Cytokine storms, defined by the dysregulated and excessive production of multiple pro-inflammatory cytokines, are closely associated with the pathology and mortality of several infectious diseases, including coronavirus disease 2019 (COVID-19). Effective therapies are urgently needed to block the development of cytokine storms to improve patient outcomes, but approaches that target individual cytokines may have limited effect due to the number of cytokines involved in this process. Dysfunctional macrophages appear to play an essential role in cytokine storm development, and therapeutic interventions that target these cells may be a more feasible approach than targeting specific cytokines. Nanomedicine-based therapeutics that target macrophages have recently been shown to reduce cytokine production in animal models of diseases that are associated with excessive proinflammatory responses. In this mini-review, we summarize important studies and discuss how macrophage-targeted nanomedicines can be employed to attenuate cytokine storms and their associated pathological effects to improve outcomes in patients with severe infections or other conditions associated with excessive pro-inflammatory responses. We also discuss engineering approaches that can improve nanocarriers targeting efficiency to macrophages, and key issues should be considered before initiating such studies. Circulating levels of pro-inflammatory cytokines correlate with the severity of many infections. Severe infections can result in uncontrolled immune responses accompanied by excessive release of pro-inflammatory cytokines, frequently referred to as a “cytokine storm”, that can be responsible for a significant degree of the pathology and mortality associated with severe infections Effective therapeutic strategies to prevent or suppress cytokine storms and attenuate their effects, or other conditions prone to this response, during severe infection do not yet exist Macrophages and related monocyte-lineage immune cells, which reside in most body tissues and play essential roles in regulating cytokine-mediated inflammatory responses and innate and adaptive immune reactions, are good potential targets for such strategies In this mini-review, we focus on the pathology of cytokine storms in severe infections, highlight the role of macrophage dysfunction in this process, and discuss nanomedicine-based therapies that could be used to target macrophage dysfunction to improve clinical outcomes in patients with severe acute infections.via chemotaxis in response to concentration gradients Many cytokines released during pro-inflammatory immune responses can activate specific leukocyte populations and target their recruitment to sites of inflammation e.g., CCL2 and CCL3) that promote local accumulation of other pro-inflammatory immune cells, including neutrophils, monocytes, and dendritic cells that can release more cytokines and reactive oxygen species to increase the severity of lung injury The term cytokine storm, first used in 1993 in reference to runaway inflammatory responses in graft-versus-host disease Most individuals are vulnerable to SARS-CoV-2 infection, but can exhibit a broad range of symptom severity, and several risk factors are associated with cytokine storm development, including age (> 60 years old), smoking, poor nutrition and pre-existing conditions that can affect immune responses, including obesity, diabetes, hypertension, cardiovascular and chronic lung disease, and cancer No specific therapeutic strategies have yet been developed to attenuate cytokine storm mediated pathology, despite the established link between cytokine storms and disease pathology and mortality.COVID-19 offers a compelling example of the effect of cytokine storms on pathology and mortality. The precise mechanisms responsible for the pathological changes observed in severe COVID-19 cases are not well understood, but several studies have reported that most patients with severe pathology have markedly elevated circulating levels of multiple pro-inflammatory cytokines, including IL-1, IL-6, IL-8, IL-21, TNF-α, and MCP-1 Macrophages are multifunctional and heterogeneous innate immune cells that reside in most tissues and play essential roles in innate immunity, the regulation of adaptive immunity, and pro-inflammatory responses to control the virulence and pathology of infectious diseases in vitro characterization studies Macrophages act as an initial defense against infection Macrophages can also display pathogen-derived proteolytic peptides on their type I and type II major histocompatibility complexes (MHCI and MHCII) to activate T lymphocytes that recognize these peptides and initiate a pathogen-specific adaptive immune response A rapid and well-coordinated innate immune response is the first line of defense against infection, but excessive immune responses can cause local and systemic tissue dysfunction and damage Figure 1) + macrophages containing SARS-CoV-2 nucleoprotein, which exhibit IL-6 up-regulation, have also been detected in the spleen and lymph node marginal sinuses of patients who died from COVID-19 Macrophage dysfunction can initiate uncontrolled cytokine release leading to the development of cytokine storms observed in many severe infectious diseases, including SARS and COVID-19  family Macrophage dysfunction also plays important roles in the pathology of other infections caused by viral and microbial pathogens, particularly when these infections progress to sepsis, due to overlap of monocyte/macrophage responses to these pathogens. Macrophages are normally activated in response to recognition of danger-associated stimuli produced upon recognition of various components of viral and bacterial pathogens (PAMPs) via therapies that exhibit macrophage-specific or -selective toxicity; (ii) inhibiting macrophage invasion to limit inflammatory responses at disease sites by blocking chemotactic monocyte surface receptors  Both clinical and experimental findings strongly suggest that dysfunctional macrophages are a major source of inflammatory cytokines in severe infections, and thus therapeutic interventions that target these macrophages may prove beneficial in attenuating cytokine storms that contribute to the increased pathology and mortality of severe infections. Therapeutic approaches designed to manipulate macrophage responses using conventional drug delivery mechanisms have been studied in preclinical models of inflammatory diseases and cancer Table 1).Nanomedicine, the medical application of nanotechnology, has emerged as a powerful platform to resolve issues associated with conventional therapeutics, including bioavailability, tissue specificity, and toxicity in vitro studies indicate that some nanoparticles are also preferentially engulfed via clathrin- or caveolin-mediated endocytosis mechanisms via different approaches that add macrophage-specific molecules to their surfaces Nanoparticles employed for macrophage targeting approaches can vary markedly in their origin  and composition, but macrophage uptake generally occurs through one of two distinct pathways: non-specific phagocytosis (passive targeting) regulated by nanoparticle physical properties, or receptor-mediated endocytosis (active targeting). Passive targeting is usually responsible for macrophage uptake of unmodified nanoparticles of medium size (10~300 nm diameter), which include most extracellular vehicles (EVs) and liposomes. These nanoparticles primarily accumulate at infection or inflammation sites as a result of phagocytosis and/or macropinocytosis by monocyte/macrophage-lineage cells that are abundantly present at these sites Figure 1). These studies used synthetic liposomes, FDA-approved nanocarriers composed of one or more lipid bilayers surrounding a hollow core that can contain therapeutic cargoes via disruption of the mitochondrial electron transport chain and cytosolic release of cytochrome C At least two studies have now examined the efficacy of nanoparticle-mediated drug delivery to transiently deplete macrophages to attenuate dysfunctional macrophage responses . EVs are natural nanoparticles (~50-500 nm) that facilitate cell-to-cell communication, and are readily engulfed by circulating monocytes and tissue resident macrophages following their infusion into mouse models of human disease ex vivo model in which perfused human lungs rejected for transplant were injured by E. coli exposure to induce severe bacterial pneumonia e.g., miR-21, miR-124) and proteins  shuttled by MSC-EVs Other studies examined the potential of unmodified EVs with anti-inflammatory properties to suppress macrophage dysfunction  e.g., solid-lipid, polymeric, or metallic nanoparticles) using this strategy have been developed for macrophage-targeted drug delivery in models of inflammatory and infectious diseases Functionalizing nanoparticle therapeutics with ligands or peptides that have high affinity for extracellular macrophage membrane factors can enhance their specific uptake to attenuate dysfunctional macrophage responses , which contain viral coat proteins but lack viral genetic material, have recently been considered as nanoparticle platforms for drug delivery, imaging, and vaccine approaches A growing body of evidence indicates the potential of macrophage-targeted nanomedicines to reduce excessive cytokine production during severe infection. We therefore believe that nanomedicine approaches designed to regulate macrophage-mediated inflammatory responses should receive greater consideration as alternative therapies for conditions where macrophage dysfunction has the potential to induce a cytokine storm and its associated pathological effects. To the best of our knowledge, studies have yet to examine the therapeutic potential of macrophage-targeted nanomedicines in animal models of COVID-19, the most recent disease where cytokine storms have been shown to play a central role in disease pathology and mortality. At minimum, we propose that EV and liposome studies should be performed using commercially available human ACE2 (hACE2) transgenic mice, which can serve as a model of human COVID-19 disease, to clarify whether nanomedicine-mediated macrophage depletion or attenuation of macrophage activation is beneficial in severe COVID-19 disease. Nanomedicine delivery approaches may also be useful to increase the targeted bioavailability or reduce potential side effects of anti-inflammatory small molecule drugs and antibody therapeutics currently under investigation for treatment of COVID-19 in clinical trials. It will be important to comprehensively evaluate the therapeutic effects of these and other potential nanomedicines using clinically relevant indicators, including, but not limited to, effects on survival, lung lesions, and cytokine profiles.e.g., at or immediately prior to the hyperinflammatory phase), to have a beneficial effect, since suppression of the innate immune response in the early phase virus infection is likely to be harmful. Since cytokine storm development can be highly dynamic during severe infections, serial evaluation using a well-designed cytokine panel is necessary to determine the most effective therapeutic period and the specific effects of an intervention. Combination therapies that employ both nanomedicines and conventional antiviral drug delivery may also provide synergistic beneficial effects. Finally, it is also necessary to address the potential for increased risk of immune disorders and bacterial infections that may be associated with any strategy to deplete macrophages or attenuate their activity. Even if data from animal models proven to be promising, additional preclinical studies are required to address biosafety, mechanisms of action, and optimal administration routes and doses. Clinical translation will also require the development of nanomedicine manufacturing approaches with standard processes and quality control early in these studies. The massive degree of collaboration now ongoing across diverse disciplines and industries, offers hope for an unprecedent rate of development for new therapies and therapeutics to combat severe infectious diseases such as COVID-19. We believe that novel nanomedicine approaches are a worthy target of such efforts.Some key issues should be considered before initiating such studies, however. Macrophage-targeted nanomedicines may need to be given at the correct stage of infection (


Despite recommendations to include a distinct intervention phase in Adult Protective Services (APS), most APS programs close cases following investigation/substantiation phases without engaging in a defined intervention phase. This study implements and evaluates a novel APS service planning/intervention model in the state of Maine. Using an experimental efficacy trial design with stratified random sampling at the level of Maine APS offices, this study compares standard APS care with an enhanced/integrated APS intervention model involving “elder advocates”. Advocates were trained in motivational interviewing, supported decision-making, teaming, restorative justice, and goal attainment scaling to develop capacity to work with both the older adult victim and perpetrator and to strengthen the family and social systems surrounding the victim-perpetrator dyad. This presentation will present results on the efficacy of this integrated APS/elder advocate model and discuss the challenges and successes in conducting elder abuse intervention research in collaboration with APS and APS clients. Part of a symposium sponsored by Abuse, Neglect and Exploitation of Elderly People Interest Group.


