicted by uniform and localized polarization of the cortex. However, current flow models demonstrate that complex electrical fields arise in biological tissues  and stanThe effects at the cellular level have been extensively reviewed . The assStudies with MEP are fundamental in bridging cellular evidence with pharmacological studies and importantly, in detailing the parameter dependence of effects, including the abovementioned effects that cannot be explained with straightforward linear mapping of polarity and duration. The fact that prefrontal circuitry would respond similarly to the motor cortex could be postulated on the ground of cortical modularity. However, observations are strictly specific to current direction i.e., tangential vs. radial, and sign. Therefore, the relationship between MEP experiments cannot be inferred without including details of prefrontal cortical folding. Direct probes of prefrontal response such has TMS-electroencephalography (EEG) evoked potentials are extremely valuable to this end, yet such approaches offer their unique challenges .At the molecular level the involvement of standard long-term potentiation/depression (LTP/LTD) mechanisms, NMDA receptors and Ca2+-dependent have been consistently described. However, a plethora of other effects affecting AMPA receptors, neurotrophic factors with induction of immediate early genes, modulation by various neurotransmitters and layer specific glia involvement have also been reported. At this level, genetic, pharmacological, and state dependent variables are likely contribute to the consistent inter-individual variability observed in response to neurostimulation. In motor cortex studies up to 50% of subjects do not show MEP modifications following anodal tDCS . CognitiOverall, these studies suggest that the effect on pyramidal neurons can result from a number of different mechanisms that affect both sides of the interacting excitatory (E) and inhibitory (I) cell network. An offset of E/I balance appears to be a more inclusive description of net effects, yet this can arise through a range of cellular and molecular effects which likely vary across the protocols, being online effects related to changes in membrane potential  and offlCurrent, cellular and molecular findings can be incorporated into cortical dynamics models exploiting the sound basis of well-established, biophysically accurate “off the shelf” templates . ConversIt is assumed that changes in excitability translate directly into effects on cortical operations. Additionally, behavioral changes are predicted, implying that cognitive processes are separable and localized. Yet, what precisely could or should be enhanced by tDCS? Can WM be indeed treated as single dimension separable from other functions? Such fundamental questions can be answered by providing an intermediate level of analysis that bridges the net microcircuitry effects of tDCS with cortical operations. To this end, concepts such as E/I balance, efficiency, zero-sum gain, stochastic resonance, activity-, and input-selectivity have been proposed in order to contrast the simplistic view of a sliding scale effect – i.e., the more excitation the better  of local pyramidal neurons was necessary to sustain persistent activity representing that location across the delay period. Sufficient excitation of inhibitory neurons  was necessary to inhibit activity of neurons representing irrelevant locations. The critical feature is the existence of iso-contour lines along the positive slope directions, representing stable E/I ratios and equivalent spatial WM performance despite changes in the absolute conductance values. Such a “sloppy” axis defines a robust balance that contrasts with a “stiff” axis over which even modest E/I balance changes results in striking changes in representations. Poor WM performance arises either both from a relative defect of excitation by pyramidal cells onto other pyramidal cells  or onto inhibitory interneurons, resulting in widespread excitation . Thus, with poor performance at either extreme of this “stiff” axis, we see WM performance can be a non-linear, inverted-U function of E/I balance.Such computational models also help in lending precision to dose/response curves and therapeutic goals. For instance, in Accordingly, insofar as tDCS affects E/I and that the biological variability spans across the explored parameter space, the effects on WM are expected to be non-linear and – in alignment with the above mentioned general E/I balance reasoning – the magnitude and direction of effects depends on individual pre-stimulation values. We can then note three theoretical main implications. First, since an optimal value exists – which is assumed to fall within the physiological range corresponding to normal or high performance – WM can be improved by tDCS if parameters are individually adapted. However, the second implication is that effects have an upper limit. The optimal level corresponds to subjects that would not benefit from tDCS of either polarity or any duration. On the contrary, their performance could actually deteriorate with any tDCS. Lastly, absolute excitatory and inhibitory values are immaterial and tDCS can restore balance across conditions regardless of the actual circuit disturbances. In the context of the NMDA hypofunction hypothesis of schizophrenia, this would point to the possibility of improving WM through balancing E/I by tuning tDCS parameters in order to shift from the lower right of the plot to a point along the diagonal. The proposed model does not address directly oscillatory dynamics. However, similar non-linear, invert-U relationships have also been observed for network gamma oscillations in computational models that vary the excitability of parvalbumin positive interneurons . Accordiin vivo in order to define pre-stimulation individual values. We addressed how glutamate/GABA indices such as magnetic resonance spectroscopy measures can only be considered as a proxy and do not provide the spatiotemporal details relevant to modeling. However, the same connection that relates prefrontal gamma to E/I – with related strengths and limitations – can be exploited to this end. Measuring cortical activity during WM tasks would appear to be a straightforward approach as it defines the very target of remediation by tDCS. However, such measures are confounded by differences in performance and execution strategy. Such hurdle can be overcome by using TMS-EEG evoked responses in the spectral domain  to probe the causal role of oscillatory activity support the involvement of appropriately timed gamma oscillations (reviewed in Both local microcircuit connections and long-range connectivity are critically involved in WM. The dynamic aspects of persistent activity and the involvement of other mechanisms makes tDCS effects less easily predictable. For instance, the basis of STSP – which is distinct from the more commonly investigated LTD/LTP – should be addressed. Similarly, tDCS could influence the mutual inhibition between subpopulations underlying multiple representations . It follThese arguments start addressing the question of whether WM modulation can be captured along a single dimension and whether it is possible to target WM in isolation. It is unclear if the E/I balance perspective provides basis for an effect that would generalize equally to all prefrontal operations as might be expected by a basic optimization principle underlying cortical dynamics. Overlooking functions regarded as dissociable, i.e., maintenance vs. control or even antagonistic such as sustained representation vs. flexible update  needs toEmpirical studies suggest that prefrontal tDCS can improve WM under certain conditions, with effects being possibly more prominent with increasing control demand. However, the most salient aspect of available findings seems to be the variability of response. At each level of description, we have outlined some of the existing uncertainties, corresponding sources of variability and shortcomings of standard assumptions.Our overview is grounded in two themes of general relevance to neurostimulation. First, a multilevel perspective indicates that anatomical precision cannot be meaningfully exploited unless targets are also defined in terms of computationally relevant changes to cellular dynamics. Second, while our understanding appears to decrease moving up from the level of current flow, the gap from cellular effects to behavior can also rely on increasingly sophisticated quantitative approaches. Biophysically accurate, domain specific models allow answering basic questions like what exactly is affected by stimulation and why it should lead to behavioral changes.In tackling the impact of tDCS on WM, the weakness of anatomical precision is further complicated by the necessity to rely on forward models of current in order to target PFC. The overlying scalp does not have the special role played in TMS and tDCS is anatomically imprecise unless montages are guided by detailed, individualized models. Basic findings from cellular and MEP studies cannot be transferred to WM enhancement unless anatomical precision include the relative geometry of electrical fields and cortical folding. Appropriate neurophysiological methods such as TMS/EEG allow direct indexing of prefrontal effects and can assist in deriving regional response curves beyond simple modular reasoning.Emerging WM models provide some understanding of empirical findings insofar WM may be supported by persistent activity. The general E/I balance framework promises to capture mechanistic relevant net tDCS effects but lacks the necessary spatiotemporally resolution. WM models help to overcome such limitations and highlight the existence of an optimal E/I balance where identical performance can be achieved regardless of absolute excitatory and inhibitory values. Accordingly, effects should be non-linear, and their magnitude and direction depend on individual pre-stimulation values. Therefore, improvement requires customization of parameters with an upper limit represented by E/I optimization. To the extent that WM impairments are related to E/I imbalance, tDCS could restore balance regardless of the actual circuit disturbances supporting tDCS use in various disorders where E/I imbalance has been postulated.Oscillatory activity and fast kinetic E/I balance underlying prefrontal gamma represents a meaningful level of analysis, which also offers a neurophysiological measure of target engagement and meaningful pre-stimulation individual characteristic. Furthermore, it provides the cellular and molecular resolution needed to contextualize