We analyze food-item level data collected from 50 adults from the United States using the Remote Food Photography Method® to provide the first estimates of plate waste gathered from adults across multiple consecutive meals and days in free-living conditions, and during laboratory-based meals with fixed food items and quantities. We find average plate waste in free-living conditions is 5.6 grams  per item and that 3.3% of all food selected is returned as plate waste, where the percent waste figure is substantially lower than previously published plate waste estimates gathered primarily from dine-out settings in the United States such as buffets and institutional settings with limited-choice meals . Plate waste from the same participants during the laboratory-based meals is significantly higher with an average of 203.2 grams of solid plate waste per meal  or 39.1% of the food provided, which is similar to the plate waste percentages found reported in some school cafeteria settings. The amount of plate waste generated in free-living conditions is significantly positively associated with portion size selected for an item. In a multivariate analysis that controls for macronutrient profile, items selected from the vegetables, fats/oils/dressings, and grains categories are associated with significantly greater amounts of plate waste per item. We find no significant associations between free-living plate waste and gender, age, race or body mass index but find that women leave more plate waste in the lab meal where portion sizes are pre-determined by the researcher and similar for all respondents. We discuss possible implications of these findings for programs focused on reducing plate waste and food waste among consumers. Countries around the world have resolved to reduce food waste in an attempt to advance food security, environmental sustainability and economic efficiency goals –4. More Most plate waste studies from the United States have been conducted among children in schools that participate in the National School Lunch Program (NSLP). Buzby and Guthrie  summarizWhile each study provides key information on plate waste, estimates taken from students may not yield estimates that translate well to the broader food sector as (1) it only considers consumption patterns of students, (2) most studies involve meals with predetermined portion sizes (rather than self-selected by the participant) chosen from a limited set of available menu items and (3) many students do not bear the cost of the food that is chosen because school meals are free or paid for by parents. Studies featuring adults that report percent waste figures range from 7% to 18% –25 whileThe studies featuring participants 18 years and older occur either in a no-price fixed-menu buffet setting , in fixeThe research closest to our work features detailed household diary data collected and analyzed in the United Kingdom for all sources of food wasted by a household while dining at home . For theIn this study we analyze food-item level data collected from 50 adults from the United States using the Remote Food Photography Method® (RFPM) to provide estimates of plate waste gathered from adults in free-living conditions across multiple meals and days. By free-living, we mean that respondents recorded plate waste data as part of their normal day-to-day routine featuring food selections chosen from foods acquired in their normal manner rather than in a meal setting designed by the researcher. Respondents had no direction from the researcher concerning the types or amounts of food selected nor was data collection limited to settings in which food selection was constrained by institutional demands, e.g., school cafeterias or limited-menu buffets, or restricted to only meals eaten at home, e.g., household food waste diaries. In addition, we have data recorded using the same method from two meals prepared and provided by the researchers to each respondent in a laboratory setting. Hence, we have the first known instance where plate waste is recorded for the same respondents both in free-living and lab conditions.Data were collected from participants during all eating occasions over approximately one week in participants’ free-living conditions; this includes all times of day, weekends as well as weekdays, and food at home as well as food away from home. Data were also collected at two meals provided during laboratory-based sessions. The data were acquired via the RFPM®, which has been previously described and validated –35. BrieCompared to alternative approaches such as written food diaries, participant burden is reduced as participants need only capture and send cell-phone photos of their plates before and after eating, and these procedures are now streamlined via the SmartIntake® app. The photos are automatically received by our server for analysis, where the research team uses a computer-assisted approach to identify a match for each food in a nutrient database and estimates portion size based on established and validated procedures , 37, 38.Participants were also asked to come to the research center two times to consume laboratory meals. These meals were weekday lunches where participants were asked to take a picture of their food selection and plate waste. Participants were instructed to eat normally prior to arrival; neither meal occurred during the free-living conditions data collection period. At enrollment, participants selected from a limited offering of sandwiches with different types of lunchmeat and condiments, and they selected a beverage. Thus, lunch meat sandwiches ) and drinks  varied based on the preferences of the participant. The meals also consisted of a fixed amount of pretzels ), fruit cup , and cookies . 44 of the 50 respondents participated in both meals.The study sample includes 50 adults age 18 to 65 years recruited from the Baton Rouge, Louisiana region. Participants were generally healthy and were not diagnosed with chronic health conditions or diseases, including diabetes, cardiovascular disease, and cancer. Participants were also free of medication use that affected body weight and were weight stable (≤500g weight change over approximately one week).Results are analyzed in Stata (version 14.2). Demographic variables available include gender, age, race and Body Mass Index where summary statistics for these variables are listed in t-test constructed with robust standard errors clustered at the subject level. Multivariate analysis explaining the waste amount is performed via a censored (tobit) regression analysis, which is estimated via maximum likelihood and features standard errors clustered at the subject level. A censored regression analysis is chosen because the dependent variable features a high percentage of zeros, which is known to bias regression coefficients estimated via ordinary least squares.Food item variables include the number of servings selected, grams selected, caloric density , the FDNNS food group, and the percentage of energy from protein, fat, and carbohydrates. The definition of servings for each type of food is based upon the most appropriate portion size image that, in some instances, leads to a high serving count for a small amount of food . Thus servings are not necessarily manufacturer standard servings nor USDA standard servings, but are likely the standard that allows for the best portion size estimation . Summary statistics for food-level items are presented in This study was approved by the Pennington Biomedical Research Center (PBRC) Institutional Review Board and were registered at clinicaltrials.gov NCT 01678885. All participants signed informed consent forms after being briefed on the study and having all questions answered by research staff.Average per-item plate waste was 5.63g  and 7.69 kcals , which cAcross the 2,400 items of food selected by the 50 participants during the course of the study, the average item consisted of 1.86 servings  are wasted in larger amounts than other items. Correlational analyses between plate waste and the continuous variables  –28 24–28Third, this study tracked both food and beverage waste, whereas much of the previous work featuring adults generally focuses on solid foods only .Fourth, the food selected by participants in the free-living portion of this study was not exclusively obtained from buffet or institutional settings. The buffet settings in the reported extant literature allow individuals to select as much as they care to eat either for a fixed price –23, for Another distinguishing characteristic of this study is the ability to connect plate waste data to individual characteristics. While we find no significant differences across demographic categories for items selected in free-living conditions, we do find that females leave significantly more plate waste than males in the lab meal, which is consistent with previous findings that women waste more food in dining settings . It alsThe RFPM® used in this study has been validated as an accurate approach for measuring energy and nutrient intake among adults in free-living conditions, and a key element of this approach is the expert assessment of photographs of plate waste. The method permits analysis on an item-by-item basis and provides details concerning both the amount selected and the amount left by participants. The 2,400 items analyzed in this study are classified into 407 distinct standard food codes, which is linked via FNDDS to provide detailed nutrient profiles for each item. Most extant studies of adults were unable to capture this degree of granularity concerning selection and waste. Exceptions include household food waste diary studies , 7, thour = 0.22). Both provide an indicator of the portion size selected by the subject. Larger portion sizes have been associated with greater consumption in a number of studies . Howeves . For thWe find that the waste amounts on a per-item basis for items in the vegetable; fats, oils and salad dressings; and grain products are relatively high compared to other food groups. Plate waste studies conducted in NSLP settings often find fruit and vegetable waste rates are among the highest categories of waste, e.g., , 16, 39.Finally, we note that plate waste from free-living conditions was substantially lower than plate waste observed in a lab meal among the same sample respondents. This likely reflects differences in selection flexibility, where in free-living conditions sample respondents have normal levels of autonomy in selecting food amounts while in the lab meal they were provided a relatively fixed amount of food with little flexibility in altering the amount or components. Given normal differences in caloric intake between women and men and the fixed quantities provided to all respondents, the significantly larger percent of food returned as plate waste among women is not surprising and is similar to other results in the literature , 26. ThiWe do not know if the measured plate waste in this study was discarded or stored for future consumption. If a large portion was stored for future consumption and then actually consumed, it would mean that even a smaller portion of served food goes unconsumed than we report. Given this possibility, we advise interpreting the plate waste figures as an upper bound on the amount of food wasted by our sample as plate waste. Further, this study did not capture food waste that occurs during food preparation and via refrigerator/freezer and cabinet cleanouts, discarding spoiled foods, etc.The data from this sample obtained during free-living conditions is reported at the item level and day level, but is not associated with specific eating occasions  and does not distinguish between meals taken at home versus in dine-out settings. In addition, the data is limited in that we have only the information from a single individual rather than from all individuals in a household. Adding this type of information could allow for additional insights into which dining occasions and household types yield greater waste.The test meal provided subjects in this study contained 1136 on average, which may be more calories than most of our subjects would select in naturalistic dine-out or cafeteria settings. While such calorie levels are not unusual for some popular dine-out settings , it mayvis a vis possible implications for household food waste. While this study involved no manipulation concerning portion size, other studies that have manipulated plate size downward in an attempt to reduce portion size [Our study yields plate waste figures considerably lower than those in the previous published literature. Given the validity of the RFPM® for measuring food selection, plate waste, and food intake, we introduce the possibility that at least one component of total food waste  is a smaller concern than previous thought and that a larger proportion of food waste occurs during food preparation and through discarding spoiled or unwanted food. Indeed, when our sample consumes a meal served to them in a laboratory setting with fixed quantities, the amount and percent of plate waste is substantially higher than those observed in free-living conditions and more in line with waste rates observed in National School Lunch Program settings where portion sizes and meal content are also not independently determined by the consumer. Our sample is small (n = 50), primarily female and taken from a single region, however, and future measurement is needed to establish more robustly the typical levels and patterns of plate waste generated in a variety of eating occasions and settings. Our finding that plate waste in free-living conditions increases with portion size (grams selected) reinforces results from the literature and suggests that interventions aimed at portion size control may warrant further investigation ion size  found inWe also note that total Figs  and 2 anS1 Table(DOCX)Click here for additional data file.S1 File(CSV)Click here for additional data file.