Unconventional oil and gas exploration generates an enormous quantity of wastewater, commonly referred to as flowback and produced water (FPW). Limited freshwater resources and stringent disposal regulations have provided impetus for FPW reuse. Organic and inorganic compounds released from the shale/brine formation, microbial activity, and residual chemicals added during hydraulic fracturing bestow a unique as well as temporally varying chemical composition to this wastewater. Studies indicate that many of the compounds found in FPW are amenable to biological degradation, indicating biological treatment may be a viable option for FPW processing and reuse. This review discusses commonly characterized contaminants and current knowledge on their biodegradability, including the enzymes and organisms involved. Further, a perspective on recent novel hybrid biological treatments and application of knowledge gained from omics studies in improving these treatments is explored. Technological advances have led to unprecedented growth in unconventional oil and gas extraction in the US over the last few decades . This enCurrent disposal methods mainly rely on reinjecting FPW into newly drilled wells or disposal into deep Underground Injection wells. Disposal into underground injection wells irreversibly removes water from the hydrological cycle and has raised concerns due to induced seismicity . AlternaAmong the 1,198 chemical compounds identified in FPW, only 14% have existing toxicity data and 24% can be detected through standard analytical methods . PresencThis review aims to summarize recent trends in biological treatment of FPW with an emphasis on organic contaminants and microbial groups involved in their degradation . We brie1, are fairly well-documented and generally involve gas chromatography paired with mass spectrometry (GC-MS), the methods developed for surface and groundwater have to be modified to account for the complex matrix in FPW  using non-targeted Liquid Chromatography-Electrospray Ionization-Mass spectrometry (LC-ESI-MS) approaches, many of which provide semi-quantitative estimation of identified compounds , especially Benzene/Toluene/Ethyl Benzene/Xylenes (BTEX), are the most commonly analyzed hydrocarbons in FPW with concentrations varying from a few ormation . BTEX arormation . Microbiormation . However+) as the dominant cation, with calcium (Ca2+), magnesium (Mg2+), and potassium (K+) as minor cations, and chloride (Cl–) as the major anion, along with small amounts of bicarbonate  . Trace m (SO42-) . Though A meta-analysis of published data on biological treatment of oilfield wastewater found average COD removal in actual wastewaters to be about 74% when TDS was low  . IncreasTreatment of a complex matrix like FPW should not only meet the requirements of the intended application but also be cost-effective. TDS greater than 40,000 mg/L leads to elevated desalination costs, thus, low TDS western brines  are more likely to be treated and reused .Experiments simulating a PW spill  on soil concluded that the high salt content of PW can disrupt soil structure and mobilize metal ions like copper, lead, aluminum and manganese during subsequent rainfall events . StudiesHF involves addition of several chemicals to water that regulate viscosity to perform various functions ranging from generating fissures to ensuring smooth flowback from the formation . Among aBiocides are added to prevent biofouling by sulfate-reducing bacteria during HF and to prevent growth of microbes that clog the pipelines during gas production . BiocideGA, a non-oxidizing, electrophilic biocide, inactivates bacteria by crosslinking amines present on bacterial membrane proteins . HypersaDBNPA  is the second most commonly used biocide , howeverPseudomonas  are frequently used amphiphilic biocides that have been found to persist in FPW . Benzalkudomonas , Thalassiabensis  isolatedpduCDE) from dominant Firmicutes was predicted to be responsible for surfactant degradation under anaerobic conditions. In another study on PEG and PPG degradation under aerobic conditions in sediment-groundwater microcosms amended with PW  mapped to Halanaerobium in PW samples and in laboratory experiments with an isolate, Halanaerobium congolense WG10.Non-ionic surfactants, including both unsubstituted polyglycols [Polyethylene glycol (PEG) and Polypropylene Glycol (PPG)] and substituted ethoxylates [Alkyl ethoxylates (AEOs) and Nonylphenol ethoxylates (NPEOs)], are employed as emulsifiers, corrosion inhibitors and crosslinkers in HF. These surfactants are generally present as a mixture of homologs and are identified by calculation of Kendrick mass defect from LC-MS data . A few r with PW , authorsin situ. Reaction with persulfate (added as a breaker in the fracturing fluid) and other abiotic processes were implicated in the production of these halogenated organic compounds, along with biotic transformation by iodide-oxidizing bacteria, specifically Roseovarius spp.  HF operations, those based on oilfield PW with comparable TDS  have also been included. The reactor configurations and dominant microbial groups identified are summarized in Activated sludge (AS) systems are the most popular form of biological reactor for wastewater treatment around the globe. A typical AS system consists of an aerated tank for mixing microbial biomass with wastewater, followed by a settling/sedimentation unit to separate biomass (sludge) from treated water. Such systems are operated in continuous flow conditions and a portion of the settled sludge is often recycled back into the aeration tank. A sequencing batch reactor (SBR) consists of a single tank to perform all the steps  of an activated sludge and hence is operated in a batch mode. Both these approaches have been used to treat FPW, and a few studies have investigated the microbes found in these systems.Pseudomonas, Ochrobactrum, Corynebacterium and Burkholderia were major bacterial groups identified from the reactor sludge using a Biolog MicrologTM System.Cellvibrionaceae, Rhodocyclaceae, Rhodobacteraceae, and Phyllobacteriaceae were some dominant groups that were found to be enriched at a TDS of 50,000 mg/L.A typical membrane bioreactor (MBR) consists of an aerated tank containing sludge fed with wastewater and a submerged membrane module to filter out the treated effluent. In high salinity wastewater like PW where bacterial floc formation is disrupted, MBRs can overcome the floc settling requirement and retain the biomass in the reactor.A lab-scale MBR was acclimated to high salinity in phases using PW from different wells to investigate impact of salinity on the microbial community . Upon inIdiomarina genus and Rhodospirillaceae family in Sample A1/2 and B, respectively.Emulating the naturally occurring stratified microbial consortia (or mats) often found in hypersaline environments, engineered microbial mats have been grown and evaluated for PW treatment in the laboratory. Biological treatability of PW samples from Utica and Bakken shale was also studied using microbial mats . These sBiologically active filters (BAF) employ microbial biofilms attached to a filter media (most commonly activated carbon) to adsorb and degrade organic compounds in wastewater along with removal of suspended solids. BAF successfully removed organic matter  from three different wastewaters  with varying salinity  and organic composition (DOC: 35.6–732 mg/L) as a pretreatment to ultrafiltration and nanofiltration . This BAFlavobacteria (predominantly genus Fluviicola) and Gammaproteobacteria) over non-aerated filters .The scalability of BAF was tested using bench-scale and lab-scale columns fed with different wastewaters  under different operating conditions like aeration, pretreatment, operating temperature and empty bed contact time . AeratioBioelectrochemical systems (BES) can simultaneously achieve reduction in organic carbon and salinity, making them a promising technology, and an advancement over other biological systems to treat PW. BES harness the microbial capacity to degrade organic compounds anaerobically to generate electrons. These electrons can then be transported, via a pair of electrodes (anode to cathode), to terminal electron acceptors like oxygen or the system can be maintained anaerobic to produce hydrogen.Several configurations of BES have been tested to treat PW. Microbial Fuel Cell (MFC) is the simplest design consisting of two electrodes separated by an ion-exchange membrane in which the wastewater to be treated is added to the anode. Microbial Desalination Cell (MDC) is a modification of MFC with a pair of ion exchange membranes between anode and cathode resulting in three chambers. Microbial Capacitive Desalination Cell (MCDC), like MDC, has three chambers but the middle chamber contains electrodes for Capacitive Deionization. These electrodes have a large surface area that adsorbs organic and inorganic ions under applied electrical potential . On the MCDC desalinated 18 times faster than MDC and 5 times faster in COD removal during treatment of Piceance basin PW . A literHalanaerobium prevalens and Marinobacter hydrocarbonoclasticus, both originating from the PW  (Cyanobacterium aponinum and Parachlorella kessleri) with halophilic bacteria could grow in PW over a wide range of salinities  and the harvested algal biomass was suitable for biodiesel production. Researchers are now looking beyond traditional methods to treat FPW. l value) . HopkinsThough biological treatment of FPW is promising and can be initiated with a readily available inoculum , most reactors need lengthy acclimation periods  which may not be practical for a field-operating full-scale reactor. Reactor parameters such as temperature, mixing/oxygenation and retention time will affect both reactor performance and community composition. Faster, more effective strategies are needed to achieve a consortium that can both tolerate the varying inorganic and organic composition of FPW and efficiently remove chemically diverse contaminants. Biological processes also have the potential to create new potentially harmful contaminants, e.g., iodinated organic compounds detected in the effluent of a BAF attributed to the activity of iodide-oxidizing bacteria . Thus, iRoseovarius  was shown to be capable of leaching gold from its ore in the presence of iodide, in a process more ecofriendly than traditional cyanide leaching  , particularly the dominant phosphate-accumulating organism is (CAP) . In factis (CAP) . That stis (CAP) .Another application of metagenomics and metatranscriptomics to wastewater treatment involved studies of reactors degrading terephthalate, a plastics byproduct, where a preliminary multi-organism pathway postulated based on early metagenome sequencing efforts was later expanded upon with a complex network of cross-feeding relationships that highlights the multilayered nature of these systems . FinallyHalanaerobium  and methanogenic archaea during later PW, when anoxic conditions develop and TDS rises , were described based on their genomes, which in turn explained the changes in key metabolites observed in the samples collected. Viral predation of these major groups was also implicated in community dynamics and nutrient cycling. Further research revealed the viral (phage) diversity in shales and phage-induced lysis of dominant Halanaerobium was shown to release intracellular metabolites that support microbes in such ecosystems  have further shed light on microbes that reside in shale with the help of metagenomics and metabolite profiling combined with supporting laboratory experiments. osystems . As a byaerobium , Frackibkibacter , Marinobnobacter , Methanolophilus , and Arccobacter  – have bin silico tests. Thorough molecular characterization of bioreactor communities with varying performance combined with machine learning could identify biomarkers of successful treatment and potentially enable current monitoring strategies to be augmented or even replaced by molecular methods, allowing early warning of adverse events affecting reactor performance. Eventually, molecular methods will become a key part of a wastewater engineer’s toolkit.On the other hand, there are few metagenomic studies on bioreactors optimized to treat FPW or even petroleum refinery wastewater. Molecular-level understanding of FPW treatment, however, is critical to successfully targeting multiple high-priority contaminants under a wide range of environmental conditions. Accurate, predictive models of FPW treatment bioreactors would dramatically accelerate optimization by replacing empirical manual parameter adjustments with rapid Treatment of FPW is challenging due to its complex chemical composition coupled with geographical and temporal variability. The low cost and effective treatment options offered by biological treatment systems in treating municipal wastewater have made them ubiquitous. Only in the past decade have we been able to understand core microbes and microbial processes behind treatment efficacy and resilience of these systems to shocks and overloads. Many studies have shown that FPW is amenable to biological treatment and different treatment modules to treat FPW have been discussed. Several studies indicate halophiles are effective for FPW treatment, but a systematic study to identify these halophiles during operation of a reactor and understand the key degradation pathways is not available. Omics guided study of core microbes should aid in constructing a core microbial community with broad metabolic potential to handle diverse contaminants and salinities as are common in FPW. Aided with optimized reactor design and robust microbial communities, a hybrid decentralized treatment module capable of handling fluctuations in composition as well as quantity of FPW could be a reality. Such a system could reduce the impacts of accidental release, promote a sustainable hydrological cycle and safeguard the environment.SA wrote the manuscript with inputs and edits from ST and RC. 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.