tDCS effects: online, immediate and prolonged after effects are likely to affect the rhythmogenic pyramidal-interneuron network in different ways and the outcome cannot be predicted at the general E/I balance level.a priori reason why tDCS effects should be limited to the machinery underlying active representations. Additional changes could occur in either direction leading to either additive/synergistic or antagonistic effects with related trade-offs.A WM improvement can be expected when active representations are suboptimal due to fast kinetic E/I imbalance. However, a growing understanding of the dynamic aspects of representations highlights the importance of other mechanisms that are poorly addressed by tDCS cellular studies and modeling. Effects on control functions can be more reliably predicted as recent evidence suggests that persistent activity is necessary for control functions while maintenance could rely on silent representations. Furthermore, additional mechanisms are expected when multiple representations are at play and the relation with other WM underpinning such as cross frequency coupling and connectivity awaits to be formally addressed. Clearly, there is no in vivo. Furthermore, such perspective motivates the integration of relevant single subject specific information from different methodologies into a tailored approach capable of controlling for and exploiting relevant sources of variability. This includes not only the morphological and connectivity details derived from structural and functional MRI methods and EEG (Multilevel modeling offers a space where tDCS parameters under our control can be effectively tracked. Such a parameter space is extremely vast, spanning across stimulation parameters that include intensity, duration, and number of sessions, as well as montages, including high resolution setups. Yet models can define upper boundaries and incorporate safety and tolerability considerations in defining the limits to what can be accomplished  and EEG , but alsin vivo experiments. The Holy Grail is identifying a unifying transfer function that, if positively affected, would improve fundamental prefrontal computation and generalize to all subserved functions. It is unclear if the E/I balance perspective satisfies this requirement, but this is a testable hypothesis.In the attempt to provide a general outline encouraging a quantitative, multilevel approach in tDCS/WM, our overview has limitations. We pointed to available thorough reviews of the present understanding of the current and cellular level . In addrNP wrote the first draft of the manuscript. NP, NR, and RC wrote sections of the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


High throughput RNA sequencing has revealed the existence of abundant circular RNAs (circRNAs) that are cell lineage-specific and have been implicated in human diseases. CircRNAs are resistant to exonuclease digestion, can carry genetic information of oncogenes, and are enriched in exosome to be transported from tissues into various body fluids. These properties make circRNAs ideal non-invasive diagnostic biomarkers for disease detection. Furthermore, many circRNAs have been demonstrated to possess biological functions in relevant cells, suggesting that they may also be potential therapeutic targets and reagents. However, our knowledge of circRNAs is still at an infant stage and far from being translated into clinics. Here, we review circRNAs in the disease setting of prostate cancer. We start by introducing the basic knowledge of circRNAs, followed by summarizing opportunities of circRNAs to be prostate cancer biomarkers, and discuss current challenges in circRNA research and outlook of future directions in translating current knowledge about circRNA into clinical practice. Although it was known for decades that there exist circular forms of RNA (circRNA) in virus, plant, fungi, bacteria, and mammalian cells , circRNACircular RNAs are synthesized by RNA spliceosome, the same splicing machinery to synthesize linear mRNAs but through a backsplicing process. During this process, the downstream splice donors are back spliced to the upstream acceptors . It shouBecause both circRNAs and linear mRNAs are processed from pre-mRNAs by the RNA splicing machinery, their relative expression levels could be either positively or negatively correlated pending upon the cell contexts. For a specific copy of an exon in the pre-mRNA, it can be processed into either one copy of circRNA or one copy of mRNA. Under this context, the levels of circRNAs and their counterpart mRNAs are negatively correlated. However, the RNA splicing process is tightly coupled with gene transcription initiation and elongation rates , and mulCircular RNAs possess several special features that make them ideal biomarkers for diseases. First, circRNAs are resistant to exonuclease degradation . They arMany circRNAs had been demonstrated to play important roles in promoting cancer cell proliferation, migration/invasion, anti-apoptosis, and differentiation , emphasizing that tumor-promoting circRNAs may be potential cancer biomarkers. The molecular functions of circRNAs had been reported to (1) regulate microRNA activity, (2) act as scaffolds or decoys for RBPs, or (3) serve as templates for cap-independent translation . It was Circular RNAs can also exert biological functions through forming complexes with proteins. For example, circFOXO3 was reported to form RNA-protein complexes with CDKN1A and CDK2, resulting in suppression of CDK2 activity and arrest of cell cycling . Circ-ANDrosophila head , to validate one of the circRNAs consisting of AR exon 2 whose expression was elevated by androgen deprivation conditions. Data from our lab had applied RISH to show that the exon 3 of the AR gene forms a circRNAs, called circ-AR3, that is highly expressed in benign and low Gleason primary tumors, but downregulated in high Gleason tumors and further reduced in CRPC (In prostate cancer (PCa), several circRNAs are promising to be potential diagnostic or prognostic biomarkers. Since the AR gene amplification and overexpression had been demonstrated to be one of the major mechanisms by which CRPC is developed , circRNA in CRPC . This co in CRPC . These fAlthough most of the PCa cells present adenocarcinoma (AdPC) phenotype with classic luminal epithelial morphology, emerging clinical evidence indicated that more aggressive subtypes of CRPC with AR indifferent phenotype become more prevalent, accounting for ∼15–20% of CRPC tumors . Many ofSeveral circRNAs had been studied for their molecular and cellular functions in PCa cells . Most ofAlthough high throughput sequencing is powerful for globally profiling circRNAs in tissues and cell models, it is not without limitations. During library preparations using polyA depletion, rRNA depletion, and RNAse R treatment protocols, there are still linear RNAs retained in the RNA samples . By contAnother challenge is that RNA samples used for RNA sequencing or microarray analyses are extracted from a homogenate of PCa tissue trunks containing not only cancer cells but also benign and stroma cells. This could compromise the accuracy of sequencing data analyses to identify tumor-specific circRNAs, since the detection of some lowly expressed circRNAs can be easily affected by the mixture of cell populations from different cell lineages. Even though all RNA samples had been processed with ribosome depletion and RNase R treatment, there is still a significant portion of none circRNAs remain. It is therefore critical to validate circRNAs identified by RNA sequencing or microarray in tissues from patients using techniques such as RISH, which will allow RISH signal to be evaluated together with the histology of tumor cells.Circular RNAs can form secondary structures of stem-loop RNA hairpins, and even three-dimensional structures complexed with RBPs . It is tProstate cancer specific circRNAs identified from tissues by RNA sequencing or microarray can provide new insights to develop non-invasive biomarkers in plasma, however, plasma circRNA levels are not always positively correlated with intratumoral circRNA levels. For example, we have shown that intratumoral circ-AR3 levels were reduced in high Gleason tumors and CRPC when compared with benign prostate and low Gleason tumors, while plasma circ-AR3 levels are increased in patients with high Gleason tumors and CRPC . MultiplOne solution to avoid the complicated factors that influence the release of PCa origin circRNAs into the bloodstream is to measure circRNAs directly from patient plasma by microarray or RNA sequencing. Such experiments had been performed in patients who have lung cancers  or gastrNew technologies enhance our understanding of the biology of RNAs in human cells. High throughput sequencing had revealed that there are aberrantly expressed circRNAs in PCa cells that have various biological functions. These findings have brought a plethora of opportunities to develop new diagnostic and prognostic biomarkers for PCa. Although we are still facing challenges, our accumulating knowledge from circRNA research will be eventually translated into clinical practice to benefit PCa patients.JL and XD developed the idea. JL and JF draft the manuscript. JQ and XD revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Multicomponent peri-operative interventions offer to accelerate patient recovery and improve cost-effectiveness. The recent National Institute of Health Research-commissioned evidence synthesis review by Nunns et al. considers the effectiveness and cost-effectiveness of all types of multicomponent interventions for older adults undergoing elective inpatient surgery. Enhanced recovery programmes (ERPs) were the most commonly evaluated intervention. An association between ERPs and decreased length of stay was observed, whilst complication rates and time to recovery were static or sometimes reduced. Important areas which lack research in the context of ERPs are patient-reported outcome measures, patients with complex needs and assessment of factors pertaining to successful ERP implementation. The next generation of ERP studies should seek to develop our understanding in these key areas. There is growing acceptance of the need to provide a standardised approach to peri-operative care, often tailored to the nature of the surgical intervention. Unwarranted variation is thought to impact both on clinical outcomes and patient safety. The cost of health care is growing exponentially and, at the same time, healthcare budgets have failed to keep pace. Enhanced recovery programmes (ERPs) are now established as multicomponent