A growing body of scientific literature suggests that not only changes in skeletal muscle mass, but also other factors underpinning muscle quality, play a role in the decline in skeletal muscle function and impaired mobility associated with aging. A symposium on muscle quality and the need for standardized assessment was held on April 28, 2016 at the International Conference on Frailty and Sarcopenia Research in Philadelphia, Pennsylvania. The purpose of this symposium was to provide a venue for basic science and clinical researchers and expert clinicians to discuss muscle quality in the context of skeletal muscle function deficit and other aging-related muscle dysfunctions. The present article provides an expanded introduction concerning the emerging definitions of muscle quality and a potential framework for scientific inquiry within the field. Changes in muscle tissue composition, based on excessive levels of inter- and intra-muscular adipose tissue and intramyocellular lipids, have been found to adversely impact metabolism and peak force generation. However, methods to easily and rapidly assess muscle tissue composition in multiple clinical settings and with minimal patient burden are needed. Diagnostic ultrasound and other assessment methods continue to be developed for characterizing muscle pathology, and enhanced sonography using sensors to provide user feedback and improve reliability is currently the subject of ongoing investigation and development. In addition, measures of relative muscle force such as specific force or grip strength adjusted for body size have been proposed as methods to assess changes in muscle quality. Furthermore, performance-based assessments of muscle power via timed tests of function and body size estimates, are associated with lower extremity muscle strength may be responsive to age-related changes in muscle quality. Future aims include reaching consensus on the definition and standardized assessments of muscle quality, and providing recommendations to address critical clinical and technology research gaps within the field. A symposium was convened at the 2016 International Conference on Frailty and Sarcopenia Research  to discuss the impact of muscle quality on age-related muscle dysfunction and to explore approaches to standardized assessment. Adverse changes in muscle tissue composition have long been acknowledged as a contributor to the diminished muscle performance observed in older adults  or dual energy X-ray absorptiometry (DXA) whole body fat, myosteatosis has been associated with insulin resistance and an increased risk of developing type-2 diabetes  age, (2) race/ethnicity, (3) aerobic fitness levels, (4) sensitivity to insulin, (5) amount of physical activity, and (6) anatomical region. Myosteatosis has been found to increase with age, and the deposition of ectopic fat accelerates over time  has thus far probably been the most utilized as a research tool to investigate myosteatosis. It is basically assessed indirectly using muscle attenuation calculated CT imaging scan, leading to close correlation with direct measurements of muscle lipid content  or lipid droplets surrounding myocytes  for sarcopenia staging, but it does not yield useful information concerning muscle quality based on adverse changes in muscle tissue composition. Both MRI and CT do provide estimates of muscle tissue composition, but CT is limited by its relative high ionizing radiation exposure, and MRI use is often beset by concerns related to access and cost. Standard segmental bioimpedance analysis (BIA) or refinements such as multi-frequency electrical impedance analysis could prove to be a non-imaging modality capable of characterizing elements of muscle quality. The phase angle derived from BIA has been associated with diminished strength in older adults and serial measures may partially reflect age-related changes in muscle tissue  and echogenicity as a proxy estimate of muscle tissue composition revealed that estimates of muscle quality via sonographic imaging were independently associated with relative grip strength, whereas LBM was not . Indeed, the study participants with higher levels of BMI and LBM (LBM > 6.75 kg/m2) exhibited lower levels of relative grip strength in comparison to those with lower levels of BMI and LBM with Class I sarcopenia  upon measuring a muscle mimetic ultrasound phantom utilizing up to 10 N of applied force. This demonstrated ability to obtain consistent image measurements at relatively high forces may have clinical implications given that the observed applied forces by sonographers may range from 5 to 14 N during abdominal examinations  is characterized by progressive disability leading to death and it remains one of the most common and devastating neuromuscular disorders of childhood , also suffers from operator-dependent and acquisition state variation discussed above. Ultrasound elastography limitations have been identified by scientists and clinicians in the context of technique performance, clinical utility, and work-flow. The most frequently acknowledged limitation is repeatability and reproducibility. A few confounding factors introduce bias and variation in stiffness measurement, including operator dependence, concerning both strain elastography and SWE, and cross-vendor system dependence of SWE caused by different shear wave excitation mechanisms, tissue mechanical models, and signal processing involved in stiffness reconstruction. Before ultrasound elastography can be fully adopted as a routinely used clinical tool for diagnosis and therapy monitoring, these technical and clinical challenges must be overcome by the entire industry.Soft tissue is mechanically non-linear, meaning that elastography measurement varies with the operator-applied transducer force . Preload-induced variation may lead to inaccurate diagnosis and poses challenges to establishing measurement standardization and clinical guidelines. Even with SWE, which is considered more operator-independent than strain elastography, stiffness measurement on the same tissue can vary significantly. The results in Figure Knowing and controlling the position and orientation of an ultrasound probe on the body is also a central issue to reducing variability over serial examinations. Local skin appearance can be used to help relocate a probe on the body. This is accomplished by attaching a small camera to an ultrasound probe and capturing high magnification images of the skin at the same time as the ultrasound images.Patterns of skin features are unique when viewing a sufficiently large area of skin and include micro reliefs, follicles, moles, and melanin variation Figure . This unThe process involves simultaneously recording, synchronously in time, ultrasound probe images inside the body and camera images of the skin. Skin features are used to track relative motion along the body. The same skin features can be used to virtually identify and tag unique locations on the body; this system permits placement of the ultrasound transducer in the same body location and orientation by different operators on serial examinations. In practice, multiple sources of information, e.g., camera images and ultrasound images and known regularities motion smoothness, are combined for optimal probe pose estimation. In this way, a body-contoured skin map is constructed and each ultrasound image is accurately localized with respect to the map—a process termed simultaneous localization and mapping  ultrasound volume derived from a standard optically tracked two-dimensional sonogram. Consequently, an ultrasound probe may be approximately registered/relocated at a known location and orientation with respect to patient coordinates. The 3D volume could be used to generate multi-planar images which should be nearly indistinguishable from directly acquired ultrasound images , negatively impact muscle quality and merit further consideration. ROS plays an extremely important role in all muscle functions and is closely related to muscle aging, contraction, fatigue, dystrophy or waste, but this topic was beyond the goals of symposium . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer ZL and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


Helicobacter pylori is a spiral-shaped bacterium that grows in the digestive tract and may be present in more than half of the world’s population.The clinical features of Helicobacter pylori range from asymptomatic gastritis to gastrointestinal malignancy. Mucosa-associated lymphoid tissue (MALT) lymphoma is a low-grade B-cell marginal zone lymphoma and Helicobacter pylori has been detected in more than 75% of the patients with MALT lymphoma.Many tests for the detection of Helicobacter pylori are available, including antibody tests, urea breath tests, stool antigen tests and endoscopic biopsies.The eradication of Helicobacter pylori usually prevents the return of ulcers and ulcer complications even after appropriate medications such as PPIs are stopped. The eradication of Helicobacter pylori is important in the treatment of the rare condition of the stomach known as MALT lymphoma. The treatment of Helicobacter pylori to prevent stomach cancer is controversial.Confirmation of eradication is recommended in associated ulcers, persistent dyspepsia despite a test-and-treat approach, MALT lymphoma, and previous treatment for early-stage gastric cancer.The urea breath test and stool antigen test can be used to confirm the eradication and should be performed at least 4 weeks after the completion of therapy.Several diseases have been reported to be associated with Helicobacter pylori infection, including hematologic diseases, such as ITP, idiopathic iron deficiency anemia and vitamin B12 deficiency. There is a positive trend in the association between Helicobacter pylori infection and neurodegenerative disorders and new data showed a reduced risk of death due to stroke and lung cancer but an increased risk of preeclampsia in infected women, which requires further investigations. It infects the stomach during childhood. In developing countries, children are very commonly infected. Helicobacter pylori may be passed from person to person through direct contact with saliva, vomit, or fecal matter. Risk factors for Helicobacter pylori infection are related to: living in crowded conditions - living in a home with many people, living without a reliable supply of clean water, living in a developing country, living with someone who has a Helicobacter pylori infection.Helicobacter pylori is a spiral-shaped bacterium that grows in the digestive tract. Helicobacter pylori infection has a very high prevalence . Helicobacter pylori is adapted to live in the harsh, acidic environment of the stomach. These bacteria can change their environment and reduce their acidity thus allowing them to survive. While infections typically do not have symptoms, they can lead to other diseases, including peptic ulcers (about 10% of the people