A 59-year-old man fell onto his outstretched hands. He was diagnosed with a left-sided transscaphoid transcapitate perilunate fracture-dislocation in the setting of previous scaphoid open reduction internal fixation (ORIF), resulting in a nonunion and scaphoid nonunion advanced collapse (SNAC). Wrist salvage in the form of primary partial wrist fusion was performed and resulted in excellent clinical and functional outcomes.What are perilunate dislocations and/or perilunate fracture-dislocations?What physical and radiologic examination findings are typically encountered with perilunate dislocations and fracture-dislocations?How are perilunate dislocations and fracture-dislocations managed?When a perilunate fracture-dislocation presents in the setting of previous scaphoid nonunion and SNAC wrist, what is the best surgical option to give the best functional outcome?Perilunate dislocations and fracture-dislocations are debilitating wrist injuries resulting from high-energy trauma. Dislocations can be purely ligamentous or involve a combination of bony and ligamentous structures. When involving only ligaments surrounding the lunate, these dislocations are referred to as lesser arc injuries. When the dislocation is associated with a radial styloid or carpal bone fractures, they are referred to as greater arc injuries.Physical examination often reveals a grossly swollen wrist with limited range of motion with or without signs of acute median neuropathy. The presence of acute carpal tunnel syndrome is an indication for urgent operative intervention if closed reduction has failed. Posteroanterior radiographic evaluation may demonstrate alteration of Gilula's lines with loss of carpal height . There m,Surgical correction involves acute carpal tunnel decompression, relocation of the carpus, repair of the capsular rent, and stabilization of the carpus with percutaneous pin fixation. Controversy exists whether acute scapholunate ligament reconstruction should be performed.4We present a case of a patient who suffered a transscaphoid transcapitate perilunate fracture-dislocation in the setting of a prior scaphoid nonunion and SNAC wrist. Radiographs revealed a greater arc injury with transmission of force through the previous scaphoid nonunion site, resulting in displacement of the cannulated screw from the proximal pole of the scaphoid  and 2. S


Understanding food web responses to global warming, and their consequences for conservation and management, requires knowledge on how responses vary both among and within species. Warming can reduce both species richness and biomass production. However, warming responses observed at different levels of biological organization may seem contradictory. For example, higher temperatures commonly lead to faster individual body growth but can decrease biomass production of fishes. Here we show that the key to resolve this contradiction is intraspecific variation, because (i) community dynamics emerge from interactions among individuals, and (ii) ecological interactions, physiological processes and warming effects often vary over life history. By combining insights from temperature-dependent dynamic models of simple food webs, observations over large temperature gradients and findings from short-term mesocosm and multi-decadal whole-ecosystem warming experiments, we resolve mechanisms by which warming waters can affect food webs via individual-level responses and review their empirical support. We identify a need for warming experiments on food webs manipulating population size structures to test these mechanisms. We stress that within-species variation in both body size, temperature responses and ecological interactions are key for accurate predictions and appropriate conservation efforts for fish production and food web function under a warming climate.This article is part of the theme issue ‘Integrative research perspectives on marine conservation'. A key link in these feedbacks underlying observed warming responses is population size structure, because of how it arises from, as well as influences, individual body growth and survival figures a and 2.


Complication in acute kidney injury (AKI) is significantly associated with developing acute respiratory failure (ARF), while ARF is one of the most important risks for AKI. These data suggest AKI and ARF may synergistically worsen the outcomes of critically ill patients and these organ injuries may not occur independently. Organ crosstalk between the kidney and the lung has been investigated by using animal models so far. This review will focus on innate immune response and neutrophil activation among the mechanisms that contribute to this organ crosstalk. AKI increased the blood level of an inflammatory mediator in high-mobility group box 1, which induces an innate immune reaction via toll-like receptor 4. The remarkable infiltration of neutrophils to the lung was observed in animal AKI models. IL-6 and IL-8 have been demonstrated to contribute to pulmonary neutrophil activation in AKI. In addition, the formation of a neutrophil extracellular trap was also observed in the lung after the exposure of renal ischemia reperfusion in the animal model. Further investigation is necessary to determine whether targeting innate immune response and neutrophil activation will be useful for developing new therapeutics that could improve multiple organ failure in critically ill patients. Acute kidney injury (AKI) is a common complication in critically ill patients treated in the intensive care unit (ICU). Reportedly, AKI occurs in ~30–60% of patients admitted to the ICU and is associated with significantly poor outcomes including morbidity and mortality . ICU patThough the primary roles are different, lung and kidney functions are intimately related regarding the maintenance of homeostasis. The blood acid-base balance is regulated by carboxy dioxide excretion by the lung and bicarbonate reabsorption by the kidney. A compensative mechanism will activate when one organ fails to keep these levels within a normal range by the other organ. Thus, respiratory complication in AKI patients is particularly important. Clinical studies revealed AKI patients were twice as likely to require invasive mechanical ventilation . On the In this review, we provide a brief overview regarding (1) the clinical data on AKI and ARF/ARDS and (2) the potential mechanisms by which AKI leads to lung injury. Recently identified mechanisms of the innate immune system including toll-like receptors (TLRs) and damage-associated molecular patterns (DAMPs) were evaluated in the kidney-lung crosstalk using animal models. Neutrophil extracellular traps (NETs) was identified as another player in the innate immune response. NETs were also demonstrated to contribute to AKI-induced lung injury.Many clinical studies suggested associations between AKI and ARF/ARDS in critically ill patients. AKI often occurs in ARF/ARDS patients, while ARF/ARDS is often observed in AKI patients. First, clinical data about AKI complication in ARF/ARDS are described below. The secondary analysis of a randomized control trial conducted by the ARDS network reported AKI occurred in ~25% of ARDS patients. The mortality rate of AKI patients was significantly higher than the non-AKI patients . AnotherSecond, ARF/ARDS complication in AKI is described below. Severe ARF requiring MV was observed in more than 70% of AKI patients in a multinational, multicenter prospective observational study. MV requirement was significantly associated with higher mortality . TherefoThird, AKI and ARF/ARDS are organ failures that can be simultaneously complicated in a critically ill patient. An observational study conducted in 18 French ICUs reported ARDS occurrence as 23%, while AKI occurrence was at 31%. Hospital mortality was 14% in this population and it increased to 42% in patients with both AKI and ARDS . In a laThe pathophysiological mechanisms of respiratory failure in patients with AKI can be categorized into inflammatory and non-inflammatory mechanisms . Non-infRabb and colleagues first demonstrated increased inflammatory gene expressions in the lung after exposure of renal ischemia reperfusion injury by using microarray analysis . Faubel Although these studies suggested that the induction of an inflammatory reaction by AKI is involved in lung injury, other studies demonstrated AKI suppressed inflammatory reactions and subsequently worsened pulmonary infection. Neutrophil function against pneumonia was evaluated in the model of bacterial pneumonia in mice complicated with AKI by folic acid administration or glycerol injection (rhabdomyolysis) . NeutropTaken together, increased humoral mediators by reduced clearance and increased expression in AKI seem to contribute to lung injury. On the other hand, few studies revealed the mechanisms of the opposite direction of crosstalk, i.e., ARF/ARDS-induced kidney injury. Slutsky et al.  reportedNeutrophil infiltration is a major finding in lung injury induced by AKI. A remarkable neutrophil infiltration in the lung together with increased neutrophil elastase (NE) activity in blood and lung tissues were observed in a mouse AKI model and specific NE inhibitor reduced lung injury . Toll-liin vitro caused by hypoxia stimulated neutrophils to form NETs by extracellularly released histones. In a mouse intestinal ischemia-reperfusion model, extracellular histone accumulation and NETs formation were observed in the liver rather than the intestine , that comprise DNA studded with histones and proteases, including neutrophil elastases . Extracentestine . Extracentestine . Human r animals .These findings above suggest that extracellular histones and NETs formation might be responsible for AKI-induced lung injury, although other pathways of inflammatory mediators such as IL-6 also contribute to AKI-induced lung injury. For the development of new therapeutics against organ crosstalk between the kidney and lung, targeting multiple pathways will be necessary. In addition, extracellular histones and NETs formation have not been sufficiently evaluated in human ARDS  and no cThe novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in Wuhan in December 2019, which has spread around the world. SARS-CoV-2 dominantly affects the respiratory system and recent clinical studies reported AKI as a significant comorbidity in COVID-19 . The celMultiple organ failure frequently observed in critically ill patients was previously considered as the “sum” of each organ failure. The sequential organ failure assessment (SOFA) score, which is widely used for evaluating the severity of ICU patients, is calculated by summing up each organ injury score. No consideration for organ crosstalk can be found in these scoring systems. Several clinical studies demonstrated possible organ crosstalk in ICU patients by applying network analysis , 35. As This review covers kidney-lung crosstalk mostly regarding lung injury caused by AKI. The opposite pathological mechanism in which ARF/ARDS causes AKI should also be considered. As described above, only a limited number of basic studies reported possible mechanisms in animal experiments. In clinical studies, ARF/ARDS caused a systemic release of pro-inflammatory mediators , which could induce or worsen AKI .Mechanical ventilation-induced lung injury has been investigated so far. Low tidal ventilation strategy against ARDS is recommended based on evidence obtained by both basic and clinical studies . Does MVAM, NH, and KD contributed to the writing of the manuscript 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.