interventions that afford the opportunity to improve the quality of clinical care whilst reducing overall costs.These ‘packages’ of care aimed at accelerating recovery and reducing length of stay (LOS) have become increasingly embedded across healthcare systems worldwide. Our recent systematic review and meta-analysis, commissioned by the National Institute for Health Research (NIHR), identified the broad range of interventions of this nature that have been studied in the UK and abroad  undergoing elective inpatient surgery  were not utilised and there is a need to study the patient-facing benefits of ERPs. We cannot say with any confidence that patient experience is improved by these interventions or that patients would like to see their LOS reduce further. There are pragmatic reasons to hypothesise that patient-experience may be improved, based on improved information-sharing, goal setting and shared decision-making, but our included studies offered no reliable evidence to substantiate this. Whilst there is evidence about patient satisfaction and experience  selected individuals who had multi-morbidities or were at greatest risk of post-operative complications or of developing complex care needs.Studies frequently excluded patients over a certain age or with the potential to experience complex needs. A number also chose to exclude ‘outliers’ or patients experiencing severe complications. Patients with risk factors for delirium were excluded from 18 studies despite delirium being a risk in many over 60-year-olds undergoing surgery. In contrast, a small number of studies (Finally, cost-effectiveness evidence was derived from only 15 studies and these studies were highly heterogeneous in terms of population, intervention and location. Whilst there was a general suggestion that interventions lead to cost savings, findings were often the result of basic alignment with daily costs, and not the result of rigorously performed economic evaluations.For colorectal surgery and lower limb arthroplasty, it can be strongly argued that further evaluations measuring the effectiveness of ERP interventions at reducing LOS, complications and re-admissions are not required. Future studies in these specialties would potentially add greater value if they had a new focus on implementation science, scaling up of adoption and the assessment of longer-term outcomes. In specialty areas where ERP effectiveness is less proven, further work should prioritise wider outcomes over longer time periods. All specialty areas have a pressing need to include outcomes that are more directly linked to the patient—including PROMs, PREM and the effects on physical activity and mental health. The effect of earlier post-operative discharge on the broader health and social care system requires elucidation, including comprehensive economic evaluation. Multicomponent interventions other than ERPs also require further evaluation, given the relative lack of quality evidence identified in these areas. Our report also offers recommendations for improving the academic quality of future studies, including adopting clear definitions of variables and methods for presenting data. Standardised variance statistics should also be included in future works to allow meta-analysis and maximise impact.For ERP, there was no core configuration of intervention components that conveyed superiority for the study populations included in this review. Similar LOS improvements were realised with a common lack of detrimental outcomes. This suggests that endeavours to find the ‘ideal protocol’ are less important than the act of whole-team engagement in scrutiny and measurement of the patient pathway. A gap in understanding is the level of compliance with which interventions are implemented. Simpson et al. have observed a weak dose-response relationship between ERP protocol adherence and decreased LOS (Simpson et al. With an ageing and increasingly co-morbid population, a final recommendation is that future studies evaluating multicomponent interventions should embrace the complexities of the older adult population. Studies were frequently observed to be selective against complex needs to the point that the UK elective surgical patient population is incompletely represented. Starks and colleagues actually observed their greatest improvement due to ERP in the oldest and most vulnerable patient cohorts who are most prone to long hospital admissions (Starks et al. Nunns et al. deliver a timely and detailed indication of our current understanding of multicomponent interventions for elderly patients undergoing elective surgery. The limits of our understanding are also defined; there is minimal knowledge of the effects of multicomponent interventions on PROMS, and most studies have excluded medically complex patients. In the future, measuring PROMs and including medically complex patients will require carefully designed studies. Understanding factors that allow multicomponent interventions to become truly embedded in practice will require a renewed approach in order to meaningfully connect the experiences of patients and staff, with measures of pathway adherence and outcomes. Ambitious expansion of our understanding of the effects of ERPs must be the future aim, rather than simply reinforcing what we already know.


To evaluate dentists’ readiness to assess the history of human papilloma virus (HPV) infections and recommend immunization among their patients.A link to a self-administered questionnaire was emailed to Ontario dentists. Dentists’ readiness and its determinants were assessed based on Transtheoretical Model’s ‘stages’ and ‘processes’ of change, respectively. Based on their current practices, dentists were either assigned to ‘pre-action’ or ‘action+’ stages.Of the 9,975 dentists contacted, 932 completed the survey; 51.9% participants were in action stage to assess the history of HPV infections and 20.5% to recommend immunization. Internationally-trained and those whose office’s physical layout was not a concern to discuss patients’ sexual history were more likely to assess the history. Dentists with higher knowledge about HPV vaccines, not concerned about the HPV vaccine safety, comfortable discussing sex-related topics with patients, or willing to exceed their scope of practice were more ready to recommend HPV immunization to their patients.Improving Ontario dentists’ knowledge and communication skills and changing their self-perceived role regarding HPV infections and vaccination can increase their capacity to minimize the burden of HPV infections. The incidence of oral cancers in high-income countries is shifting from oral cavity cancers generally attributable to tobacco consumption to oropharyngeal cancers (OPC) linked to human papillomavirus (HPV) oral infections . In CanaHPV infection is one of the most common sexually-transmitted infections, and it has been implicated as a cause of cancer for various anatomic sites including the cervix, vagina, vulva, penis, anus and oropharynx ,5. VertiIn recent decades, vaccines have been developed to prevent HPV infections and subsequent development of HPV-related cancers. Development of HPV-related OPC is associated with HPV types 16 and 18. While it is too early to identify the vaccine’s ability to lower the number of HPV-related OPC, randomized clinical trials have demonstrated the efficacy and safety of HPV vaccines ,11. In gDentists are poised to contribute significantly to both the uptake of the vaccine and completion rates . To imprUnderstanding the determinants of dentists’ readiness to assess HPV risk and recommend the HPV immunization is crucial for increasing the presence of dental professionals in HPV prevention. Daley and colleagues identified dentists’ knowledge of HPV and the HPV vaccine, their attitudes towards discussing HPV and its relation to sex, and the barriers dentists identified are keeping them from addressing HPV infections with their patients ,25. Our Accordingly, the objectives of this study were to determine Canadian dentists’ readiness to: assess patient’s HPV infection history; recommend HPV immunization; and explore associated determinants.Ethics approval was obtained for conducting this survey from the Research Ethics Board of Public Health Ontario (File number 2017–040.01). A statement was included in the survey questionnaire to record the active consent of participants. To further protect respondents’ privacy, sociodemographic groups with five or less respondents that could not be combined with another group, were dropped from the final analyses.The survey instrument was developed following a robust review of the literature. Based on relevancy to the study’s purpose, survey questions were framed using the Transtheoretical Model  and processes of change (POC)) . The surDentists’ readiness to assess HPV infection history/status and recommend HPV immunization and the associated determinats were assessed based on the TTM . TheoretAccording to the TTM, dentists indicating non-assessment of patient HPV infection history/status or not recommending immunization were placed in the ‘pre-action’ stage (precontemplation/ contemplation/ preparation), while those indicating assessing either all or some of their patients’ HPV infection history/status or recommending immunization were included in the ‘action +’ stage (action/ maintenance). Determinants of dentists’ readiness to act in each of the abovementioned categories included demographics, subject knowledge , and other items derived from POC . These iFirstly, descriptive analyses were performed: assessed the proportions of respondents as per their socio-demographic characteristics; calculated proportions who were in pre-action or action+ stage for assessing HPV risk and immunization; calculated median overall knowledge score (14 out of 20) and also specific knowledge scores of OPC (2 out of 4), HPV infections (9 out of 10), and HPV immunization (3 out of 6), dichotomized proportion of respondents based on median knowledges scores, and examined their distributions into pre-action or action+ stage; and assessed propotions of agreed or not agreed to statements based on POC and accordingly if they were in pre-action or action+ stage.Secondly, binary logistic regression analyses were performed to assess the association between each determinant and dentists’ readiness (pre-action vs. action+) to take HPV infection history/status and recommend HPV immunization. Lastly, multivaraible logistic regression models were developed that included only the statistically significant variables (p<0.05) emerging from the simple binary logistic regression models. As 93.13% of the