infected with Helicobacter pylori) and gastritis. The long-term use of non-steroidal anti-inflammatory drugs also increases the risk of peptic ulcers. Helicobacter pylori gastritis causes a mixed acute and chronic inflammatory reaction, stimulating both neutrophils and eosinophils, as well as mast and dendritic cells. While Helicobacter pylori has been traditionally considered a non-invasive pathogen, recent studies have shown that it is a facultative intracellular bacterium of innate immune cells, capable of interfering with the phagosome maturation which could explain the difficulty in eradicating the bacteria. Helicobacter pylori infection, along with Ebstein-Barr infection, are known risk factors for gastric carcinoma [Clinical features3]. The clinical features of Helicobacter pylori range from asymptomatic gastritis to gastrointestinal malignancy. An antral-based gastritis occurs in up to 95% of the infected patients and predisposes to duodenal ulcers, whereas the less common corpus-predominant gastritis is a risk factor for gastric ulcers. Up to 50% of the gastric ulcers and 80% of the duodenal ulcers are associated with this infection and the eradication of the organism significantly reduces the risk of ulcer recurrence [4]. The most common manifestation of Helicobacter pylori is gastritis. Immediately after infection, the bacteria will cause an acute form of gastritis, characterized by hypochlorydia, which will later evolve into a chronic active gastritis that can affect either the antrum , the corpus (associated with gastric atrophy and achlorhydria) or both [3]. Patients with intestinal metaplasia (on routine biopsy) should be tested and treated for infection with Helicobacter pylori because intestinal metaplasia is an independent risk factor for gastric malignancy. After the eradication of the organism, the extent to which there is a regression of metaplasia is not currently known. Gastric adenocarcinoma from Helicobacter pylori infection develops through a sequence of gastritis → atrophy → intestinal metaplasia → dysplasia → carcinoma  [3]. Patients who undergo endoscopic resection for an early-stage gastric cancer with remaining gastric mucosa should be tested and eradicated because of the risk of metachronous neoplasia.Helicobacter pylori is a group I carcinogen. Mucosa-associated lymphoid tissue (MALT) lymphoma is a low-grade B-cell marginal zone lymphoma and Helicobacter pylori has been detected in more than 75% of the patients with MALT lymphoma. Patients with an early-stage disease are most likely to have a complete remission with the antibacterial treatment and those with a more extensive disease  are more likely to require standard lymphoma therapy [5]. The most studies showed a higher cumulative incidence of gastric cancer in countries with a higher prevalence of infection. Helicobacter pylori was associated with an increased risk of both diffuse and intestinal type of gastric cancer. Cag-seropositivity was associated with a higher risk of gastric cancer. A recent meta-analysis showed a significant reduction in the risk of gastric cancer in Helicobacter pylori infected subjects who received eradication therapy. Based on these evidences, it was well agreed that Helicobacter pylori is an important risk factor of gastric cancer. However, large well-designed randomized trials are highly anticipated to assess the effectiveness and risks of the “screen and treat” strategy in the development of gastroesophageal reflux disease, obesity and allergic diseases after Helicobacter pylori eradication . Many bacterial communities, from Prevotella to Streptococcus, have been identified in atrophic gastritis.Helicobacter pylori may represent the main, but not the only, microbial trigger for different gastric diseases and that microorganisms, other than Helicobacter pylori, may play a relevant role in the development of complications in Helicobacter pylori – related gastritis [7]. Enko D and Kriegshauser G consider Helicobacter pylori infection to be significantly associated with the presence of small intestinal bacterial overgrowth - SIBO . SIBO rates appeared to have increased after eradication therapies [8]. The impact of the presence of Helicobacter pylori infection on the reduction of the ferritin and iron levels of coronary artery disease patients as a risk factor independent of other classic factors (including lipid profiles and inflammatory factor) is proved in another study [9]. A study which was undergone by Del Zompo et al. showed a significant association between the Helicobacter pylori infection and methane production, suggesting the influence gut microbiota composition [10]. In a case-control study, the authors observed type 1 diabetic children are at risk of acquiring Helicobacter pylori infection, especially cases with the longer duration of diabetes [11]. Recently, an association between Helicobacter pylori infection and preeclampsia was established, suggesting a role for infection in impairing placental development and increasing the risk of developing preeclampsia. The study opens the new perspective of a potential screening and treatment for Helicobacter pylori infection in pregnancy [12]. In a randomized, double-blind, placebo-controlled trial it was demonstrated that Helicobacter pylori eradication improves glucose homeostasis in patients with type 2 diabetes (decrease in pro-inflammatory factors) [13]. During the past year, many articles regarding the extragastric diseases related to Helicobacter pylori infection have been published. The role of Helicobacter pylori in idiopathic thrombocytopenic purpura, iron deficiency anemia, vitamin B12 deficiency is well known; there is a growing interest in the bacterium’s association with cardiovascular, neurologic, hematologic, dermatologic, head and neck, uro-gynecologic diseases, diabetes mellitus and metabolic syndrome with very promising results [14]. In a meta-analysis, Upala et al. showed that the infection is positively associated with the metabolic syndrome. Infection with Helicobacter pylori is also associated with higher triglyceride, body mass index, homeostatic model assessment of insulin resistance (HOMA-IR), systolic blood pressure and lower HDL [15]. A study which evaluated Helicobacter pylori infection in 58 patients with eosinophilic esophagitis and 116 age and sex-matched controls demonstrated that the Helicobacter pylori infection is inversely associated with eosinophilic esophagitis [16]. Current evidence indicates that Helicobacter pylori eradication therapy, added to iron therapy, might be beneficial in increasing ferritin and hemoglobin levels . The histopathological grading as well as the identification of more severe strains, like the cagA-positive strains which have been proven to cause more severe forms of gastritis, could help identify cases at higher risk and provide a guide for the targeted agents . While more expensive and time consuming than the previous tests, histopathological tests can provide more information related to the consequences of the chronic Helicobacter pylori infection, identifying intestinal metaplasia as well as gastric carcinoma. The recognition of the bacteria has been done routinely by using the hematoxylin and eosin staining, which is appropriate for most cases. The Giemsa staining is also frequently used to diagnose the Helicobacter pylori infection, and has better sensitivity and overall accuracy compared to hematoxylin-eosin [PCR test is not widely available or standardized and is not practical for routine diagnosis.22]. Zeng et al. studied 2199 vaccinated children (with 3 doses of a fusion protein) versus 2204 children on placebo and demonstrated a 55% reduction in the new infections after 2 years [Table 2. The treatment for Helicobacter pylori should be offered to all patients with a positive Helicobacter pylori test [23]. Helicobacter pylori is difficult to eradicate because it is capable of developing resistance. Therefore, two or more antibiotics are usually given together with a PPI and/ or bismuth containing compounds to eradicate. Studies have shown that the resistance of Helicobacter pylori to clarithromycin is common among patients who have a prior exposure to clarithromycin or other chemically similar macrolide antibiotics (such as erythromycin). The Helicobacter pylori resistance to metronidazole is common among patients who have had a prior exposure to metronidazole. Recommended therapies in areas with antibiotic resistance are detailed in Fig. 2. The triple therapy is the most commonly used initial treatment and consists of a PPI, amoxicillin, and clarithromycin. Metronidazole is used in place of clarithromycin if the patient is from an area with an increased clarithromycin resistance, same as bismuth-based regimens which also have the advantage of being low cost. The eradication of Helicobacter pylori usually prevents the recurrence of ulcers and ulcer complications even after appropriate medications such as PPIs are stopped. The eradication of Helicobacter pylori is important in the treatment of the conditions of the stomach, like MALT lymphoma. The treatment of Helicobacter pylori to prevent stomach cancer is controversial. Standard treatment schemes are detailed in 24]. The sequential therapy has shown promising results, with eradication rates of more than 90%. The treatment failure is usually the result of noncompliance with the medical therapy or of antimicrobial resistance and given the low reinfection rate (< 2% patients for one year). If both clarithromycin and metronidazole resistance is suspected, salvage therapy should be considered. Salvage therapy may be better tolerated and more effective than bismuth-based quadruple therapy, but further validation is required.Bacterial antibiotic resistance is regionally variable. Clarithromycin resistance has been rapidly increasing in many countries over the past decade, with rates as high as approximately 30% in Japan and Italy, 40% in Turkey and 50% in China. Resistance rates are much lower in Sweden and Taiwan, at approximately 15%; there are limited data in the USA [6]. The use of high dose PPI twice daily increases the efficacy of triple therapy. Esomeprazole and rabeprazole may be preferred in Europe and North America, where the prevalence of PPI extensive metabolizers is high . A large randomized controlled intervention trial to prevent gastric cancer by the eradication of Helicobacter pylori in China included 184 786 residents aged 25-54 years, Helicobacter pylori prevalence was 57.6% and the overall eradication rate was 72.9% in the active group. The findings of this trial lead to a distinct evaluation of the factors influencing eradication [6]. Second line therapies are detailed in Fig. 3.Helicobacter pylori “screen-and-treat” strategies are recommended in communities at high risk of gastric cancer . Some authors recommend testing the eradication of infection after treatment in all patients in order to monitor the changes in antibiotic resistance of the bacteria [Helicobacter pylori-the truth of today may be the error of tomorrow?27].Over the last year, several diseases have been reported to be associated with Helicobacter pylori infection. In some hematologic diseases, such as ITP, idiopathic iron deficiency anemia and vitamin B12 deficiency, their role has been fully validated and included in the current guidelines. There is a positive trend in the association between Helicobacter pylori infection and neurodegenerative disorders and there is new data concerning a reduced risk of death due to stroke and lung cancer in these patients, but also an increased risk of preeclampsia in infected women, which requires further investigations [Disclosure statementThe authors declare that there is no conflict of interest regarding the publication of this paper.