Endometriosis, an estrogen-dependent inflammatory disease, is commonly observed in gynecologic practice. Spontaneous hemoperitoneum is a rare but serious complication of endometriosis. Most cases of endometriosis-induced hemoperitoneum are attributable to a ruptured endometrioma or utero-ovarian vessel hemorrhage. We report a case of massive hemoperitoneum secondary to intra-abdominal bleeding from the peritoneal endometriotic deposits with spontaneous abortion that was misdiagnosed as a ruptured ectopic pregnancy.A 36-year-old Korean woman was admitted to our hospital for acute abdominal pain and vaginal bleeding. She was suspected of ruptured ectopic pregnancy on the basis of a positive serum human chorionic gonadotropin test result and ultrasonographic evidence of pelvic fluid collection. During hospitalization, her symptoms deteriorated with peritoneal irritation sign on physical examination, hypotension, and tachycardia. Emergency exploratory laparoscopy was performed and revealed active bleeding from the peritoneal endometriotic deposit, which was treated with laparoscopic electrocoagulation. The patient’s postoperative course was uneventful. Spontaneous abortion was diagnosed on the basis of decreased serial serum human chorionic gonadotropin level estimation.Although rare, gynecologists should consider endometriosis-induced hemoperitoneum with spontaneous abortion in the differential diagnosis in women of reproductive age presenting with a positive serum human chorionic gonadotropin test result and acute abdomen with intra-abdominal bleeding. Endometriosis is an estrogen-dependent inflammatory disease characterized by the deposition of endometrial tissue at extrauterine (ectopic) sites. It is a relatively common condition that mainly affects women of reproductive age . CurrentA 36-year-old gravida 1, para 1 Korean woman presented to our emergency department with a 1-day history of acute abdominal pain and vaginal bleeding. Her physical examination showed lower abdominal tenderness, and her speculum examination revealed a small amount of vaginal bleeding. Her menstrual cycle was regular at 30-day intervals, and her last menstrual period had been approximately 5 weeks prior to presentation.Upon admission, her vital signs were stable . Her laboratory test results showed mild anemia with a serum hemoglobin level of 10.1 g/dl and hematocrit of 29.0%. Her urine pregnancy and serum human chorionic gonadotropin (hCG) (1149 mIU/ml) tests showed positive results.Transvaginal ultrasonography revealed a large amount of complex fluid and material of mixed echogenicity compatible with blood and blood clots in the pelvic cavity. The bilateral ovaries were not well visualized by ultrasonography, and a normal gestational sac was not identified in the endometrial cavity.During her hospitalization, the patient developed pallor with dizziness, and physical examination showed positive peritoneal irritation signs along with hemodynamic instability , necessitating emergency exploratory laparoscopy.Laparoscopy revealed approximately 1800 ml of fresh liquid and clotted blood in the abdominal cavity. After suctioning the blood, we explored the entire abdominal cavity to identify the source of bleeding. Continuous active bleeding was observed from the peritoneal wall of the pouch of Douglas. Excisional biopsy was performed at the site of bleeding, and bleeding was controlled using electrocoagulation . The gold standard for definitive diagnosis remains visual inspection via laparoscopy and histopathological examination of biopsy specimens .Our patient presented with vaginal bleeding and acute abdominal pain and had a positive serum hCG test result. Transvaginal ultrasonography revealed hemoperitoneum without a normal gestational sac in the endometrial cavity. Considering that she presented with a positive serum hCG test result and that her serum hCG level was less than the discriminatory level (3510 mIU/ml), we could not exclude the possibility of a normal intrauterine pregnancy despite the absence of an intrauterine gestational sac on transvaginal ultrasonography . TherefoSeveral complications related to endometriosis that most gynecologists can overlook have been reported. Endometriosis-related spontaneous hemoperitoneum in pregnancy causes increased maternal and fetal morbidity and mortality, and endometriosis-related ascites often cause a diagnostic dilemma due to symptoms similar to an ovarian malignancy –5. In adet al. reported a case of hemoperitoneum caused by active bleeding from a peritoneal endometriotic deposit on the pouch of Douglas. The patient presented with sudden onset of lower abdominal pain from day 5 of her menstrual cycle and showed a negative serum hCG test result [Acute abdomen and hemoperitoneum are rarely attributable to intra-abdominal bleeding from endometriotic deposits, and only a few cases have been reported previously in the literature. Togami t result . Mutihirt result .Our patient’s case is similar to the two aforementioned cases in that endometriosis-induced hemorrhage occurred during progesterone withdrawal , 10. TheSeveral studies have reported differences in the incidence of abortion between women with and without endometriosis or the possibility of reducing the incidence of abortion in women treated for endometriosis; however, convincing clinical evidence is unavailable . EndometGynecologists should consider hemoperitoneum secondary to intra-abdominal bleeding from endometriotic deposits with spontaneous abortion, as well as ruptured ectopic pregnancy or intrauterine pregnancy with corpus luteal hemorrhage in women of reproductive age presenting with acute abdomen and hemoperitoneum and a positive serum hCG test result.


Widespread transmission of a novel coronavirus, COVID-19, has caused major public health and economic problems around the world. Significant mitigation efforts have been implemented to reduce the spread of COVID-19 but the role of ambient noise and elevated vocal effort on airborne transmission have not been widely reported. Elevated vocal effort has been shown to increase emission of potentially infectious respiratory droplets, which can remain airborne for up to several hours. Multiple confirmed clusters of COVID-19 transmission were associated with settings where elevated vocal effort is generally required for communication, often due to high ambient noise levels, including crowded bars and restaurants, meat packing facilities, and long-stay nursing homes. Clusters of COVID-19 transmission have been frequently reported in each of these settings. Therefore, analysis of COVID-19 transmission clusters in different settings should consider whether higher ambient noise levels, which are associated with increased vocal effort, may be a contributing factor in those settings. Mitigation strategies that include reduction of ambient noise, softer speech practices, and the use of technology such as microphones and speakers to decrease vocal effort will likely reduce the risk of transmitting COVID-19 or other airborne pathogens. They calculated a 0.37% probability that a 10-μm droplet contains at least one virion, which suggests that the risk of transmission is significantly increased during loud speech when large numbers of respiratory droplets are emitted. Several recent studies have characterized respiratory droplets emitted during different types of speech, which are potential vectors of viral particles. et al., of social distancing impacts on COVID-19 transmission found that closing restaurant dining rooms and bars and/or entertainment centers/gyms led to statistically significant reductions in COVID-19 cases (These findings have important implications for settings with increased ambient noise where elevated levels of vocal effort are required for communication . A recen19 cases . In theiOther settings have also been associated with increased transmission of COVID-19, and there appears to be a significant association between centers of outbreaks and areas of increased ambient noise and/or elevated vocal effort in most cases. Significant outbreaks of COVID-19 have been reported in senior living centers and nursing homes . These lSignificant levels of COVID-19 transmission have also been reported in meat packing plants (These studies reveal that high levels of vocal effort due to increased ambient noise could be an important factor in the airborne transmission of COVID-19 in settings where physical distancing is limited. Broad implementation of countermeasures to promote softer speech and reduce vocal effort could have a significant impact on decreasing emission of potentially infectious respiratory droplets. This has important implications for businesses, schools, and other venues that are implementing policies to reduce the risk of COVID-19 transmission in their facilities.There is substantial evidence that softer speech and decreased vocal effort may have an impact on reducing COVID-19 transmission. This suggests that settings with lower levels of ambient noise may have reduced risks of COVID-19 transmission. Strategies to reduce the risk of COVID-19 transmission may include community-based emphasis on approaches to decrease ambient noise exposures when feasible, combined with steps to promote softer speech practices and reduce vocal effort. Masks and face coverings can provide some protection by filtering infectious respiratory droplets in situations where vocal effort is required , but oth


Medicare home health providers are required to offer family caregiver training; however, there is little information regarding the impact of family caregiver training on home health care intensity. A better understanding of this relationship is necessary to inform development and prioritization of caregiver training interventions in this setting. This research assesses whether and how family caregiver need for training affects care intensity during Medicare home health. We examine 1,217  fee-for-service Medicare beneficiaries who participated in the National Health and Aging Trends Study (NHATS) between 2011-2015 and received Medicare-funded home health care within one year of survey. Using propensity score adjusted, multivariable logistic and negative binomial regression, we model the relationship between family caregiver need for activity-specific training and the number/type of visits received during Medicare home health. We found that older adults whose family caregiver required training on self-care tasks had greater odds of receiving any therapy visits , aide visits , or training visits . Older adults whose family caregiver required training on medication management had greater odds of receiving any nursing visits  and incurred 1.06  additional nursing visits. Findings support the importance of connecting family caregivers to training resources. Additionally, findings suggest that home health providers should consider prioritizing training interventions which focus on caregiving activities most closely tied to resource utilization: self-care and medication management.