participants reported complete data, all estimates are based on complete-case analyses. The distributions of missing data are reported in Of the 9,975 dentists contacted, 932 dentists completed the survey . Approximately 52% of respondents were in the action stage for assessing patient HPV- history/status, but only 20.5% of respondents recommend HPV-immunization to patients . Fig 1A Statistically significant socio-demographic predictors of dentists’ readiness to assess patient HPV-related history/status include place of training, primary setting of occupation, and years practicing in Canada . When coIn terms of knowledge, dentists whose OPC knowledge scores were equal to or above the median value were more likely  to assess the history of HPV infections than their counterparts. Statements developed using POC show that dentists who are comfortable with patients of opposite sex and minors, and in discussing sexual history, find dental appointments time adequate, do not worry about confidentiality, perceive assessing HPV history to be in their scope of practice, and do not find their dental office layout as a barrier for such discussions are statistically significantly more in action+ stage than their counterparts.Statistically significant socio-demographic predictors of dentists’ readiness to recommend HPV vaccine include age, primary setting of occupation, and practice type . Older dIn terms of knowledge, dentists scoring equal to or above the median overall knowledge score  and HPV immunization knowledge score  were more likely to recommend immunization to their patients than their counterparts. Statements based on POC show that dentists who are not concerned about the HPV vaccine safety or liability issues, believe that it is their role to recommend immunization, find dental appointments time adequate, and comfortable discussing sexual history with patients are statistically significantly more in action+ stage than their counterparts.Place of training, OPC knowledge, and perceiving the physical layout of the clinic as a barrier to assess sexual history remained significant predictors for dentists’ readiness to assess the history of HPV infections . InternaDentist’s age, HPV vaccine knowledge score, and agreement with statements derived from the POC remained significant predictors for readiness to recommend HPV immunization . DentistThe objectives of this paper were to assess dentists’ readiness to assess the history of patient HPV infections/status and willingness to recommend HPV immunization, and to explore the readiness-associated determinants. Our findings reveal low proportions of dentists in both outcomes, with dentists’ readiness to assess patient HPV history/status higher than their readiness to recommend HPV immunization. However, a comparison of current study findings to earlier findings with Florida dentists, point to an even lower proportion of Florida dentists who were recommending HPV immunization to their female patients . This diDentists’ readiness to assess HPV infection history and status was predicted by place of training, OPC knowledge, and the physical layout of the clinic. The existing literature does not fully explain the difference in readiness to assess history of HPV infections between the Canadian and internationally trained dentists. One possible explanation is that internationally trained dentists are less influenced by the self-perceived barriers because of utilizing more diverse communication techniques . AlternaIn addition to place of training, dentists’ readiness to assess history of HPV infections was also predicted by OPC knowledge, but not HPV infection knowledge. This is understandable as it is expected that educational interventions for dentists would focus primarily on oral implications of HPV infections including OPC. In addition, this finding highlights the importance of more educational interventions to increase OPC related knowledge. Additionally, dentists’ readiness to assess patient history of HPV infection was predicted by whether dentists’ view the physical layout of the clinic as a reason for not assessing the history of HPV infections. This concern was also indicated by a group of dentists and dental hygienists in a mixed-method study ; particiFor dentists’ readiness to recommend HPV immunization, among all socio-demographic characteristics, age was the only factor that was positively associated. This finding is consistent with what Hosking et al. (2017) reported when they surveyed a sample of Pediatric Dentistry Graduate Program Directors in the U.S. The increased age among the Program Directors was positively correlated with recommending HPV immunization to patients . The reaIn addition to age, dentists’ HPV vaccine knowledge and concerns about the vaccine safety, discussing sex-related topics, and exceeding the scope of practice were significant predictors of dentists’ readiness to recommend HPV immunization. These findings add to the current understanding how dentists’ readiness to recommend HPV is shaped across the SOC. Daley et al (2014) identified that absence of concerns about liability issues is associated with occupying the contemplation stage rather than the pre-contemplation stage while our study suggests that absence of concerns about liability issues does not predict occupying the action+ stage . Daley eSignificant predictors identified in this study were derived from four different POC; consciousness raising, dramatic relief, self-reevaluation, and stimulus control. These four processes represent different cognitive and behavioral activities that individuals perform to move between the stages. Consciousness raising and dramatic relief usually mediate transition from pre-contemplation to contemplation. Self-reevaluation often mediates transition from contemplation to preparation, while stimulus control is proposed to mediate transition from action to maintenance . Our resDespite the facts that we utilized a theory-informed approach to answer critical research questions, no formal tests have been performed to assess the validity and reliability of the survey instrument. Accordingly, this study should be interpreted as an exploratory study that highlights potential areas for future intervention. The cross-sectional design of our study did not allow us to confirm the mediation effects of the POC. It is possible that these processes were activated after progressing to a given stage. Therefore, caution must be exercised when designing professional interventions to shift dentists to the action+ stage. Moreover, our study did not evaluate all POC due to the length of the survey. Including all the POC and other TTM constructs may change the estimates and/or reveal new predictors. Furthermore, our study dichotomized the SOC into pre-action and action+ stages, which may not directly reveal how dentists move from one particular stage to another stage.In terms of the generalizability of the study findings to Ontario dentists, the low participation rate in the study may limit the generalizability of the results to Ontario dentists who are similar to the study sample. Although our communication with the RCSO indicates that the characteristics of the study sample is comparable to the characteristics of the registered Ontario dentists in term of age, sex, and training country (data not shown), it is expected that those who participated in the study are those who are currently in the action+, which may overestimate Ontario dentists’ readiness to assess the history of HPV infections and recommend HPV immunization and underestimate the effects of the examined determinants on their readiness .Although this study demonstrated that dentists have the potential to play key roles in the prevention of HPV infections, collaboration between different stakeholders can improve dentist’s readiness to assess the history of HPV infections and recommend HPV immunization. Academic institutions need to enrich their curricula with more information about OPC, HPV immunization and how to communicate such sensitive issues with patients. Regulatory colleges also need to promote developing HPV related content for continuing dental education courses. Professional dental organizations can address dentists’ discomfort and concerns about patients’ privacy by adding items about HPV infections and immunization to the medical history forms. More importantly, the role of dentists in the prevention of HPV infections, including their role in the risk assessment of OPC, and recommending immunization needs to be more clearly defined . FurtherThis study shows the minimal contribution dentists are making to the prevention of HPV infection. Also demonstrated is the larger role dentists can play in reducing HPV infection and its sequel. Dentists’ lack knowledge in the areas of HPV-related OPC and available HPV vaccines, including safety and efficacy. Other determinants for dentists’ readiness include patient privacy, discussion of sensitive topic, and dangers of exceeding their scope of practice. Future research should explore the role of the other POC and Transtheoretical Model constructs and patient-related factors in dentists’ readiness to engage in HPV prevention behaviors. Development of educational interventions to ameliorate dentists perceived barriers to HPV screening are also needed.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