Genetic variants at hundreds of loci associated with cardiovascular phenotypes have been identified by genome wide association studies. Most of these variants are located in intronic or intergenic regions rendering the functional and mechanistic follow up difficult. These non-protein-coding regions harbor regulatory sequences. Thus the study of genetic variants associated with transcription—so called expression quantitative trait loci—has emerged as a promising approach to identify regulatory sequence variants. The genes and pathways they control constitute candidate causal drivers at cardiovascular risk loci. This review provides an overview of the expression quantitative trait loci resources available for cardiovascular genetics research and the most commonly used approaches for candidate gene identification. The ultimate goal of any genetic association analysis is to identify genetic variation linked to variation of a phenotype and to elucidate the molecular mechanisms, which are altered by the sequence variation. Genome wide association studies have been tremendously successful in identifying thousands of disease-associated loci as documented by the steady growth of the continuously updated GWAS catalog . This prRecent large-scale efforts have annotated a plethora of functional regulatory elements such as enhancers residing in the non-protein-coding part of the genome , 10. TheIntegrated analysis of the genetics of gene expression provides an elegant way of directly assessing the consequences of putative regulatory sequence variants on transcription. In this study design , a populRegulatory elements and also the effects of variants on those elements can be highly tissue specific, therefore it is key to investigate the tissue relevant for the disease , 25, 30.cis-eQTL when the distance between gene and variant is not further than 500 kb−1 Mb, as opposed to trans-eQTL, where the distances are greater or the variant and gene are located on different chromosomes. Cardiovascular candidate genes such as SORT1 . Pathways can be represented as sets of genes of the same process or as networks preserving the topological information which genes are connected to one another, for instance by catalyzing adjacent steps in a metabolic pathway. Alternatively, networks can be derived from high-throughput experiments such as transcriptome profiling (co-expression network) or protein-protein interaction (PPI) screening (PPI network). Pathways and networks defined either from prior knowledge or from data can subsequently be used for the interpretation of disease associations derived from GWAS. Representing pathways as sets of genes, one can ask, whether a set of genes shows higher evidence of association to disease than random gene sets of the same size. Because GWAS test individual SNPs and not genes, a mapping between SNPs and genes is required, for instance based on genomic positions. Methods such as SNP set enrichment analysis , 61 can immunity .Since eQTL experiments require transcriptome profiling in large cohorts, it is natural to use this data to define data driven gene co-expression networks and gene sets, so called co-expression modules. These gene sets are then annotated according to their gene function or cell type specificity and then related to disease via GWAS results using SNP set enrichment analysis. The link between genes and SNPs can naturally be established via cis-eQTLs of the genes of a co-expression module. This approach was also used in the CAD study mentioned above . It is iin vitro studies  are more important , 62–65. eQTL data provides first leads toward uncovering the mechanisms underlying the statistical associations observed between genetic loci and common cardiovascular diseases. Major challenges for a broad applicability of this approach need to be overcome. First, regulatory elements and therefore also the regulatory impact of sequence variation is highly cell type specific. The GTEx project is addressing this challenge by providing a large scale cross tissue eQTL data base. However, not all conceivable tissues and cell types can be systematically analyzed. In particular transient developmental stages might leave a lasting phenotypic footprint. Induced pluripotent stem cells from cohorts offer an elegant solution  as they The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A consensus panel recently used clinical evidence and pathologic parameters to rename noninvasive encapsulated follicular variant of papillary thyroid carcinoma to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) to better reflect the indolent course of this tumor. NIFTP has stringent histopathologic diagnostic criteria established by the panel, including papillary-like nuclear features, and submission of the entire tumor capsule to exclude invasion. From a molecular standpoint, NIFTP is often characterized by RAS-type mutations, similar to other follicular-patterned lesions. While there has been prior evidence in the literature for the low malignant potential of these tumors, projects moving forward will help to independently reinforce the reliability of these criteria and nomenclature. With planned inclusion of NIFTP into the latest World Health Organization endocrine tumor classification scheme, this nomenclature shift provides a model for pathology efforts to refine diagnostic classifications to better guide treatment. In this review we discuss this nomenclature change and review the current literature. A group of experts in endocrine neoplasia were led by Dr. Nikiforov to formally assess the tumor previously known as “noninvasive encapsulated follicular variant of papillary thyroid carcinoma (FVPTC)” to develop diagnostic criteria and study prognosis. Based on the group's consensus findings, the new term “noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)” was announced at the meeting of the Endocrine Pathology Society in March 2015 . The terClinically, NIFTP presents similarly to most thyroid neoplasms by detection of a nodule on routine or focused physical examination or incidentally during unrelated diagnostic imaging. If NIFTP grows large enough, it can also potentially present by mass effect on surrounding structures, leading to dysphonia, globus sensation, or airway compromise .Grossly, NIFTP appears as a solid well-circumscribed or encapsulated nodule. The capsule may be thin and difficult to discern; however, a clear demarcation between the lesion and surrounding thyroid tissue will be readily appreciated. The cut surface is often paler than normal surrounding thyroid tissue and necrosis and hemorrhage are unlikely to be seen. In the NIFTP series studied by Nikiforov et al., the 109 tumors ranged in size from 1.1 to 9 cm .The histological diagnosis of NIFTP is made using strict inclusion and exclusion criteria following submission of the entire tumor capsule for histology and careful examination of nuclear features, as well as overall architecture. The name NIFTP aptly conveys this lesion's prognosis and histologic features. Beginning with “noninvasive,” the capsule or tumor/normal interface must be entirely examined microscopically to rule out invasion as capsular or vascular invasion would exclude the tumor from a NIFTP classification . Next, aThe introduction of the NIFTP nomenclature has posed a potential problem for cytopathologists. Often, the first specimens obtained from thyroid nodules for review by a pathologist are fine needle aspirates (FNA), on which evaluation of capsular invasion is not possible, and differentiating nuclear features of NIFTP and papillary thyroid carcinoma can be challenging. Many worry that making the diagnosis of PTC on cytopathology now carries the risk of a false-positive result in NIFTP. The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) assigns a risk of malignancy to each of the possible diagnostic categories into which biopsies are placed by the pathologist. The creation of NIFTP has introduced a shift to the currently described risk of malignancy for each of these categories. Early studies seem to indicate that the risk of false-positive for a Bethesda VI diagnosis is low, with most NIFTPs being classified on preoperative FNA into indeterminate categories. Strickland et al. performed a single institution study correlating FNA biopsies to surgical specimens (655-patient cohort) and found NIFTP was most often classified into the indeterminate categories of the BSRTC  and thus correspondingly significantly lowered the risk of malignancy associated with each of these indeterminate categories. Most significantly, the risk of malignancy in the suspicious for malignancy category decreased by 41.5% . Faquin Driving clonal alterations have been found in NIFTP tumors, though to date data is limited on the specific entity of NIFTP as such . The genGiven the recent description of the entity, the diagnostic criteria for NIFTP do not include a characteristic mutation, much like other thyroid tumors. Molecular studies are much more likely to play a critical role in guiding management at the time of FNA of these lesions. The presence of RAS mutations may contribute supportive evidence favoring a diagnosis of NIFTP, follicular adenoma, or follicular carcinoma, in contrast to BRAF mutations which are more commonly observed in association with classical papillary thyroid carcinoma –14. The The utility, predictive value, and reporting schemes of currently available molecular tests will need to be reassessed in the era of NIFTP. Early work confirms that the shift in nomenclature will alter test specificity and overall rate of malignancy , 15–17. The main differential diagnosis for NIFTP is invasive encapsulated FVPTC as this lesion shares the well-circumscribed, often encapsulated structure, follicular architecture and papillary-like nuclear features with NIFTP and differs only with as much as a single focus of capsular or vascular invasion. Invasive encapsulated FVPTC harbors similar RAS-type mutations as NIFTP, follicular adenoma, and follicular carcinoma. In order to differentiate these diagnoses, the tumor capsule must be entirely submitted for microscopic examination