Nonalcoholic fatty liver disease is a major global health concern with increasing prevalence, associated with obesity and metabolic syndrome. Recently, quantitative ultrasound-based imaging techniques have dramatically improved the ability of ultrasound to detect and quantify hepatic steatosis. These newer ultrasound techniques possess many inherent advantages similar to conventional ultrasound such as universal availability, real-time capability, and relatively low cost along with quantitative rather than a qualitative assessment of liver fat. In addition, quantitative ultrasound-based imaging techniques are less operator dependent than traditional ultrasound. Here we review several different emerging quantitative ultrasound-based approaches used for detection and quantification of hepatic steatosis in patients at risk for nonalcoholic fatty liver disease. We also briefly summarize other clinically available imaging modalities for evaluating hepatic steatosis such as MRI, CT, and serum analysis. Nonalcoholic fatty liver disease (NAFLD) is considered to be the hepatic manifestation of metabolic syndrome and is dramatically increasing in prevalence, paralleling the global obesity epidemic Early detection of NAFLD, continuous monitoring, and early therapeutic intervention, such as lifestyle modifications as well as treatment with pharmaceutical agents  can improve overall patient outcomes and potentially decrease the economic burden on healthcare costs. Other patient subgroups such as those undergoing chemotherapy or bariatric surgery are at risk of development of fatty liver and may also benefit from monitoring of hepatic fat fraction. Non-targeted liver biopsy remains the gold standard for diagnosis and grading of hepatic steatosis, fibrosis, and inflammation Here, we summarize methods in grading of NAFLD, including non-imaging biomarkers and corresponding scoring systems currently in use for managing hepatic steatosis. We then provide a comprehensive review of imaging in liver fat quantification, focusing on innovative QUS approaches studied in human subjects Table . FinallySeveral non-imaging biomarkers such as electrical impedance tomography Conventional ultrasound  is the most common imaging modality for subjective evaluation of hepatic steatosis, with good sensitivity and specificity in detecting moderate to severe levels of steatosis  Several QUS techniques have been studied to improve the diagnosis and classification of hepatic steatosis in NAFLD. These include controlled attenuation parameter (CAP) measured by transient elastography (TE) device; attenuation (AC) and backscatter coefficients (BSC); computerized calculation of hepatorenal index (HRI); and ultrasound envelope statistic parametric imaging . Speckle statistics include acoustic structure quantification (ASQ) and Nakagami imaging; QUS spectroscopy; speed of sound (SoS); and shear wave elastography (SWE) metrics such as dispersion and viscosity. Emerging QUS techniques, integrating statistical methods most notably attenuation-based Nakagami imaging and backscatter-derived quantitative ultrasound spectroscopy show promise and could potentially become the noninvasive imaging method of choice in screening, grading, and monitoring NAFLD patients on therapy. These techniques compared to liver biopsy, could be implemented for screening purposes, compared to an ordinal scale, or provide an accurate continuous measurement of liver fat; the latter two would be most useful for the longitudinal follow-up of NAFLD patients to assess treatment response. Limitations of QUS techniques include confounding effects of body habitus and ascites. Further, QUS cannot simultaneously quantify fat in other organs as can be done with MRI based techniques. Finally, multiple simultaneously emerging QUS techniques from different vendors may prohibit widespread-buy in and may limit inter-vendor comparisons.Controlled attenuation parameter (CAP) is the best-studied and clinically available technique for liver fat quantification, with the first clinical studies dating back to 2010  volume, which is significantly larger than the region analyzed through a liver biopsy, decreasing the potential risk for sampling bias. Limitations of CAP include poorly standardized cut-off values in classifying hepatic steatosis and the potential for CAP estimation of hepatic steatosis to be affected by differences in skin-to-capsule ratio, which may also confound other fat quantification methods. Furthermore, although CAP is an ultrasound technique, measurements are obtained without visualization of the liver. Thus, blind estimation of liver fat may result in inadvertent inclusion of masses, vessels, ducts, or uneven steatosis, any of which may limit accurate assessment. As such, there is a need for QUS parameters to be associated with radiological ultrasound machines to overcome these challenges.Measuring CAP has multiple advantages, including simultaneous assessment of hepatic steatosis and fibrosis, which is valuable in predicting progression and treatment strategies in NAFLD. Measurement of CAP is typically performed by a hepatologist in an office setting in less than five minutes. Values are obtained from a 3 Acoustic waves are attenuated differently by steatotic versus normal liver parenchyma, and this difference is quantified in AC measurements. Unlike CAP, AC values are obtained from ultrasound systems Figure . AttenuaBackscatter coefficient (BSC) is another widely studied QUS parameter first described in 1973 In conventional ultrasound, the diagnosis of hepatic steatosis is typically made by comparing the echogenicity of the liver and right kidney in the same image. Multiple factors affect this comparison, including variations in machine parameters such as gain/depth/power, time-gain- compensation settings and patient anatomy such as attenuation caused by rib shadow or subcutaneous fat, etc. These variations can result in variability of results Prior studies have shown an excellent correlation between HRI and fat fraction obtained through MRS Ultrasound-based envelope statistical imaging, also known as speckle statistics, is based on the passive parametrization of ultrasonic speckle patterns using established statistical distributions/models, which in turn relate to the structural and acoustic properties of tissues (scatterer density and size) Nakagami imaging is one of the most popular model-based speckle statistic methods, first introduced in 2000 . Only a few animal studies have explored the utility of spectroscopy techniques in evaluating fatty liver and demonstrated the potential of spectroscopy parameters to detect and characterize steatosis Quantitative ultrasound spectroscopy uses frequency-dependent parameters extracted from raw RF ultrasound data related to characterize tissue microstructures 82Speed of sound (SoS) measurement is a QUS parameter used for evaluating hepatic steatosis, and can be used to characterize tissue properties based on alterations in ultrasound echo wave speeds in various media Transient elastography and SWE are ultrasound-based elastography methods that measure liver stiffness, which have been successfully adopted clinically to detect and classify hepatic fibrosis Hepatic fat fraction estimated by MRS has proven to be an accurate substitute for liver biopsy and noninvasive imaging standard reference for liver fat quantification The MRI-PDFF is a newer method to estimate liver fat utilizing chemical-shift imaging (CSI) in a single breath-hold. Water protons precess faster than fat protons by about 3.5 parts per million (ppm) Hepatic steatosis can be detected with unenhanced and contrast-enhanced computed tomography (CT) when absolute attenuation of the liver is ≤ 40 Hounsfield units (HU), especially when hepatic fat is > 30% In conclusion, nonalcoholic fatty liver disease is a major health issue with a worldwide increase in prevalence, paralleling the global obesity epidemic. Accurate noninvasive alternatives to liver biopsy in evaluating and monitoring levels of hepatic steatosis are have evolved significantly in the past decade. Emerging quantitative ultrasound-based approaches, integrating innovative statistical methods are promising new technologies to non-invasively assess hepatic steatosis.


An 85-year-old man with cardiac history notable for atrial fibrillation diagnosed 10 years ago which was being treated with atenolol and warfarin presented to our institution with persistent atrial fibrillation. His echocardiogram showed ejection fraction (EF) of 56%, no regional wall motion abnormalities, mild mitral and pulmonary regurgitation, and trivial tricuspid regurgitation. Despite this treatment, he had recurrent episodes of paroxysmal symptomatic atrial fibrillation with a rapid rate requiring multiple emergency department visits and hospital admissions. Given difficulty to control the rate, he underwent atrioventricular (AV) nodal ablation and leadless pacemaker insertion. Fifteen days after the procedure, he was found to have a severe mitral regurgitation murmur. Leadless pacemakers have been shown to have lesser risk of complications such as pocket infections, endocarditis, pacemaker-induced tricuspid regurgitation, and tamponade. However, this newer technology can lead to significant mitral regurgitation due to iatrogenic LBBB and left ventricular (LV) dyssynchrony.An 85-year-old man presented to our institution complaining of recurrent fever and a mitral regurgitation murmur. He has a past history significant for atrial fibrillation being treated with apixaban status post leadless pacemaker implantation and AV nodal ablation 15 days ago, hypertension, hyperlipidemia, obstructive sleep apnea on continuous positive airway pressure, diverticulosis and diverticulitis, dental caries, melanoma in situ, and persistent pulmonary coccidioidomycosis on fluconazole.He underwent a transthoracic echocardiogram which showed normal left ventricular size and no wall motion abnormalities, LVEF of 56%, severe mitral regurgitation due to incomplete coaptation of the mitral valve leaflets Figures , mild riHis cardiac history is notable for atrial fibrillation diagnosed 10 years ago which was treated with atenolol and warfarin. Despite this treatment, he had recurrent episodes of paroxysmal symptomatic atrial fibrillation with a rapid rate requiring multiple emergency department visits and hospital admissions . Given dGiven the absence of degenerative mitral valve abnormality and no evidence of cardiomyopathy, his diagnosis of new-onset severe mitral regurgitation is the direct result of abnormal electrical conduction related to iatrogenic LBBB due to AV nodal ablation and single-chamber paced rhythm.Mitral regurgitation in majority of cases is related to primary mitral valve diseases such as mitral valve prolapse, endocarditis, or rheumatic heart disease which was not the case in our patient . Mitral In conclusion, given the prior absence of mitral valve abnormality and cardiomyopathy, this diagnosis of new-onset severe mitral regurgitation is the direct result of abnormal electrical conduction related to iatrogenic LBBB  due to A