Age-related macular degeneration (AMD) is one of the leading causes of irreversible blindness in the developed world. Antivascular endothelial growth factor therapy has transformed the management and outcome of neovascular AMD (nAMD), although the need for repeated intravitreal injections—even lifelong—and the related complications, high drug costs, frequent clinic visits and repeated imaging have resulted in an enormous burden both to healthcare systems and patients. The application of gene therapy approaches for sustained delivery of a range of antiangiogenic proteins has the promise of helping to address these aforementioned challenges. A number of early phase clinical trials of gene therapy in nAMD have provided encouraging results, with many more ongoing or anticipated. There remain significant areas of controversy, including regarding the optimal treatment targets, routes of administration and potential safety concerns. In this review we aim to provide an update of the current status of gene therapy for nAMD and briefly discuss future prospects. Age-related macular degeneration (AMD) is a progressive disease that leads to severe impairment of central vision. It is a leading cause of irreversible blindness in the elderly population.AMD can be categorised into two main groups: dry or non-neovascular AMD, and wet or neovascular AMD. Neovascular AMD (nAMD) presents with the growth of abnormal vessels, most often emanating from the choroidal circulation, but can originate from the retinal vasculature, causing acute vision loss through leakage, and if chronic through fibrosis and atrophy.RPE65-associated retinal dystrophy approved by the Food and Drug Administration and the European Medicines Agency has helped pave the way for a new era of retinal gene therapy products.Gene therapy offers the very real possibility of such a sustained delivery—in a ‘one and done’ manner. The gene therapy for 165 is the predominant isoform and most active in vasculogenesis.Angiogenesis is a complex and critical physiological process which is tightly regulated by proangiogenic and antiangiogenic factors.FLT1) and VEGFR2 (FLK1/KDR) are responsible for regulation of cell proliferation, migration and vascular permeability in ocular disease, whereas VEGFR3 is mainly expressed in lymphatic endothelial cells and is mostly responsible for lymphangiogenesis.VEGFR1  and capsid organisation, which facilitate genetic modification, thus enabling customisation of its properties.One of the principal considerations of gene therapy is the potential immune response to AAV capsid, which may have a damaging tissue effect, but might also mitigate therapeutic benefit. AAV vector administration in humans, unlike most animal models, results in antigen-specific T-cell activation.An additional consideration, in direct contrast to the majority of subjects with inherited retinal diseases (IRDs) who may be targeted with gene therapy, patients with nAMD will be significantly older. This may be advantageous in terms of the likely less rigorous immune responses anticipated in older people compared with children/young adults, but also potentially disadvantageous, as older patients may be more susceptible to possible deleterious effects of systemic immunosuppression and also have pre-existing medical conditions, making them ineligible to participate and/or more likely to have side effects.The route of administration is another major determinant of the efficacy of gene delivery. It allows the targeting of specific cell types by delivering the vector as close as possible to the desired tissue.CEP290 and USH2A variants , although these do not require a viral vector. While subretinal delivery with its associated transient retinal detachment is likely to be inherently associated with greater tissue damage/disturbance compared with intravitreal, the available trial data suggest that it is well tolerated, safe and may provide effective treatment.Although more complex and invasive than intravitreal injections, subretinal delivery is arguably preferable for diseases primarily affecting the retinal pigment epithelium (RPE) and/or photoreceptors. Since most IRDs affect either of these two cell types or both, subretinal delivery is the most commonly used route of administration in gene therapy trials for most monogenic conditions. However, intravitreal delivery has been undertaken for (1) the two X linked retinoschisis (XLRS) gene therapy trials (NCT02317887 and NCT02416622), with one stopping due to lack of efficacy and inflammation concerns (NCT02416622); and also (2) delivery of antisense oligonucleotide therapies for Intravitreal injection of anti-VEGF agents has become the mainstay of treatment for nAMD, diabetic eye disease and other retinovascular diseases. Although much less invasive than subretinal injections and readily delivered by non-specialist surgeons, the majority of currently available AAVs are unable to reach the outer retina, including the RPE and choroid, mainly due to the inner limiting membrane (ILM) acting as a physical barrier, thereby primarily limiting transduction to the inner retinal layers. However, modified AAVs  are proposed to be more effective in penetrating the ILM and able to result in broader transduction.et alSuprachoroidal delivery has also been explored and is arguably an attractive route for nAMD and other conditions affecting the choroid. Preclinical and animal data suggest that administration via suprachoroidal injection results in more posterior and circumferential distribution of the agent.Gene therapy holds the potential to continuously express therapeutic levels of angiostatic proteins. The completed and ongoing gene therapy trials for nAMD are summarised in PEDF) (AdGVPEDF.11D) in three murine models of choroidal neovascularization (CNV) significantly inhibited neovascularisation.8 particle units (PU) or more of AdPEDF.11 were significantly more likely to remain stable or have a reduction in the size of CNV lesions than patients who received less than 108 PU, suggesting a dose-related response.The intravitreal administration of a transgene vector of AAV5 carrying pigment epithelium derived factor . Another two patients had retinal haemorrhage, one had multiple retinal tears 1 month after injection, and there was a death in the study, with none of these believed to be associated with the procedure or the gene therapy product.Another phase I, dose-escalation study, sponsored by Sanofi Genzyme, evaluated the safety profile of a single intravitreal AAV2-sFLT-1 injection in patients with advanced nAMD (NCT01024998). It is similar to AVA-101, except that it is a fusion protein of the sFLT-1 domain 2 with the Fc domain of IgG1. Nineteen patients were divided into four dose cohorts and followed up for 52 weeks. Four subjects showed substantial and sustained macular fluid reduction through week 52, with reductions of central subfield thickness (CST) ranging from 128 µm to 443 µm. Improvements in VA may have been limited due to pre-existing subretinal fibrosis/scarring and variability in baseline fluid. Overall the intravitreal injection was well tolerated at all doses, although one patient had transient intraocular inflammation at the highest dose  remained free of needing any anti-VEGF injections for 6 months, associated with improvement in vision and retinal thickness.RGX-314 is a recombinant AAV8 vector carrying a coding sequence for a soluble anti-VEGF protein related to ranibizumab. Regenxbio is conducting a phase I/II, dose-escalation study to evaluate the safety and tolerability of subretinal RGX-314 in subjects who have been previously treated with any anti-VEGF drug (NCT03066258). Forty-two patients were recruited and divided into five cohorts of 3×10RetinoStat is an equine infectious anaemia lentiviral vector that expresses angiostatin and endostatin, both of which are inhibitors of angiogenesis. Animal models of rhesus macaques and rabbits have shown that subretinal administration was safe and capable of persistent expression.Hemera Biosciences recently started two phase I trials using intravitreal AAVCAGsCD59 for both nAMD and dry AMD . This molecule targets the terminal step of complement activation that leads to the formation of the membrane attack complex.Gene therapies for nAMD are largely focused on the use of vector systems to express antiangiogenic proteins that either directly or indirectly block the VEGF pathway as discussed earlier. Other possible targets for gene therapy are discussed in the following sections and presented in PDGF mediates the recruitment and survival capabilities of pericytes. PDGF has been implicated in the pathogenesis of several fibrotic conditions and may also play a role in the development of subretinal fibrosis.Tie-2 tyrosine kinase receptor is a potential target present in endothelial cells. The angiopoietin (Angpt)–Tie2 system functions as a key regulator of adult vascular homeostasis.Gene silencing has been attempted via small RNA interference (siRNA), which has been shown to successfully suppress expression of VEGF in mice models.et alVEGF has been found to be efficient and to reduce formation of CNV in preclinical murine models of wet AMD. An alternative to siRNAs is the use of microRNAs, a method that has been previously investigated by the same group of researchers. Intramuscular delivery of AAV containing polycistronic miRNA clusters efficiently silenced VEGF as early as 21 days after delivery in mice.In a study by Askou In summary, AMD is a complex disease with a multitude of pathways involved in its pathogenesis, with this heterogeneity posing therapeutic challenges. The approach to date has been to continuously express anticomplement and/or antiangiogenic proteins . There is no doubt that gene therapy holds promise to ameliorate the social and economic burdens associated with chronic anti-VEGF therapy by providing reliable and sustainable release of antiangiogenic drugs.Several early phase trials have shown significant promise, with final results expected from the associated expansion phases in the near future. The competitive landscape revolves around multiple issues, including (1) the therapeutic target, (2) route of administration and (3) preventing/mitigating immune-mediated responses to viral vector administration. It is likely that anti-VEGF-directed gene therapies will be the first to be approved, whereas the route of administration remains more uncertain, with intravitreal, subretinal and suprachoroidal all being actively investigated and all having relative merits and disadvantages. With respect to inflammation, the nAMD patient population is significantly older than the IRD population receiving gene therapy, which may pose difficulties with tolerability to any systemic immunosuppressive drugs used in the preoperative and postoperative period, but alternatively older patients may be less likely to mount as robust an immune reaction than younger subjects.Gene therapy allows the exciting possibility of expressing more than one active agent over time, with the capability of additional targets to VEGF, potentially resulting in greater efficacy, more sustained effect and being beneficial in patients who currently are poor responders to serial intravitreal anti-VEGFs in routine clinic use. Moreover, a greater understanding of the underlying drivers of inflammation in ocular gene therapy and its prevention/management is needed, as are developments in viral vectors that can be safely delivered intravitreally and have robust expression profiles. These two developments will arguably be game-changing, resulting in safe, readily delivered therapy to millions of patients worldwide with nAMD and potentially other common disorders including diabetic eye disease.It is anticipated that the number of gene therapy trials will increase dramatically over the next 5 years, with cautious optimism of approved therapies within that timeframe.