to exclude invasion in the case of NIFTP .Follicular adenoma is another entity that shares a similar morphological appearance and molecular genotype to NIFTP . FollicuWhile there is little in the literature assessing clinical outcome in NIFTP by the NIFTP name, there has been much in the literature describing the indolent clinical characteristics of EFVPTC without invasion , 9. GhosEarly reports suggest that nodal metastasis is a rare event in NIFTP, with one series presented at the 2016 American Thyroid Association meeting demonstrating no NIFTPs with nodal metastases  and anotPrior to the reclassification of NIFTP, there was a lack of evidence to support conservative management  of noninvasive encapsulated FVPTC, and if the lesion measured greater than 1.5 cm, many physicians recommended completion thyroidectomy with subsequent radioactive iodine therapy and extensive follow-up, similar to conventional papillary thyroid carcinoma . In addiThe American Thyroid Association strongly recommends follow-up of differentiated thyroid cancer by means of serial serum thyroglobulin measurement, serum thyroid stimulating hormone (in patients on thyroid hormone therapy), cervical/neck ultrasonography, and other tests depending on the clinical scenario . Under tThe rigorous evidence-based efforts made by the expert panel convened to reclassify noninvasive encapsulated FVPTC to NIFTP have paved the way for reframing our approach to diagnosis and treatment of indolent thyroid lesions. They provided clear criteria for diagnosis and supporting evidence with long-term follow-up demonstrating benign behavior in the population they studied . NIFTP,


Their ontogeny, together with the absence of turnover from the periphery and the singular environment of the central nervous system, make microglia a unique cell population. Supporting this notion, recent genome-wide transcriptional studies revealed specific gene expression profiles clearly distinct from other brain and peripheral immune cells. Here, we highlight the breakthrough studies that, over the last decades, helped elucidate microglial cell identity, ontogeny, and function. We describe the main techniques that have been used for this task and outline the crucial milestones that have been achieved to reach our actual knowledge of microglia. Furthermore, we give an overview of the “microgliome” that is currently emerging thanks to the constant progress in the modern profiling techniques.Microglia are essential for the development and function of the adult brain. Microglia arise from erythro-myeloid precursors in the yolk sac and populate the brain rudiment early during development. Unlike monocytes that are constantly renewed from bone marrow hematopoietic stem cells throughout life, resident microglia in the healthy brain persist during adulthood  Until the beginning of the XXI century, the central nervous system (CNS) was seen as an immune-privileged site sealed by the blood–brain barrier, a barrier that was thought to prevent peripheral immune cells infiltration . Over thvia constant self-renewal without turnover from circulating blood progenitors . –10. via s Figure –20.in vivo studies revealed that these ramified microglia are highly active, continuously extending and retracting their fine processes, and scanning the CNS microenvironment without disturbing the neuronal fine wire. This notable movement activity sets microglia as the fastest moving structures in the adult healthy brain, monitoring the entire brain parenchyma in less than four hours  by Rudolph Virchow in 1856 . NeuIn the early 1870s, a major breakthrough in neuroglia was empowered by Camillo Golgi and his famous “Reazione nera” (Black reaction)  . in vivo that microglial activity is critical for normal brain development (Ex vivo microglial gene expression profiles from different physiological or pathological conditions show that they scarcely resemble to those classified as the classical polarization states (in vitro microglia studies highlight their immune properties (in vitro observations? Are microglial cells essential for CNS host defense or are they professional phagocytes fundamental for brain development? Which cells are the real immune cells of the brain? Further investigations, taking advantage of the technological progress, need to be carried out to properly address these open questions. For example, single-cell transcriptomic and proteomic technologies are gaining their momentum to directly access gene and protein expression profiles (In summary, it has been shown elopment . Ex vivon states , 33, whioperties . Overallprofiles –143. TheCS and AM conceived and wrote the manuscript. CS prepared the tables. CS and AM created the pictures. CS, KB, and AM critically revised and approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Nonadherence to prescribed regimens for opioid analgesic agents contributes to increasing opioid abuse and overdose death. Opioids are frequently prescribed on an as-needed basis, placing the responsibility to determine opioid dose and frequency with the patient. There is wide variability in physician prescribing patterns because of the lack of data describing how patients actually use as-needed opioid analgesics. Digital pill systems have a radiofrequency emitter that directly measures medication ingestion events, and they provide an opportunity to discover the dose, timing, and duration of opioid therapy.The purpose of this study was to determine the feasibility of a novel digital pill system to measure as-needed opioid ingestion patterns in patients discharged from the emergency department (ED) after an acute bony fracture.We used a digital pill with individuals who presented to a teaching hospital ED with an acute extremity fracture. The digital pill consisted of a digital radiofrequency emitter within a standard gelatin capsule that encapsulated an oxycodone tablet. When ingested, the gastric chloride ion gradient activated the digital pill, transmitting a radiofrequency signal that was received by a hip-worn receiver, which then transmitted the ingestion data to a cloud-based server. After a brief, hands-on training session in the ED, study participants were discharged home and used the digital pill system to ingest oxycodone prescribed as needed for pain for one week. We conducted pill counts to verify digital pill data and open-ended interviews with participants at their follow-up appointment with orthopedics or at one week after enrollment in the study to determine the knowledge, attitudes, beliefs, and practices regarding digital pills. We analyzed open-ended interviews using applied thematic analysis.We recruited 10 study participants and recorded 96 ingestion events . Study participants reported being able to operate all aspects of the digital pill system after their training. Two participants stopped using the digital pill, reporting they were in too much pain to focus on the novel technology. The digital pill system detected multiple simultaneous ingestion events by the digital pill system. Participants ingested a mean 8 (SD 5) digital pills during the study period and four participants continued on opioids at the end of the study period. After interacting with the digital pill system in the real world, participants found the system highly acceptable  and reported a willingness to continue to use a digital pill to improve medication adherence monitoring .The digital pill is a feasible method to measure real-time opioid ingestion patterns in individuals with acute pain and to develop real-time interventions if opioid abuse is detected. Deploying digital pills is possible through the ED with a short instructional course. Patients who used the digital pill accepted the technology. Deaths from opioid overdose in the United States have paralleled a rise in the number of opioid analgesic medications being prescribed . In 2014Determining adherence to a prescribed opioid medication regimen after discharge and measuring the ways in which patients ingest as-needed medications pose methodological challenges. Because patients determine opioid ingestion dose and frequency based on temporal perception of pain, common measures of adherence  are impractical or provide aggregate measures that cannot delineate temporal patterns of opioid ingestion . These tDigital pills that activate upon contact with the stomach provide a reliable method to directly measure, rather than infer, opioid ingestion patterns in real time ,11. DigiOur study was based at a large tertiary care academic ED, and approved by its institutional review board . We used a digital pill  compounded with oxycodone tablets in patients who presented to the ED after suffering an acute extremity fracture to measure real-world ingestion patterns in these patients. Digital pills were purchased directly from the manufacturer (eTectRx) and compounded with 5 mg oxycodone tablets using a standard capsule-filling machine by our hospital investigational drug services pharmacy. Compounded digital pills were dispensed in blister packages. We considered alternative digital pill systems that used radiofrequency signaling to detect ingestion events. Other digital pills required the radiofrequency emitter to be adhered onto a placebo pill, thus requiring ingestion of the study medication and placebo pill to record an ingestion event. We elected to utilize the eTectRx system because it offered the opportunity to directly measure, rather than infer, medication ingestion.A convenience sample of ED patients was recruited during daytime hours when research staff was available. Patients were eligible for the study if they were consenting adults (>18 years); presenting to the ED after an isolated acute fracture; had no history of psychiatric illness, substance abuse disorder, or chronic opioid use (prescribed opioids for more than one week in duration); and were planned to be discharged with opioid analgesics. Patients who met the eligibility criteria were approached by study staff. A chart review was conducted to ensure potential study participants did not meet exclusion criteria. Basic demographic information including age, gender, and ED pain scale were collected. Study staff then briefed potential participants on the purpose of the study and potential study participants were shown components of the digital pill. Participants who agreed to participate in the study provided written informed consent. Participants were compensated US $100 for participation in the study.Study staff provided participants with hands-on training lasting approximately 20 minutes on the operation of the digital pill. Training included a demonstration of digital pill operations, explanation of all the hardware components, and registration of the study participant on the cloud interface. Participants were counseled by the study staff to use nonopioid analgesics  to manage their pain, and use oxycodone-containing digital pills as needed for episodes of pain not controlled with