Arterial stiffness assessed by arterial tonometry – in particular pulse wave velocity and augmentation index – is associated with increased cardiovascular risk. It is now possible to use cardiovascular magnetic resonance imaging (CMR) for direct imaging of aortic function. This provides a precise assessment of the elastic properties of the aorta within distinct regions of the aorta. We therefore studied what parameters of aortic function are related to arterial tonometry-derived indices of arterial stiffness.We compared aortic stiffness assessed by cardiovascular magnetic resonance (CMR) pulse wave velocity (PWV) based on flow, velocity or acceleration, and aortic distensibility (AD)) to widely used arterial stiffness estimates provided by arterial tonometry (pulse wave velocity (PWVS) and pulse wave analysis (AI)).Thirty young healthy volunteers (aged 23–33) underwent tonometry (Sphygmacor) for determination of carotid to femoral PWVS and radial pulse wave analysis for AI estimation. They then underwent CMR to assess aortic elastic properties.Aortic distensibility was assessed from breath-hold ECG-gated, steady state free precession (SSFP) images  acquired at the level of the right pulmonary artery through the ascending and proximal descending aorta and through the distal aorta below the diaphragm to determine aortic distensability. Distensibility was calculated as the relative change in area divided by the central pulse pressure.Pulse wave velocity was measured by an ECG-gated, free breathing, spoiled gradient echo phase-encoded acquisition  at the same locations as the aortic cine images. Three variations of the transit time method were used for calculation of pulse wave velocity (PWV). Arrival of the pulse wave was defined as a) the foot of the curve of mean blood velocity of the blood during the cardiac cycle b) the foot of the curve of total blood flow during the cardiac cycle c) maximum blood acceleration rate  during the cardiac cycle  Figure  but withAortic pulse wave velocity calculated by all three MR methods yielded an inverse correlation with descending aortic distensibility  Figure  but PWVSPWVS and AI most closely reflect acceleration-based CMR PWV measurements of overall aortic stiffness. Arterial tonometry has been validated in large scale clinical studies suggesting this CMR method may be most useful for interpretation of clinical risk. Regional and overall aortic measures of elasticity were not strongly related. However, CMR PWV measures inversely correlated with aortic distensibility, suggesting that MR PWV values may provide a closer estimate of local aortic elastic properties.


Internal jugular vein (IJV) thrombosis is an unusual condition, especially when it develops bilaterally. This is a case of bilateral IJV thrombosis in a 77-year old female who presented to the emergency department with neck and arm swelling after discontinuing apixaban and undergoing an oropharyngeal procedure. The diagnosis of bilateral IJV thrombosis was made with the use of point-of-care ultrasound to evaluate bilateral jugular vein distention and bilateral upper extremity pitting edema found on her physical examination. A 77-year-old female with a history of atrial fibrillation currently taking apixaban presented to the emergency department (ED) with swelling of her neck and arms for the past seven days. Two weeks prior, she underwent an embolization of a greater palatine pseudoaneurysm, for which she stopped taking apixaban. After being discharged from the hospital, she continued to experience neck swelling, and had an upper extremity ultrasound evaluation which was negative for thrombus. She returned to the ED for worsening neck swelling. She denied shortness of breath, chest pain, fever, or a history of thromboembolic disease. Her physical exam showed pitting edema on bilateral upper extremities and bilateral jugular vein distention. Point-of-care ultrasound was performed on patient’s neck and upper extremities, revealing thrombosis in bilateral internal jugular veins (IJV) as seen in the IJV thrombosis is an uncommon condition and very rare when it occurs bilaterally. Previous studies indicate that it usually occurs in patients with a history of malignancy, oropharyngeal infections, or deep vein thrombosis.What do we already know about this clinical entity?Internal jugular vein (IJV) thrombosis may develop in patients with malignancy or oropharyngeal infections.What is the major impact of the image(s)?IJV thrombosis may develop bilaterally in patients presenting with jugular vein distention without exhibiting the common causes of bilateral thrombosis of the internal jugular veins.How might this improve emergency medicine practice?Point-of-care ultrasound is effective at providing a prompt diagnosis of bilateral IJV thrombosis and should be monitored after anticoagulation is provided.Video.A) Thrombus in the right internal jugular vein (arrow) seen on transverse view. B) Sagittal view of right internal jugular vein thrombus (arrow) with color doppler showing obstruction of venous outflow and turbulence proximal to the thrombus. C) Thrombus in the distal left internal jugular vein (arrow) seen on transverse view. D) Color doppler of the left internal jugular vein thrombus (arrow) showing partial occlusion of the lumen seen on transverse view.


Subjective cognitive decline (SCD) is a construct of high interest in aging and dementia because individuals endorsing it are at higher risk of developing cognitive problems. It is unclear how individuals arrive at the judgement that they have SCD. Here we aimed to understand which SCD symptoms give rise to the perception of decline as older adults age. Community-dwelling adults , completed the Subjective Cognitive Decline Questionnaire (SCD-Q) online, using an online crowdsourcing site. The SCD-Q consists of one global question regarding self-perceived decline (yes/no) and 24 questions about everyday functioning which we utilized to form a memory, language, and executive functioning domain score, higher for greater perceived decline. Logistic regression revealed that memory and language domains predicted the likelihood of endorsing SCD for adults aged >64 . Only the memory domain predicted the likelihood of endorsing SCD for adults <63 . Executive functioning domain scores did not play a role in the relationship between SCD likelihood in either age group. The higher the self-perceived memory or language decline, the more likely older adults are to conclude they have SCD. Our results suggest there is an age-related trajectory in how people evaluate their cognition, with younger people only considering memory and older people considering both memory and language. Clinicians should be aware of this trajectory when examining patients with SCD. Executive functions should be specifically queried because they may not emerge from older adults’ self-reported cognitive problems.


Engaging in physical activity (PA) in adulthood has multiple protective health effects in later ages. However, unknown are the extent to which PA habits are laid down earlier in life and persist into adulthood, and the extent to which greater opportunities for PA during adolescence stem from differences in socioeconomic status (SES) which then affect opportunities for PA. We investigated potential mechanisms underlying these relationships using the longitudinal Project Talent Twin and Sibling Study (assessments in 1960 and 2014). With this design, we are able to hold genetics constant by modeling relationships between monozygotic twins (who share 100% of their genes) and therefore isolate effects of contextual factors on later-life PA (mean age ~70). We found that higher family SES  and sports participation in adolescence  predicted PA 55 years later, adjusted for gender and physical limitations. This held true when partialling out genetic variation that could otherwise explain these relationships. More education also predicted later-life PA  separately from family SES and partially mediated the effect of family SES on PA. While school-level resources  did not predict later life PA, they did associate with adolescent sports participation . Overall, later-life physical activity was influenced by earlier life sports participation and education, with family rearing resources being more important than high school resources. As twin pair correlations suggest gender differences, future research will examine whether family or school resources differentially benefit males or females for later-life physical activity.


HighlightsAt the acute phase of epidermal necrolysis, patients requiring mechanical ventilation had more alveolar macrophages and higher alveolar concentrations of IL-13 than age- and sex-matched patients with the acute respiratory distress syndromePatients with epidermal necrolysis also showed longer duration of mechanical ventilation and more frequent ventilator-acquired pneumonia episodesTo the Editor,+ T lymphocytes, monocytes/macrophages, and natural killer cells. Yet, the pathophysiology of respiratory system involvement during the acute phase of EN is not well understood. The current study aimed at exploring the clinical and biological characteristics of acute lung injury during the acute phase of EN in mechanically ventilated patients.During the acute phase of epidermal necrolysis , mucosal lesions involving the tracheo-bronchial tract have been reported , 2 and aThis is a retrospective monocentric cohort study including patients with EN admitted in the intensive care unit (ICU) of the French National Reference Center for EN during 2011 and 2015 who required endotracheal intubation for acute respiratory failure. This observational cohort study was approved by the institutional ethics committee . Patients received information during hospital stay that data abstracted from their medical charts could be used for research purposes.i.e. percent of neutrophils, macrophages and lymphocytes) cell counts were measured as recommended [2 or Fisher tests for qualitative variables and the Mann–Whitney test for continuous variables. Ventilator-associated pneumonia was defined according to the presence of clinical findings suggesting infection  along with a radiographic infiltrate that is new or progressive and a positive distal quantitative sample [EN patients were age- and sex-matched with a historical control cohort of patients with pneumonia-associated acute respiratory distress syndrome (ARDS) . As stanommended . Cytokine sample .2/FiO2 ratios both at ICU admission and during ICU stay and lower SOFA scores at admission. Yet, EN patients had longer durations of mechanical ventilation than ARDS patients and underwent more frequent ventilator-acquired pneumonia. Total BAL cell counts were not significantly different between EN and ARDS patients . Patients received information during hospital stay that data abstracted from their medical charts could be used for research purposes.Not applicable.The dataset used during the current study is available from the corresponding author upon reasonable request.All authors declare no competing interest for this work.