Whilst any type of bereavement can be traumatic, bereavement through violent or sudden causes is associated with more severe negative health and wellbeing outcomes compared to other types of loss. Social support has been found to have a positive impact on wellbeing after traumatic events in general. However, this association appears to be less consistently demonstrated in studies that focus on bereavement, and the literature in this area has not yet been systematically reviewed. This study aimed to review the international literature to examine systematically whether there is an association between informal social support from family and friends after bereavement through sudden and/or violent causes and post-bereavement wellbeing.We conducted a systematic search for quantitative studies that tested for an association between social support and any outcome related to wellbeing after a sudden and/or violent loss. Included studies were assessed for quality, and findings were reported using the approach of narrative synthesis. The review was pre-registered on Prospero (registration number CRD42018093704).We identified 16 papers that met inclusion criteria, 11 of which we assessed as being of good or fair quality and 5 as poor quality. Fifteen different wellbeing outcomes were measured across all studies. We found consistent evidence for an inverse association between social support and symptoms/presence of depression, predominantly consistent evidence for an inverse association between social support and symptoms/presence of post-traumatic stress disorder (PTSD), and conflicting evidence for an inverse association between social support and symptoms/presence of complicated grief.Our systematic review identified evidence to suggest that social support after sudden or violent bereavement is associated with a reduced severity of depressive and PTSD symptoms. Further longitudinal research is needed to explore potential causality in this relationship, widening the focus from common mental disorders to include other mental illnesses, wellbeing outcomes, and suicide-related outcomes after bereavement. There is also a need for consensus on the conceptualisation and measurement of social support. Our findings imply that interventions to improve access to and quality of social support may reduce the burden of mental illness after bereavement, and may therefore be worth investing in. Bereavement is a stressful life event that can have a long-lasting negative impact on wellbeing and quality of life . All typThis model is compatible with the idea that certain types of loss are more challenging to adapt to than others . Losses Social support has been proposed as protective against the negative effects of stressful life events . Whilst There is limited empirical support for the effectiveness of formal social support interventions following sudden and violent loss , findingThe most recent review of the impact of informal social support on wellbeing outcomes after bereavement was carried out 14 years ago . HoweverTo address an identified gap in current knowledge, our review sought to understand whether informal social support is associated with wellbeing after a loss through sudden and/or violent causes, by synthesising evidence from studies that compared measures of psychological wellbeing in those who received varying levels of informal support after bereavement.We included peer-reviewed primary observational  research studies published as a full paper rather than solely an abstract, which used quantitative methods to investigate the association between social support and wellbeing of adults (18 years old or over) following bereavement through violent and/or sudden death. Violent deaths were defined as those that were unnatural and caused by human action , whereasExposure was defined as participants’ first-hand experience of any form of social support, provided by family or friends outside a formal setting (i.e. excluding peer mentoring groups or care-giving agencies) after their loss. We only included studies in which social support measures had been psychometrically validated regarding one or more of: content, criterion or construct validity. We included studies that assessed the outcomes of: i) psychological wellbeing, defined as positive psychological adjustment, measured using validated indicators of psychological adjustment ; or ii) psychiatric symptoms ; or iii) a measure of service use in relation to mental health problems.Our exclusion criteria were: studies that solely analysed data qualitatively or did not specify cause of death.We registered the protocol for this review with PROSPERO: registration number CRD42018093704. Our search terms combined terms for: sudden or violent bereavement; and informal social support; and mental health or wellbeing  as well as grey literature sources . For each study identified for inclusion in the review, we hand-searched the reference list and used forward citation tracking. We extracted and managed references using Endnote software.In addition to the database searches, we hand-searched from journal inception three relevant journals, For 29 studies that reported they had recorded death type but not distinguished between types of death in statistical analyses, authors were contacted to request further information.To screen references we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines , and some distinguishing between structural support  and functional support (specific functions provided by others) and measuring one or both , and somAcross the 15 different studies, 15 different mental health and psychological wellbeing outcomes were measured. The most frequently measured outcomes were post-traumatic stress disorder , 50, 52,Table In addition to the NOS, we noted that exploratory approaches were common, with multiple statistical models often used in study analyses, reflecting multiple outcomes and exposure variables. There was also great variation in the degree to which analyses controlled for potential confounding variables, and in the specific variables chosen as potential confounders, resulting in a risk of residual confounding in reported estimates.Table There was limited evidence that social support was associated with reduced risk of meeting the threshold for depression diagnosis or reduced depression symptom severity, with seven studies , 47, 48 Four studies , 47, 48 Two more exploratory studies reported a partial positive association between social support and depression. A study judged as fair quality  found thThere was limited evidence that social support was associated with a reduced risk of meeting the threshold for PTSD diagnosis or with reduced symptom severity. All six studies , 50, 52 In the longitudinal study , one , and some of the samples recruited through support groups may have completed measures of social support with reference to their support group rather than informal support from friends and family.Overall, generalisability is limited by the homogeneity of included samples, but cross-cultural validity is relatively good for research in this area with the inclusion of minority and non-Western populations. The inclusion of samples recruited exclusively through support organisations would limit generalisability in these studies to those who have proactively sought help, and are well enough to be involved with these organisations.The conclusions that can be drawn from this review are limited by the lack of published longitudinal studies to clarify the temporal direction of associations. The cross-sectional studies identified do not establish whether social support improves psychological wellbeing following bereavement, or if poor psychological wellbeing following bereavement reduces actual or perceived social support through its impact on relationships with others . EstabliThe findings of this research suggest that professionals supporting those who have been bereaved through sudden and/or violent causes, and especially those bereaved through suicide, should consider how the quantity and quality of available informal social support could be increased as a potential means to improve outcomes for their service users .Priorities for research in this area should be to establish which specific types of informal support are most likely to improve psychological wellbeing, the temporal association between the degree of informal social support and a broad range of psychological wellbeing outcomes after bereavement, and the extent to which the degree of psychological morbidity influences the amount of social support available. The wider social support literature includes evidence to support a bidirectional relationship between social support and PTSD , 72. WhiGiven the inconsistencies in quantitative conceptualisation of the measurement of social support, qualitative research would complement this body of research by providing valuable insights to the bereavement experience in social settings. Qualitative work would also help identify the mechanisms by which some forms of informal social support may impact wellbeing after a loss.This systematic review of studies describing the relationship between post-loss informal social support and psychological wellbeing after sudden and/or violent bereavement suggests that informal social support may be important in improving psychological wellbeing following violent and/or sudden bereavement. However, current evidence is of insufficient quality or quantity to permit robust conclusions. Large, longitudinal studies with demographically varied samples are required to better understand the temporal direction of the relationships between different types of informal social support and psychological wellbeing following sudden bereavement. This information is important to the development and evaluation of programmes to enhance the availability or use of specific types of informal social support for people experiencing sudden and/or violent bereavement.Additional file 1 Appendix 1. Search Strategy. Appendix 2. PRISMA checklist. Appendix 3. Data extraction.