other medications. Participants then ingested an oxycodone-containing digital pill under observation by study staff to demonstrate their understanding of the system and to verify that all components of the system were operational. If a patient reported their pain levels were managed during the time of system training, participants demonstrated their understanding of the system without ingesting an oxycodone pill. On discharge, participants received a prescription for one-to-two digital pills containing 5 mg oxycodone every 8 hours as needed for pain  in addition to a hip-worn device to capture ingestion data. Study participants enrolled in the study did not receive additional opioid analgesics from the primary team.Participants returned to the hospital’s clinical research center at the time of their orthopedic follow-up appointment or at one week after ED discharge to return the digital pill system and any uningested oxycodone digital pills. Equipment return and appointments were arranged with the study participants by study staff. We validated ingestion data from the digital pill using pill counts; we resolved discrepancies, if present, with the participant.Investigators  conducted brief (approximately 15 minutes), open-ended interviews with each study participant. We used an interview guide to ensure that each participant was asked the same questions; questions centered on acceptance of the digital pill, barriers to use, adequacy of pain control, and potential improvements in the system. We adapted the technique of applied thematic analysis to code interviews in the context of this pilot study . ParticiEighteen individuals met the inclusion criteria for the study and were approached by the study team . Ten indParticipants ingested a mean 48 (SD 24) mg oxycodone during the course of the study . OxycodoThe digital pill system was able to accurately measure oxycodone ingestion events . ParticiWe completed open-ended interviews with all participants at the end of the study period . ParticiParticipants did not report any concerns regarding issues of privacy when utilizing the digital pill. Participants preferred real-time transfer of ingestion data to their physician, especially if their physician could use their ingestion data to intervene at potential times of escalating use. Interestingly, participants reported that they preferred text message-based confirmation of ingestion events and, in the context of chronic disease, would have liked mobile phone-based text messages reminding them to take medications.Acceptance of system 90% of participants reported a positive experience integrating digital pill into medication regimenSystem became part of medication routine and participants developed different techniques for system use based on individual habitsDigital pills were easy to swallowAppreciated receiving text messages after taking medication when an ingestion event was recordedSample of participant response:“I thought it was easy. It helped me, because I had a routine of just take the reader off of the charger and go get the medicine”“I like getting the (text) message, it showed me that the device was working.”Willingness to use in chronic disease Participants willing to use in coordination with health care provider for observation of medication taking behaviorSample of participant response:“A prompt would be nice if it was a medication I had to take daily, because people, like myself, forget to take their medication”“Using the system actually really helped me to realize how much (oxycodone) I was taking”2 participants reported they would not be willing to use the system in chronic disease (see barriers to use)Equipment failure and barriers to use Problem: participant 2 lost reception due to poor cell coverage, so ingestion events were not transmitted via SMS to study serverSolution: ingestion events are stored on reader automatically for manual upload to server as backupProblem: participant 5 reported that system was hard to remember to use when in severe pain; stopped using system on day 3Solution: focus on patient-centered improvements for ease of use in next-generation digital pill ; use digital pill for conditions not involving severe painProblem: participant 5 reported improved battery life would have made system easier to use when in severe pain; participant 6 did not plug in reader when not in use causing the reader to lose power and ingestion events were not recorded on day 1 and day 2; participant 10 reported that they would not be willing to use system in chronic disease because of having to charge reader consistentlySolution: next-generation reader will have improved battery life and not need to be charged consistently when not in useWe demonstrated the acceptability and usability conditions of digital pills as a medication monitoring method among patients with acute painful conditions. Importantly, we successfully deployed the digital pill among ED patients; ED-based research is unique in that it oversamples poor, indigent, homeless, and immigrant populations . NotablyOur data show that digital pills can detect not only real-time oxycodone ingestion in real-world patients, but also the patterns by which they take these medications. Our ability to reliably measure medication ingestion events using the digital pill arises from the technology’s capacity to detect simultaneous ingestion of two separate digital pills. When two simultaneous digital pills were ingested, the digital pill recognized two distinct ingestion events 100% of the time. These pilot data demonstrate that digital pills can mirror an individual’s medication ingestion pattern in the real world and that these data can be delivered to physicians in real time.Failure of the digital pill to record ingestion events resulted from technical difficulties of the emerging technology , not operator error. Notably, in cases when the reader could not link to a cellular network, the reader recorded ingestion events in its on-board memory, which we downloaded at participant follow-up. The 20 minutes of hands-on instruction—a time period expected to drop as technology improves—ensured fidelity to tasks needed to operate the digital pill. This short training period and 90% acceptance of the system implies that it is simple and intuitive for the user. We believe technical improvements in the reader—improved battery life, the ability to switch between wireless networks, low energy Bluetooth and cellular transmission, and improved capture of the radiofrequency signal—will only improve detection accuracy and decrease the steps required to operate the reader.We identified conflicting responses regarding the impact of a medication monitoring system on participant behavior. For example, participants did not perceive that physician notification of real-time ingestion events altered their decisions surrounding medication use or altered the dose or frequency with which they ingested digital pills. Conversely, in the theoretical case of medication monitoring for chronic disease, participants reported that the technology would be an adherence-improving measure in itself.Importantly, our formative interviews of study participants demonstrate their perception that the digital pill maintains patient privacy. This finding contrasts with multiple reports in the lay media hypothesizing that real-time detection of medication ingestion events could violate privacy ,16. Our Discovering the ways in which patients take opioids in natural environments is of particular interest given the increasing rate of opioid overdose deaths. Ingestion data from our study shows that patients may require only brief periods of opioid analgesia following an acute extremity fracture. Most study participants ingested opioids for only 72 hours after their injury while self-tapering their dose. Study participants experienced greatest pain in the first 48 hours following injury. Participants successfully controlled subsequent episodes of pain with nonopioid analgesics such as acetaminophen or ibuprofen. Study participants who ingested opioids after 72 hours reported doing so for specific reasons, such as treating a second painful condition  or to maximize analgesia before bedtime. This formative data, although drawn from a small cohort of patients, may provide guidance for physicians hoping to provide effective yet safe duration of opioid therapy.This study represents the first time digital pills have been deployed from the ED. We demonstrate that digital pills feasibly monitor medication ingestion events in the real world, require minimal training, and are acceptable by users, even those of low socioeconomic status. Our approach may be adapted to the deployment of digital pills to monitor chronic medication adherence in chronic conditions such as antiretroviral agents to prevent or treat HIV infection, or the use of anticoagulants in atrial fibrillation. Continued advances in radiofrequency signaling and energy harvesting will boost signal strength for future digital pills while continued miniaturization, improved battery life, and advanced detection techniques will allow future receivers to blend into the background of daily life, increasing acceptance and fidelity of digital pills. Automated interpretation of adherence data and integration with electronic medical records will improve data visualization by physicians and patients and may serve as a novel method to boost adherence. Digital pills may be an effective method to detect real-time medication ingestion events for many chronic, expensive, and intractable conditions.This study had several limitations. First, our data demonstrate the feasibility of a digital pill to monitor medication ingestion, but the small sample size makes it difficult to determine whether decreased opioid usage was statistically significant. Second, we studied patients with acute extremity fracture—a painful condition for which opioids are commonly prescribed. Therefore, our data should not be generalized to all painful conditions. Future studies should focus on various painful conditions to guide the creation of a more comprehensive set of opioid-prescribing guidelines. Third, patients in this study had stringent enrollment criteria, including the lack of psychiatric illness or a history of substance abuse. Fourth, we did not follow patients after their operative repair because our main goal was to understand the feasibility and acceptability of the digital pill. Therefore, we do not know the patterns of chronic opioid use.This pilot study demonstrates the feasibility of digital pills to detect medication ingestion events and discern patterns of opioid analgesic use in patients discharged from the ED. Patients readily accept and interact with digital pills in the real world. Our study adds to the growing data regarding natural environment interactions with digital pills. When formulated with oxycodone, digital pills can help clinicians discover natural ingestion patterns of opioids.