Previous studies show that physical activity is beneficial for emotional well-being. This study extends prior research by examining whether engagement in physical activity moderates the association between daily stressor severity and daily emotional well-being. We used data from the second wave of the National Study of Daily Experiences, a sub-project of the Midlife in the United States (MIDUS) study. Respondents  reported their daily experiences across eight consecutive days. Multilevel models explored concurrent and lagged interaction effects between daily stressor severity and physical activity on negative and positive affect and whether these associations differed by age. Physical activity was measured by engagement in vigorous physical activity for at least 30 minutes. Results showed significant interactions between stressor severity and physical activity on same-day negative and positive affect. Specifically, stressor severity was associated with smaller elevation in daily negative affect on physically active days  compared to non-active days . Reductions in daily positive affect were greater on physically inactive days  compared to active days . These associations did not differ by age, but additional findings revealed that stressor severity was associated with greater elevation in negative affect among younger respondents  than older adults . These results highlight the importance of engagement in physical activity for emotional well-being under stressful situations in daily context.


This paper investigated whether experiencing a major asset shock  changed the cognitive health trajectories of older adults (aged 65+ at baseline)? There is a robust literature supporting a relationship between potentially modifiable environmental and individual risk factors and cognitive health and emerging literature supporting a relationship between physical health shocks and later-life financial stability in both the US and internationally. This analysis employed six waves of Health and Retirement Study Core Data (2006-2014) to estimate the causal effect of major asset losses in the period of the 2008 financial crisis. We matched respondents using a rich variety of covariates including education, race/ethnicity, income, total assets, chronic health conditions, depressive symptoms, frequency of physical activity engagement, and engagement with religious activities. Using both propensity score-matched growth curve and difference-in-differences models, we found a small, but significant, negative relationship between major asset shocks and total cognition scores. We also identified a significant overall negative effect on total cognition on all older adults in this sample regardless of exposure to asset shocks. Additionally, both the frequency of asset shock exposure and magnitude of effect on total cognition scores was larger for low-income African-American and Hispanic older adults. These findings suggest in part that recovery from large economic crises may be especially difficult for older adults occupying vulnerable socioeconomic positions and that such events may accelerate the cognitive decline of those who are at or near retirement when asset shocks occur.


Bos mutus f. grunniens) and cattle (B. primigenius f. taurus)), which resulted in the higher loss. Further, compensation and insurance schemes were dysfunctional, with few households insuring their livestock and receiving compensation for depredated livestock over the past two years. We recommend improving herding practices and the implementation of compensation and insurance schemes to lower the economic loss faced by herders due to predation and creating positive avenues for the co-existence of snow leopards and humans.Conflict between snow leopards and humans across the trans-Himalaya is a pressing conservation concern. Conflict severely impacts the socio-economy of the local pastoralist community and threatens snow leopard survival. We investigated the socio-economic factors influencing such conflict and pastoralist attitudes towards snow leopard conservation using semi-structured interviews for a better understanding of what factors influence the variability in losses among the households in the Narphu valley, Nepal. While snow leopards caused significant losses to impoverished pastoralist households, respondents were generally accepting of their presence due to religious reasons and strict law enforcement. We observed poor herding and guarding practices with households owning larger numbers of total livestock  using semi-structured questionnaires targeting herders in the Narphu valley of the Annapurna Conservation Area, Nepal. During the two years (2017/18 and 2018/19), 73.9% of the households interviewed (n = 65) lost livestock to snow leopards, with an annual average loss of two livestock per household. Of the total depredation attributed to snow leopards, 55.4% were yak , 31.7% goat, 6.8% sheep, 3.2% horse and 2.8% cattle. Results from applying Generalized Linear Mixed Models (GLMMs) revealed the total number of livestock owned and the number of larger bodied livestock species as the main explanatory covariates explaining livestock depredation. Forty-one (41%) of all herders considered snow leopard’s preference for domestic livestock as the main factor in livestock predation, whereas only 5% perceived poor herding practice as the main reason for the loss. Our study found poor and changing herding practices in the valley, whereby 71% herders reported careful herding as a solution to snow leopard depredation, and 15% of herders considered the complete extermination of snow leopards as the best solution to the problem. Tolerance levels and awareness among herders towards snow leopard conservation is increasing, mainly due to the Buddhist religion and strict law enforcement within this protected area. We recommend the effective implementation of a community-based livestock insurance scheme to compensate the economic loss of herders due to predation and improved herding practices as the recommended mitigation measures for ensuring livestock security and snow leopards’ conservation in the valley.Livestock depredation across the trans-Himalaya causes significant economic losses to pastoralist communities. Quantification of livestock predation and the assessment of variables associated with depredation are crucial for designing effective long-term mitigation measures. We investigated the patterns and factors of livestock depredation by snow leopards ( Panthera uncia) and Himalayan wolf (Canis lupus chanco) are key mountain species across Himalayan range countries  with their presence indicative of a healthy ecosystem . Th. Th17]. The total mean attitude scores of respondents close to zero suggests that local people were very weakly accepting the presence of snow leopards, probably due to the high level of livestock losses by snow leopard . On the We found a decrease in livestock holdings with higher predation from snow leopards over the study period. Herders owning larger livestock size and larger bodied livestock incurred more economic loss due to livestock depredation. The livestock herding trend is decreasing mainly due to livestock predation by snow leopards and outmigration of village youths to urban centers. In order to reduce economic losses, we recommend encouraging small bodied livestock  while encouraging other appropriate changes in livestock composition (number and livestock species). Moreover, the effective implementation of a community-managed insurance program, with education toward improvement of herding practices and equitable compensation for depredation losses would help in building positive attitudes among herders for supporting snow leopard conservation and minimize these conflicts in the Narphu valley. Similarly, conservation programs focused on empowering herders through educational programs to improve herding techniques and herder motivations  would likely reduce overall losses, especially when livestock are grazed on open pastures or housed in poorly constructed corrals at night. Programs that reduce out-migration of the younger generation and encourage them towards herding could help preserve traditional herding practices in the Narphu valley. For reasons stated above, this paper highlights conflict between snow leopard and humans as a complex phenomenon requiring holistic, multi-pronged approaches for minimizing negative impacts and ensuring positive species coexistence with pastoral-dependent communities.


Bats play important roles as pollen disseminators and pest predators. However, recent interest has focused on their role as natural reservoirs of pathogens associated with emerging infectious diseases. Prior to the outbreak of severe acute respiratory syndrome (SARS), about 60 bat virus species had been reported. The number of identified bat viruses has dramatically increased since the initial SARS outbreak, and most are putative novel virus species or genotypes. Serious infectious diseases caused by previously identified bat viruses continue to emerge throughout in Asia, Australia, Africa and America. Intriguingly, bats infected by these different viruses seldom display clinical symptoms of illness. The pathogenesis and potential threat of bat-borne viruses to public health remains largely unknown. This review provides a brief overview of bat viruses associated with emerging human infectious diseases.