Refugees fleeing conflict often experience poor mental health due to experiences in their country of origin, during displacement, and in new host environments. Conditions in refugee camps and settlements, and the wider socio-political and economic context of refugees’ lives, create structural conditions that compound the effects of previous adversity. Mental health and psychosocial support services must address the daily stressors and adversities refugees face by being grounded in the lived reality of refugee’s lives and addressing issues relevant to them.We undertook a rapid qualitative study between March and May 2019 to understand the local prioritisation of problems facing Congolese refugees living in two refugee settings in Uganda and Rwanda. Thirty free list interviews were conducted in each setting, followed by 11 key informant interviews in Uganda and 12 in Rwanda.Results from all interviews were thematically analysed following a deductive process by the in-country research teams. Free list interview findings highlight priority problems of basic needs such as food, shelter, and healthcare access; alongside contextual social problems including discrimination/inequity and a lack of gender equality. Priority problems relating to mental and psychosocial health explored in key informant interviews include discrimination and inequity; alcohol and substance abuse; and violence and gender-based violence.Our findings strongly resonate with models of mental health and psychosocial wellbeing that emphasise their socially determined and contextually embedded nature. Specifically, findings foreground the structural conditions of refugees’ lives such as the physical organisation of camp spaces or refugee policies that are stigmatising through restricting the right to work or pursue education. This structural environment can lead to disruptions in social relationships at the familial and community levels, giving rise to discrimination/inequity and gender-based violence. Therefore, our findings foreground that one consequence of living in situations of pervasive adversity caused by experiences of discrimination, inequity, and violence is poor mental health and psychosocial wellbeing. This understanding reinforces the relevance of feasible and acceptable intervention approaches that aim to strengthening familial and community-level social relationships, building upon existing community resources to promote positive mental health and psychosocial wellbeing among Congolese refugees in these settings. Globally more than 70 million people are displaced, with over 80% in countries neighbouring their country of origin , many inConceptual frameworks aid our understanding of the complex and cyclical relationships between the ecology of refugee settings - including familial, social, community, and structural context such as conditions of poverty and disadvantage - and mental health and psychosocial wellbeing. These include frameworks that foreground conditions of adversity that arise through daily stressors such as difficulties accessing basic necessities of food and shelter , 11 and Design, Implementation, Monitoring and Evaluation (DIME) rapid qualitative approach [Consequently, to be acceptable and successful, approaches to MHPSS services must be rooted in the daily stressors and adversities refugees face, situating mental health and psychosocial problems in their socio-cultural context. To achieve this, research to understand local community needs and priorities is critical , 20. Gaiapproach  with Conapproach  which wifree-list interviews with local community members to identify problems the community face and a brief description of each. The results are analysed to identify priority problems relating to mental health and psychosocial wellbeing. Second, the priority problems are further explored in key informant interviews with community representatives knowledgeable about the selected topics. We conducted the study in each site (30 free list and 10–15 key informant interviews). Interviews were conducted in Kinyarwanda in Rwanda, and Congolese Kiswahili in Uganda.We applied the DIME rapid qualitative approach developed and applied extensively with adults in low resource settings , 21, incOver the last two decades, the Democratic Republic of the Congo (DRC) has experienced three large-scale conflicts: the First Congo War (1996–7) and Second Congo War (1998–2003), and the Kivu Conflicts in Eastern DRC which continue to date , 27. As Gihembe refugee camp was established in 1997, and as of March 2015 hosts 14,774 refugees  in 3030 Congolese refugees have experienced evolving Ugandan and Rwandan refugee policy and practice, with both countries recently committing to the United Nations Comprehensive Refugee Response Framework , 33. UgaGiven the long and complex history of conflict in the DRC and the Great Lakes Region more broadly, refugees in these settings have been displaced at different times . Gihemben = 60) purposively selected according to the inclusion criteria: Congolese refugee living in Gihembe/Kyangwali, over 18 years of age, fluent in Kinyarwanda or Congolese Kiswahili, and able and willing to talk to the research team. Participants were recruited from a selection of villages/neighbourhoods (umudugudu in Kinyarwanda) spread geographically across each site, with efforts made to achieve gender and age-range representation.We interviewed male and female adult Congolese refugees living in Gihembe Camp, Rwanda; and Kyangwali Settlement, Uganda. Free list interviews were conducted with a convenience sample of 30 participants in each site . This approach aims to ensure that interview responses prioritise local community perceptions of problems and solutions, rather than views underpinned by professional training . The demResearch was conducted between March and April 2019. Twelve interviewers in Kyangwali , and 8 in Gihembe  who spoke the participants language were locally recruited. All interviewers received a 3-day training in the basic principles of qualitative interviewing, including how to conduct free list (FL) interviews, and the key principles of ethics including obtaining voluntary informed consent.FL interviewers worked in pairs, one asking questions and probing responses, and the second making a verbatim written record of what was said in the local language. Each FL interview lasted between 20 and 45 min. In FL interviews participants were asked to list all the problems that adults living in Gihembe/Kyangwali face, and to provide a 1–3 line description of each. At the end of each interview the transcript was reviewed to ensure clarity of the written record, and the interviewers reviewed the list of problems to identify those that might be related to mental health and psychosocial wellbeing . IntervFollowing FL interview data analysis to select priority problems (described below), key informant (KI) interviews were conducted to gather more detailed data on the priority problems relating to mental health and psychosocial wellbeing. Interviewers were provided an additional 1 (Gihembe) or 1.5-day  training for KI interviews, covering asking open-ended questions and probing skills, and refreshing key principles of research ethics and voluntary informed consent. In KI interviews the participants were asked to provide: a) a description of the problem, including symptoms and effects; b) perceived causes of the problem; c) effects of the problem on the individual and those close to them; d) what people currently do about the problem; and e) what people think could be done about the problem. Interviewers again worked in pairs with one asking questions and the other recording a written summary responses in the local language. Creating a written record is the recommended DIME approach, which seeks to facilitate rapid data collection and analysis in humanitarian settings. Written transcripts were reviewed with the KI at the end of each interview to ensure clarity of meaning and completeness. Each KI interview lasted on average 60 min, including obtaining consent. Should the participant have more to say or be knowledgeable about additional problems identified for KI interviews, interviewers would agree a subsequent date and time to continue the interview.Ethical approval for the study was provided by the University of Liverpool, the University of Makerere, Uganda National Council for Science and Technology, and the University of Rwanda. Additional administrative approvals were obtained to conduct research in the Kyangwali refugee settlement and the Gihembe refugee camp.All participants were approached by interviewers, provided a brief description of the study, and asked if they would consider taking part. If in agreement the interviewers would find a quiet location to discuss the participant information sheet, answer any questions, and complete a written informed consent form with the participant, including consent to reporting anonymised research results. For illiterate participants a line or mark was accepted in lieu of a signature, alongside witness confirmation (a participants’ nominated family member or friend) of the voluntary nature of consent. Participants were free to pause or end the interview at any time without repercussions, and were provided refreshments during the interviews. Study trainers were available throughout data collection and analysis, and conducted daily team de-briefs. All data was anonymised through participant identification numbers. The only exception to this was the names of potential KIs recommended by FL participants which were recorded separately to FL data and destroyed once interviews had been conducted.All data was analysed in the original languages at each site by the interviewers, supported by the trainers who were provided verbal translations where required. A thematic analysis approach was applied that was deductively driven by the interview questions, as recommended in the DIME manuals. For FL analysis interviewing pairs reviewed written FL interview transcripts and listed problems and their reporting frequency on a summary sheet. When problems were worded differently a consensus decision was made as to whether the items were the same or different to one another. When the same, the most appropriate wording was selected for the summary sheet by consensus. If no consensus could be reached, both items were listed as separate problems. Once complete, the problem lists were re-ordered by frequency alongside a single brief description using the participants wording that interviewers agreed best described the problem. Summary sheets were then reviewed with local community stakeholders (representatives of organisations in the refugee settings) to identify problems potentially related to mental health and psychosocial problems - defined as those relating to thinking, feelings and relationships - to explore in KI interviews. Additional considerations in the selection of priority problems included that they were mentioned by multiple respondents and contained descriptions that appeared to be severe in terms of impact.A similar process was followed for KI interviews analysis with the interviewers and trainers reviewing written transcripts and recording responses to: a) description; b) perceived causes; c) perceived effects on the individual and those close to them; d) what people currently do; and e) what people think could be done. These responses were compiled into summary tables alongside the codes of participants. Where participants had reported what interviewers agreed was referring to the same thing the interviewers would agree the wording of the item and record both participant codes alongside it.For the purpose of reporting the data has been translated into English, with original language terms - in Kiswahili for Uganda, or Kinyarwanda in Rwanda - retained where relevant. Analysis was conducted independently at each site, before the results were compared across the two sites. This approach sought to ensure analytical attention to the specificities of the data at each site, before considering the data sets alongside one another to identify potential commonalities and differences in the experiences of Congolese refugees in two settings, following previous DIME studies that have adopted this approach .The Uganda and Rwanda FL results are provided alongside one another. We then identify the priority mental health and psychosocial problems selected for KI interviews, and present KI interview results for thematically similar problems explored across both sites.n = 30) and Rwanda (n = 30) in decreasing order of frequency.In Table Across both settings the most commonly reported problems relate to daily living such as poverty, unemployment, and lack of healthcare access and education opportunities. Alongside these participants reported social problems including alcohol and drug abuse, sexual and gender-based violence, teenage pregnancy, and discrimination/segregation. Problems related to their refugee status were also highlighted, including difficulties obtaining official papers or in Rwanda obtaining employment if one’s status is identified as “refugee”, and a lack of resettlement opportunities. This problem was mentioned more often by refugees in Rwanda as compared to Uganda, which may reflect that the majority of study respondents had been living in Gihembe for over 21 years.