An important factor in reducing variability in mouse test outcomes has been to develop assays that can be used for continuous automated home cage assessment. Our experience has shown that this has been most evidenced in long-term assessment of wheel-running activity in mice. Historically, wheel-running in mice and other rodents have been used as a robust assay to determine, with precision, the inherent period of circadian rhythms in mice. Furthermore, this assay has been instrumental in dissecting the molecular genetic basis of mammalian circadian rhythms. In teasing out the elements of this test that have determined its robustness – automated assessment of an unforced behaviour in the home cage over long time intervals – we and others have been investigating whether similar test apparatus could be used to accurately discriminate differences in distinct behavioural parameters in mice. Firstly, using these systems, we explored behaviours in a number of mouse inbred strains to determine whether we could extract biologically meaningful differences. Secondly, we tested a number of relevant mutant lines to determine how discriminative these parameters were. Our findings show that, when compared to conventional out-of-cage phenotyping, a far deeper understanding of mouse mutant phenotype can be established by monitoring behaviour in the home cage over one or more light:dark cycles. As thes2One of the first and widely utilised methodologies used for the long term assessment of animal activity in the home cage is voluntary wheel running. The first reported investigation was published in the late 19th century and used such techniques to analyse the effect of diet and alcohol on the activity of rats . HoweverThe success and longevity of voluntary wheel running as a method of home cage activity is in part down to its simplicity. Animals are assessed in the home cage, thus removing stress effects of a novel environment which may otherwise affect results and can be assessed for long periods of time to remove intradaily differences in behaviour or activity which may otherwise be present. Additionally, at a practical level the data files produced are small (under 200KB for a month-long screen) and, while analysis can be performed using specialised software, there are some open source options available for analysis of data e.g. . AlthougWheel running activity monitoring is limited to a measure of voluntary activity. This is evident when comparing wheel-running activity records of mouse strains with respective activity measurements using video-tracking based systems . AlthougImmobility defined sleep screens have been successfully used to identify novel sleep phenotypes in high throughput mouse mutagenesis screens  and charOne notable recent addition to the technologies measuring sleep and circadian activity is the COMPASS system . This te3Characterising progressive neurodegenerative and muscle wasting diseases such as Huntington’s disease, Multiple Sclerosis and Duchenne’s muscular dystrophy in mouse models requires a battery of tests to investigate various aspects of motor function and motor coordination . Tests sTo expand the repertoire of meaningful motor function tests in mice, we tested, optimised and validated, a home-cage-based wheel running system to study motor deficits in mice. Standard running wheels such as those discussed in the circadian rhythms and sleep section have shown consistently reproducible results in detecting motor phenotypes in mouse models of Duchenne’s muscular dystrophy and Huntington’s disease . By deve4Given the increased discriminative power of home cage assessments of activity and motor function, we have been interested in establishing whether similar systems could be used to study cognitive function in the home cage. Our goal was to automate and increase the throughput of behavioural testing by combining home-cage behavioural protocols with automated remotely controlled equipment. This was established by restricting access to food in the home cage and introducing a ‘work for food’ paradigm using an operant nose-poke wall . A numbe5Automated analysis of mouse home cage behaviour allows for readily standardised phenotypic experiments to be conducted on a much longer time scale, without the need for human intervention. This means that the data generated is likely to be more reproducible across different laboratories and free from experimenter bias . Furtherob/ob  and −/−Htr2c . They deduced from the animals’ movements that, whilst both mice were obese, the ob/ob mice were less active compared to control mice but the −/−Htr2c indulged in more ‘snacks’ between rest periods. This insight into the nature of genes influencing appetite and satiety would have been overlooked, were it not for continuous monitoring, especially through the dark phase.Automated systems using beam breakers and detectors have been in use for a number of years and are still being used successfully to measure locomotor activity in singly housed mice . In theiWhilst detectors and beam breakers have been used effectively to measure locomotor function and location , direct Recent advances in informatics and image analysis have enabled the collection of data with such precision and granularity that systems such as HomeCageScan (CleverSys Inc) are able to capture and categorise over two dozen behaviours including fine movements such as grooming, head bobbing and sniffing . Such de6Mice are social animals in the wild, however, the methods described above require solitary housing. Removing the mouse from its cage-mates and placing it into a novel environment has been shown to affect behaviour, general wellbeing and metabolism, and so could in itself cause behavioural artefacts . Recent Social interactions are critical to the survival and reproduction of most animal species while a number of human conditions such as Autism Spectrum Disorders (ASD) and schizophrenia have a large social element . The majAnother proven method of tracking is the use of radio frequency identifier (RFID) microchips . Such syEven so such systems are incompatible with a standard mouse vivarium and require the mice to be removed into a bespoke environment for the duration of the experiment See .Table 1COur ability to record automated detailed behavioural parameters over time in an undisturbed cage encouraged us to explore whether true home cage phenotyping was feasible. True home cage in this context was defined as a normal rack-mounted cage, where mice are born, reared and housed within their established social groups . To evalUsing the HCA system, we have been expanding our analysis to investigate behavioural interactions in a group-housed home-cage setting. Tracking interacting animals and monitoring social groups using a combination of detectors and video analysis is not new. True home cage phenotyping over long periods has the potential to greatly enhance the study of a wide range of neurobiological diseases by enabling the accurate measurement of progressive behavioural changes in the same animals over weeks and months . There iThe combined use of RFID and infrared video monitoring allows one to track individual home-cage behaviours continuously. However, a remaining challenge is to use computer automation to record home-cage behaviours automatically, developed using previously-annotated video segments. The HCA system has the potential to record and automate a spectrum of biologically-relevant home-cage behaviours. As a preliminary study, we focused on the automated analysis of cage-bar climbing activity as a subtle measure of motor function in an unprovoked environment. Using this tool, climbing is detected over 6 frame blocks using the temporally smoothed output of a linear SVM classifier, trained  on over 7Most behavioural phenotyping relies on the use of multiple testing platforms to study any one behavioural domain. For example, motor function or anxiety in mice can be tested using numerous tests while each can provide different, but informative, phenotypic information. Likewise, the techniques described in this review have the potential to open a whole new dimension of mouse behaviour by shedding light on aspects of mouse behaviour that have hitherto gone unobserved. Moreover, rather than challenging the validity of existing work, these techniques should provide complementary information in establishing complex behavioural phenotypic patterns in mice. For example, while group-housed home-cage behaviours can provide valuable information on multiple social behaviours, social entrainment cues themselves might negatively impact upon the innate circadian period or sleep/wake behaviour of an individual animal. In these instances, amongst others, it would still be preferable to study the behaviour in singly housed conditions where the impact of social interaction will not mask the behaviour of the individual.Our findings highlight the importance of testing mouse behaviours over extended periods in undisturbed conditions (for at least one 24-h cycle). The discriminatory power of these tests is far greater than conventional out-of-cage phenotyping. However, testing during the dark phase need not necessarily be the most informative or most discriminative as test outcomes are dependent on the specific behaviours or on the particular mouse strain/mutant line being studied. Careful consideration should be given to individual behavioural studies but, ultimately, longitudinal studies throughout the light:dark cycle are desirable. Progress with the automation and diversity of home cage testing will be a critical factor in enabling such studies. Though the field has seen an explosion of several commercial and non-commercial systems, the challenge ahead lies in the ensuring that these systems are robustly validated through manual and cross laboratory validation.The authors RS and JA were/are employed by or were shareholders in Actual Analytics Ltd at the time the research was performed and therefore declare a competing financial interest. Actual HCA is commercially available from Actual Analytics Ltd.