Coronary angiography (CAG) sometimes shows nonobstructive coronary arteries in patients with suspected angina or acute coronary syndrome (ACS). The high prevalence of nonobstructive coronary artery disease (CAD) in those patients has recently been reported not only in Japan but also in Western countries, and is clinically attracting attention. Coronary spasm is considered to be one of the leading causes of both suspected stable angina and ACS with nonobstructive coronary arteries. Coronary spasm could also be associated with left ventricular dysfunction leading to heart failure, which could be improved following the administration of calcium channel blockers. Because we rarely capture spontaneous attacks of coronary spasm with electrocardiograms or Holter recordings, an invasive diagnostic modality, acetylcholine (ACh) provocation test, can be useful in detecting coronary spasm during CAG. Furthermore, we can use the ACh-provocation test to identify high-risk patients with coronary spasm complicated with organic coronary stenosis, and then treat with intensive care. Nonobstructive CAD includes not only epicardial coronary spasm but also microvascular spasm or dysfunction that can be associated with recurrent anginal attacks and poor quality of life. ACh-provocation test could also be helpful for the assessment of microvascular spasm or dysfunction. We hope that cardiologists will increasingly perform ACh-provocation test to assess the pathophysiology of nonobstructive CAD. We often perform percutaneous coronary intervention (PCI) with coronary stent implantation for significant organic coronary artery stenosis with induced myocardial ischemia. PCI has become a useful treatment for relief of chest symptom in patients with significant coronary organic stenosis. However, coronary angiography (CAG) sometimes shows nonobstructive coronary arteries that do not need revascularization in patients with suspected angina –11. IndeYasue and coworkers previously reported that the intracoronary injection of acetylcholine (ACh) is a useful test for the provocation of coronary spasm –23. SincAlthough the etiologic mechanisms of stable angina and acute coronary syndrome (ACS) in patients with nonobstructive CAD remain obscure, coronary spasm can play an important role in the pathogenesis of these diseases , 36, 37.In this review article, we discuss the significance of ACh-provocation test as a tool for pathophysiological evaluation in nonobstructive CAD including coronary spasm.Coronary spasm usually occurs at rest, particularly from midnight to early morning –27. CoroACh usually causes vasodilation by releasing nitric oxide from the endothelium, and intracoronary injection of ACh in humans provokes coronary vasodilation in young healthy subjects, whereas it causes vasoconstriction in patients with coronary endothelial dysfunction such as coronary atherosclerosis –51. The Nonobstructive CAD includes not only angina with epicardial coronary spasm but also microvascular spasm –7, 62. H® (ACh chloride) was approved as an inducer of coronary spasm during CAG in 2017 in Japan. This approval will lead to more testing for provocation of coronary spasm in Japan, adaptation of the treatment based on the patient's progress, and detailed pathophysiological evaluation of nonobstructive CAD including coronary spasm.OvisotIn addition to ACh, ergonovine (ER) is also useful for pharmacological provocation of coronary spasm. According to the Japanese Circulation Society (JCS) Guidelines , the intStudies in Japan have made many contributions to the pathophysiology, diagnosis, and treatment of coronary spasm, leading to the development of the Guidelines for Diagnosis and Treatment of Patients with Vasospastic Angina by the JCS , 75–78. According to the JCS Guidelines for Vasospastic Angina (Coronary Spastic Angina)  Fig. 2)2), we caWe and others previously reported different patterns of angiographic changes including focal  and diffuse spasm (severe diffuse vasoconstriction) during the spasm provocation test , 81, 82.According to the JCS Guidelines, ACh-provocation test is not recommended during emergent CAG in patients with ACS . The AmeT/C single nucleotide polymorphism in endothelial nitric oxide synthase gene were associated with ACh-provoked myocardial lactate production in patients with coronary spasm [Epicardial coronary spasm can be seen angiographically during the ACh-provocation test; however, it is unclear whether the coronary spasm causes myocardial ischemia. For this reason, we usually measure myocardial lactate production in the coronary circulation during ACh-provocation tests in the left coronary artery as a supporting diagnostic marker for the evaluation of coronary spasm-induced myocardial ischemia , 86. OurCoronary spasm can occur at sites of varying arteriosclerosis severity. We and others previously reported that coronary spasm could be associated with the progression of atherosclerosis –91. PatiWe previously reported that ACh-provoked coronary spasm occurring at the site of significant coronary artery stenosis was a more significant prognostic factor for MACE than ACh-provoked coronary spasm occurring at the site other than the site of organic stenosis, suggesting that coronary spasm can be associated with the cause of MACE when the coronary spasm occurs at the site of organic stenosis , 101. ThAt present, we often perform PCI with coronary stent implantation for significant organic coronary artery stenosis. Coronary spasm occurring after coronary stent implantation has become a clinical problem , 102–107Recent studies reported that epicardial coronary spasm could be associated with left ventricular (LV) dysfunction –41. We pA previous study reported that the ACh-provocation test induced coronary spasm in 20/42 patients (48%) who had idiopathic DCM-like LV dysfunction without significant organic coronary arteries stenosis . PatientOn the other hand, ACh-provoked coronary vasomotor abnormality  in our previous study was shown to be closely associated with myocardial fibrosis (expressed as late gadolinium enhancement in cardiac MRI) in patients with heart failure and without organic coronary artery stenosis , 112. CoThe coronary arterial tree consists of not only the epicardial coronary arteries, but also smaller arteries and arterioles (< 500 μm). The latter feed the capillaries and play an important role in the coronary microcirculation, being the main site of regulation of myocardial blood flow , 119. EpModalities for diagnosing obstructive CAD such as CAG or CTA have improved remarkably. However, in patients with suspected angina, we can sometimes see both nonobstructive epicardial coronary arteries and non-ACh-provoked epicardial coronary spasm. Nonobstructive CAD has included not only angina with epicardial coronary spasm but also microvascular spasm or dysfunction , 124 5). We de2, respectively. These clinical features of the microvascular spasm, such as female sex, middle age, and low body mass index, are reminiscent of postmenopausal phenomena, which invites speculation of an association between the pathogenesis of microvascular spasm and age-dependent estrogen deficiency in those patients.Our report mentioned above  of the 1The ACh-provocation test has several limitations. The ACh-provocation test cannot provoke coronary spasm in all patients with coronary spasm, although our previous study showed high sensitivity and specificity of the test in patients with variant angina , 21. In ACh-provocation test has several potential complications. In our institution, the number of life-threatening arrhythmias during ACh-provocation test was 9 (0.5%) of 1637 patients who underwent this test . A previAs summarized in this review, ACh-provocation test can be a safe and reliable method not only to diagnose epicardial coronary spasm but also to assess the pathophysiology of nonobstructive CAD. The ACh-provocation test is not often performed in routine clinical cardiovascular practice because multiple procedures of this test are required. However, the pathophysiology showed by ACh-provocation test can be associated with prognosis in patient with nonobstructive CAD. We can identify the high-risk patient with coronary spasm or microvascular spasm diagnosed by ACh-provocation test and treat with intensive care for the patients.We hope that cardiologists will routinely perform the ACh-provocation test to assess the pathophysiology of nonobstructive CAD.


Prior research has established transitions into and out of nursing homes as periods of suicide risk for older adults. Deaths by suicide were found to be 2.4 times as likely among Veterans within six months of discharge from US Veterans Health Administration (VA) nursing homes when compared with gender and age-matched Veterans from the general VA patient population . Despite these trends, suicide prevention interventions implemented during nursing home and post-acute care transitions, including those taking place from Centers for Medicare and Medicaid Services regulated nursing homes, are lacking. Suicide Awareness for Veterans Exiting the Community Living Center (SAVE-CLC) was piloted as a quality improvement intervention to reduce suicide risk for older Veterans discharging from VA nursing homes. VA clinicians from three sites provided a friendly contact by phone after discharge (n = 66) to screen for depression, facilitate a strengths-based discussion about service needs, and provide service referrals. Compared to a group of patients discharged prior to the start of the intervention , SAVE-CLC patients received more depression screening within 30 days after discharge  and were seen more quickly for mental health care  when indicated. Implications for suicide prevention with older Veterans and for the general population of older adults receiving short stay services in US nursing homes will be addressed.


Microplastics in the biosphere are currently of great environmental concern because of their potential toxicity for aquatic biota and human health and association with pathogenic microbiota. Microplastics can occur in high abundance in all aquatic environments, including oceans, rivers and lakes. Recent findings have highlighted the role of microplastics as important vectors for microorganisms, which can form fully developed biofilms on this artificial substrate. Microplastics therefore provide new microbial niches in the aquatic environment, and the developing biofilms may significantly differ in microbial composition compared to natural free-living or particle-associated microbial populations in the surrounding water. In this article, we discuss the composition and ecological function of the microbial communities found in microplastic biofilms. The potential factors that influence the richness and diversity of such microbial microplastic communities are also evaluated. Microbe-microbe and microbe-substrate interactions in microplastic biofilms have been little studied and are not well understood. Multiomics tools together with morphological, physiological and biochemical analyses should be combined to provide a more comprehensive overview on the ecological role of microplastic biofilms. These new microbial niches have so far unknown consequences for microbial ecology and environmental processes in aquatic ecosystems. More knowledge is required on the microbial community composition of microplastic biofilms and their ecological functions in order to better evaluate consequences for the environment and animal health, including humans, especially since the worldwide abundance of microplastics is predicted to dramatically increase. Plastics have been produced since the 1940s, and world production reached 360 million metric tons in 2018, which has resulted in severe plastic pollution of the environment worldwide  were also enriched in microplastic biofilms  and one plant pathogen (Pseudomonas syringae) were exclusively found in microplastic biofilms  biofilms represent the major groups of bacteria capable of degrading PHBH  represented important microbial associations within microbial communities of the plastisphere  microplastic characteristics (“substrate-specific”), (ii) period/succession (“time-specific”), (iii) microbial community and (iv) environmental conditions Fig. . The lasAlphaproteobacteria and Gammaproteobacteria, while Burkholderiales (formerly Betaproteobacteria) dominated on polyethylene microplastic biofilms in the North Atlantic garbage patch  for microbial growth, pollutants , physicochemical parameters  and aquatic biota  are critical factors controlling microbial biofilm formation and succession on microplastics. In lake water, temperature, nutrient levels and suspended particle concentrations determined microbial assemblages on various plastics (Chen et al. Mytilus edulis developed a similar bacterial community composition as the mussel’s gut microbiome (Kesy et al. Aquatic plants and animals play an important role in the transfer of microplastics across complex food webs (Au et al. The formation and development of the microbial community structure of microplastic biofilms to a large extend depend on “location-specific”, “time-specific” and “substrate-specific” characteristics. However, most studies reveal that location-specific characteristics play a more important role than substrate-specific” factors in shaping the bacterial community composition of microplastic biofilms (Amaral-Zettler et al. Factors influencing microbial community composition and function require further studies to better understand underlying processes and mechanisms. Most prior studies have been restricted to traditional non-degradable plastics, but the worldwide increasing use of degradable plastics means that these less refractory polymeric compounds also need to be carefully considered. A total of 127 countries have adopted some form of legislation to regulate the use of plastic bags UNEP , but mosThe advantages and limitations of current research methods for microplastic biofilms have been summarized (see Arias-Andres et al. The focus of future studies on microbial biofilms on microplastics should concentrate on functional and ecological aspects affecting aquatic food web dynamics and biogeochemical processes. Meta-transcriptomics, metaproteomics and metabolomics are now well established and important tools to assess functions and ecological roles of microbial communities Fig. . These m


Frail community-dwelling older adults increasingly receive home care and continue to face barriers to participating in physical activity (PA) that could help maintain their function. Home care aides (HCAs) are well-positioned to promoting PA among older home care recipients because of their established relationship and regular interpersonal exchanges; yet, the role of HCAs in promoting and supporting PA in home care settings is seldomly studied. Using the quantitative and qualitative data from a 4-month home-based gentle PA intervention delivered by HCAs to their clients in a Medicaid-funded home care setting, the current study examined whether outcome expectations for exercise (OEE) held by HCAs led to client PA outcomes  through social support for exercise (SSE) provided by HCAs. Longitudinal mediation analysis of 46 HCA-client dyads showed that higher baseline OEE held by HCAs were related to greater SSE reported by clients after the intervention , controlling for client-level covariates, including baseline OEE, age, gender, comorbidity, and whether HCA was client’s family member. Unexpectedly, SSE did not have significant association with client PA outcomes nor mediated the relationship between OEE held by HCAs and client PA outcomes. Qualitative data suggested alternative factors may explain the results, such as clients’ family beliefs in the intervention and clients’ participation experiences (such as expectation fulfillment). Future research should consider older home care clients’ family contexts to enhance our understanding of HCAs’ roles in preserving the function of growing numbers of older home care recipients.