(ubaguzi) (n = 8), no intervention for torture and trauma victims  (n = 4), domestic violence (ukatili wa nyumbani) (n = 3), and alcohol and substance abuse (kutumia pombe na madawa ya ulevi mubaya) reported as “drunkardness/alcoholism” (ulevi) (n = 2). After discussion between the Ugandan research team and local stakeholders the problem of alcohol abuse was expanded to incorporate substance abuse because these were felt to be interconnected problems that should be considered holistically. In Rwanda KI interviews explored unwanted pregnancies amongst girls (n = 7), inequity/inequality (ubusumbane) (n = 4), sexual and gender-based violence (ihohoterwa rishingiye kugitsina) (n = 3), and drug abuse (kwishora mu biyobyabwenge) (n = 3). We chose further explore the problem of discrimination (Uganda) and inequity/inequality (Rwanda) because as a problem related to social relationships and cohesion this was felt demand require further unpacking to consider its relationship to mental wellbeing.Problems potentially related to mental health and psychosocial wellbeing  selected for KI interviews in Uganda include discrimination We summarise KI interview responses for mental health and psychosocial problems across the two sites that explore similar themes of social inequalities, sexual and gender-based violence (SGBV), and alcohol and drug abuse. The results are drawn from 11 KI interviews in Uganda, with 7 respondents exploring all three problems, and 4 addressing one or two; and 16 KI interviews in Rwanda, with 4 respondents exploring each problem.ubaguzi, Uganda, Table ubusumbane, Rwanda, Table First we present the results for the problems of discrimination . These differences potentially reflect the refugee communities in each setting, with Uganda hosting a greater diversity of nationalities, languages, and ethnic origin.ukatili wa nyumbani, Uganda, Table ihohoterwa rishingiye kugitsina, Rwanda, Table Second, we present results for the problem of domestic violence . We adoProblem FL findings reflect dimensions of human development as conceptualised by the United Nations, which builds on Sen’s work on human capabilities . Brieflygetting lost on the road, being dirty everyday and falling down while walking and talking obscene and also fighting. These descriptions echo another aspect of the COSTAR study which explored what FL participants consider to be a ‘good life’. Findings identified the role of outward appearance and dress which are linked with self-esteem and how a person is viewed in the community, including the avoidance of shame .Building on the FL findings, KI interviewees’ exploration of priority mental health and psychosocial problems bring out their common roots in problems of social cohesion. The relationship between alcohol and drug abuse and mental health problems has been explored in research with Burundian refugees , includilack of love for one another, back-stabbing among different tribes and not respected because you are a refugee. Whilst in Uganda intra-community tensions were structured by gender, tribal, linguistic or religious affiliations; in Rwanda, inter-community inequities were more commonly reported, arising between the treatment of refugees compared to Rwandan nationals. The difference in the internal/external conceptualisation of these problems is potentially related to the structural environment in which refugees are embedded, emphasising the role of the social, economic and political systems for how refugees relate to one another [neglect and mistreatment. These echo studies exploring violence and protection risks for adolescent refugees living in refugee settings in Uganda that highlight the complex interplay of societal norms towards violence [These connections are echoed in KI findings relating to discrimination/inequity where participants described a  another , and theviolence ; and conviolence . Therefofighting, hatred within villages, jealousy among people and to lose hope. These effects indicate both low levels of social cohesion seen in a lack of connectedness or sense of belonging, as well as feelings of hopelessness, indicating low levels of mental wellbeing. The interconnected relationship between low levels of social cohesion and poor mental health outcomes has been identified in a recent study with Congolese refugees in Rwanda that highlights the relationship between mental health problems and suicidal ideation, and social cohesion including a low sense of connectedness and belonging [Specifically, our findings foreground that problems of social cohesion in family and community relations negatively impact the mental health and psychosocial wellbeing of Congolese refugees in Gihembe and Kyangwali. This is evident in participant’s descriptions of the effects of problems, for example for the problem of inequity/discrimination participants’ identify this leads to: elonging . Our finelonging –13.feeling despair, self-isolate and disowning oneself, sadness, lack of self-worth/respect and wanting to forget many bad thoughts, reflecting previous research with conflict-affected populations that identified a common syndrome with core features of sadness and social withdrawal that bore similarities to classifications of mental states such as depression or anxiety [What is absent from the data is the spontaneous identification of problems that directly reference psychological or emotional states commonly recognised in the US and Europe, such as depression or anxiety. Whilst the data does reveal descriptions that may capture culturally bound idioms of distress  such as  anxiety . In this anxiety . It is a anxiety , with re anxiety . Our fin anxiety , 51, 52.Consequently, the problems impacting upon mental health and psychosocial wellbeing in this study have their roots in disruptions to social cohesion. As such, proposed interventions should build on interpersonal, familial and community-level supports  to suppoA unique contribution from this study is the comparison of findings collected with the same methodology in two sites hosting Congolese refugee populations. This is important for understanding the commonalities and differences between the experiences of Congolese refugee communities living in two distinct settings, and for identifying potential opportunities for group-based psychosocial programs to help address the identified problems. Potential study limitations include the number of key informant responses for each problem, notably in Rwanda where adverse weather led to limited access to Gihembe camp to collect data within timelines. However, the high level of congruence of themes, and their confirmation at meetings with community stakeholders including organisations supporting refugees and refugee community representatives, suggest findings are broadly representative of the experiences of Congolese refugees living in Gihembe camp and Kyangwali settlement. Finally, whilst efforts were made to ensure a broad sample including mixed gender, ages, and length of time in the refugee setting to capture the potential diversity of experiences resulting from participant characteristics that affect their daily living, it is possible that the gender affiliations of our research assistants may have affected the engagement of some potential participants.The DIME approach applied in this study has two interrelated objectives  to eliciRecognising the importance of anchoring MHPSS interventions in the context of refugees’ everyday lives, this rapid qualitative study has explored the priority problems of Congolese refugees living in two settings in Uganda and Rwanda. Our study makes an important contribution to the literature on the position of Congolese refugees by exploring the commonalities of experiences across two distinct refugee settings. Notably, findings reveal significant commonalities in the priority problems related to mental health and psychosocial wellbeing that are rooted in problems of social cohesion within refugee communities and between refugee and host communities. This understanding reinforces the importance of proposed intervention approaches that strengthen familial and community-level social relationships to promote positive mental health and psychosocial wellbeing, alongside addressing structural conditions that lead to forced migration and conditions of daily adversity that precipitate mental health problems –13, 53.


Implant-associated infections remain a tremendous challenge, and all efforts should be taken to improve the prevention and treatment of this entity. A critical factor in the establishment of implant-associated infections is the colonization of the implant surface and subsequent biofilm formation by bacteria or fungi in the context of the “race for the surface” Antimicrobial coatings technologies offer the option of local protection of the implant surface against the above-mentioned implant colonization and biofilm formation of microorganisms. Despite tremendous research in this field, there are currently only a few clinically available implants with antimicrobial coatings on the market In the narrow sense, implant coatings include technologies with direct modification of the actual implant surface , which can directly be used by surgeons in the operating room. These technologies mainly consist of systems that release agents with antimicrobial activity such as silver, gentamicin and povidone-iodine. These compounds are attached directly to the implant surface during the manufacturing process by orthopaedic device companies clinicaltrials.gov).Implant coatings are different from surface treatment of implants by surgeons. In the latter, the surgeons apply a compound directly to the metallic surface of the implant immediately prior to implantation. Hydrogels or other antimicrobial drug delivery systems, such as antibiotic-loaded calcium sulfates and calcium phosphates, belong in this category Most experimental coatings involve antibiotics or antimicrobial compounds that have been tested in the laboratory setting. Novel compounds include CZ-01127 that allow elution of high antibiotic concentrations Regarding direct coating technologies, passive modification of the implant surface design with modification of its morphology or hydrophilic/hydrophobic properties is another theoretical approach to prevent bacterial adhesion and improve the implant's robustness against infection, but none of these technologies have reached market approval yet in vitro data for orthopedic devices, there is still a lack of human clinical data Current regulatory requirements are challenging for the market approval of antimicrobial coated implants in the orthopaedic field Clinical safety of all currently available technologies has been demonstrated. There is growing evidence to reduce infection rates by direct coatings, mainly for certain antibiotics, silver and povidone iodine. However, these data have been mainly derived from case series or cohort studies on megaendoprostheses in orthopaedic oncology and complex revision cases with an elevated (re)infection risk, but not from prospective randomized controlled trials. Alternative “indirect” coatings,  have not been officially approved as implant coatings. Future technologies, such as covalently bonded antibiotics or silicone-based coatings, are on the horizon but will have to undergo complex regulatory approval processes before their official clinical use.In conclusion, the given clinical safety of the currently available coatings justifies the use of antimicrobial coated implants in “high risk” cases, but individual risk benefit analysis should be performed for each single patient. The orthopaedic community, industry and regulatory agencies are urged to pave the way for further and sound clinical evaluation regarding clinical efficacy of antimicrobial coated implants in randomized controlled clinical trials.