Many environmental justice studies have sought to examine the effect of residential segregation on unequal exposure to environmental factors among different social groups, but little is known about how segregation in non-residential contexts affects such disparity. Based on a review of the relevant literature, this paper discusses the limitations of traditional residence-based approaches in examining the association between socioeconomic or racial/ethnic segregation and unequal environmental exposure in environmental justice research. It emphasizes that future research needs to go beyond residential segregation by considering the full spectrum of segregation experienced by people in various geographic and temporal contexts of everyday life. Along with this comprehensive understanding of segregation, the paper also highlights the importance of assessing environmental exposure at a high spatiotemporal resolution in environmental justice research. The successful integration of a comprehensive concept of segregation, high-resolution data and fine-grained spatiotemporal approaches to assessing segregation and environmental exposure would provide more nuanced and robust findings on the associations between segregation and disparities in environmental exposure and their health impacts. Moreover, it would also contribute to significantly expanding the scope of environmental justice research. Human exposure to environmental harm is a function of various socioeconomic processes that push people toward the threshold of environmental stressors, rather than just a product of accidental environmental impacts . NumerouA number of quantitative environmental justice studies have sought to understand the association between residential segregation and disparities in exposure to environmental health hazards  or health benefits  among different social groups. However, the heavy use of aggregate data and the narrow focus solely on residential contexts in past studies have led to several methodological problems as well as inconsistent findings on the association. In this review paper, we discuss the limitations of residence- and place-based approaches in segregation and environmental exposure assessment. We then suggest that future environmental justice research should consider spatiotemporal population dynamics and regard individuals as mobile agents in urban spaces in order to address the complexity of the dynamic sociospatial mechanisms underlying unjust environmental exposure among social groups. This in turn calls for a reconceptualization of and new measures for segregation, as well as a redelineation of the individual geographic and temporal contexts in which people actually experience segregation and unequal exposure to environmental factors.Early environmental justice scholars focused largely on the residential neighborhoods of socially marginalized people and their proximity to noxious resources and facilities ,13,14,15As an extension of these residence-based studies in the vast environmental justice literature, several researchers argued that residential segregation may be one of the fundamental factors perpetuating inequalities in environmental exposure and health ,27,28,29There has been a long history of measuring residential segregation by developing indices in sociology and demography , but it Although the literature has increasingly linked residential segregation to social disparities in environmental exposure and associated health risks, recent studies have noted that it is still unclear whether segregation is significantly associated with such disparities ,39. Rese10). These mixed associations, however, may be due in part to the size of the spatial unit used to derive relevant variables . An MSA may be too large to capture small-scale spatial variations with respect to some air pollutants, and the resulting imprecise macro-scale analysis may lead to erroneous results [Previous empirical studies on the association between residential segregation and unequal exposure to air pollution have reported inconsistent results, ranging from a strong association to no association. Using the dissimilarity index––the most commonly used measure of residential segregation––Lopez  found th results .Unlike the aforementioned studies, which focused only on a dyadic racial comparison, Morello-Frosch and Jesdale  utilized2) than income disparity.Contrary to the findings of these studies, however, several empirical studies concluded that the association between residential segregation and environmental health disparities is either unclear or nonexistent. For instance, Downey  found thThis paper argues that the mixed findings regarding the association between segregation and environmental exposure are due to several methodological problems usually found in residence- and place-based approaches in environmental justice research. The next section discusses these methodological problems and how they can lead to misleading research findings.For decades, segregation studies have developed various indices to measure levels of residential segregation, with most early works completed by sociologists and demographers . It was D), developed by Duncan and Duncan [D) is calculated by the following equation [ith sub-areal unit; ith sub-areal unit). Although this index has been the most commonly used, even until recently due to its easy calculation [For example, the dissimilarity index  because it is affected only by the population mix within each spatial unit , not by spatial patterns between the units across the entire region  of the units. Due to such limitations in traditional measures of residential segregation, some scholars have cast doubt on using indices to understand segregation. Johnston et al.  pointed i* statistic [i* statistic returns a z-score, which indicates which areas with low or high attribute values cluster spatially. If an area has a high z-score, it means that its neighboring areas also have high attribute values, and vice versa. The statistic is calculated by the following equation: i and j ; j; and n is the total number of areas.). Similarly, a more recent study used the same spatial statistical method to investigate the joint effects of racial segregation and air pollution on cardiovascular outcomes [Some efforts have been made to develop spatial segregation measures , to identify people’s true geographic and temporal contexts . GPS canSome recent environmental exposure studies have made use of the Big Data  revolutHowever, while richly detailed individual-level data have significantly benefited environmental exposure/health studies via the increased accuracy of exposure assessments, environmental justice scholars have not yet adequately taken advantage of such benefit. It may be because of the challenges in obtaining or using such high-resolution data, including the significant amount of cost and time of data collection, data confidentiality, computational complexity and the need to protect research participants’ privacy ,76 Tabl. HoweverTraditionally, socioeconomic or racial/ethnic segregation has been a static notion closely associated with residential areas . This noRecent studies have suggested that the scope of segregation-related research should be extended to include workplaces, grocery stores, or churches to better capture the dynamic experiences of segregation in various daily-life contexts . This exIn addition to workplace segregation, another important but less recognized segregation type is free-time segregation. Different racial/ethnic groups tend to visit, for example, different parks , groceriAlong with this extended scope, the scale of segregation measures has also shifted from global measures  to iConsidering individuals as active actors moving through the city, Netto et al.  visualizDespite the growing literature, however, there is still no consensus on the term used to describe this dynamic dimension of segregation in the literature . Some stNoting the need for a more comprehensive term that can embrace both time-geographic and activity-space approaches, Park and Kwan  recentlySome studies have found only weak associations between the social and physical characteristics of people’s residential neighborhoods and those of their jobs, schools, shops, churches, recreational venues and other socially significant places ,122,145.Disparities in exposure to environmental stressors among different social groups can be intensified or mitigated depending on how greatly people are segregated at work or social/recreational venues and how much the environmental characteristics of these places differ from those of their residential neighborhoods. For example, if different social groups are more integrated in their workplaces or leisure-activity places than in their residential neighborhoods, then they may be equally exposed to similar levels of air quality in these non-residential places. If environmental quality of these non-residential areas is better than that of socioeconomically marginalized groups’ residential areas, being mobile may enable them to mitigate some of the environmental disadvantages of their residential neighborhood. This can ultimately reduce the disparity in total exposure to environmental health hazards among social and ethnic groups. Inagami et al.  found thOn the other hand, the disparity may increase when a particular group has limited access to workplaces or other activity places with better air quality than their residential neighborhoods, while other groups enjoy greater access. In general, whites or affluent people tend to have the social privilege and financial capacity  to select their activity places . They teThe same can be said for unequal exposure to beneficial environmental factors, such as exposure to urban green space, blue space, biodiversity, good aesthetics and community resources. Environmental injustice among social groups has been observed not only in exposure to environmental health hazards but also in exposure to environmental health benefits. Some studies have reported that minority groups or people from socioeconomically deprived communities tend to have poor access to and poor quality of green space, which may affect their health adversely ,150. TheThis review paper suggests a future direction of quantitative environmental justice research. We argue that future research that seeks to link segregation and social disparities in environmental exposure should go beyond residence-based approaches and assess both segregation and environmental exposure at a fine spatiotemporal scale to address several methodological problems in residence-based methods. Integrating the notion of multi-contextual segregation into environmental justice studies, instead of the concept of residential segregation, would help examine the full range of segregated contexts in which people are disproportionately exposed to environmental health hazards or benefits. Such fine-grained research would provide more nuanced and fruitful insights into the complex socio-spatial mechanisms behind the perpetuating disparities in environmental exposure and health.Kwan  argued t