Environmental drivers of increased ecosystem respiration in a warming tundra

Arctic and alpine tundra ecosystems are large reservoirs of organic carbon1,2. Climate warming may stimulate ecosystem respiration and release carbon into the atmosphere3,4. The magnitude and persistency of this stimulation and the environmental mechanisms that drive its variation remain uncertain5-7. This hampers the accuracy of global land carbon-climate feedback projections7,8. Here we synthesize 136 datasets from 56 open-top chamber in situ warming experiments located at 28 arctic and alpine tundra sites which have been running for less than 1 year up to 25 years. We show that a mean rise of 1.4 °C [confidence interval (CI) 0.9-2.0 °C] in air and 0.4 °C [CI 0.2-0.7 °C] in soil temperature results in an increase in growing season ecosystem respiration by 30% [CI 22-38%] (n = 136). Our findings indicate that the stimulation of ecosystem respiration was due to increases in both plant-related and microbial respiration (n = 9) and continued for at least 25 years (n = 136). The magnitude of the warming effects on respiration was driven by variation in warming-induced changes in local soil conditions, that is, changes in total nitrogen concentration and pH and by context-dependent spatial variation in these conditions, in particular total nitrogen concentration and the carbon:nitrogen ratio. Tundra sites with stronger nitrogen limitations and sites in which warming had stimulated plant and microbial nutrient turnover seemed particularly sensitive in their respiration response to warming. The results highlight the importance of local soil conditions and warming-induced changes therein for future climatic impacts on respiration.

Differential regulation of Kiss1 gene expression by oestradiol in the hypothalamus of the female Damaraland mole-rat, an induced ovulator

Kisspeptin, a product of the Kiss1 gene is considered a potent stimulator of gonadotropin release, by interacting with its receptor, the G protein-coupled receptor 54. Kiss1 neurons are known to mediate the positive and negative feedback effects of oestradiol on GnRH neurons that control the pulsatile and surge secretion of GnRH. While in spontaneously ovulating mammals the GnRH/LH surge is initiated by a rise in ovarian oestradiol secreted from maturing follicles, in induced ovulators, the primary trigger is the mating stimulus. Damaraland mole rats (Fukomys damarensis) are cooperatively breeding, subterranean rodents that exhibit induced ovulation. We have previously described in this species the distribution and differential expression pattern of Kiss1-expressing neurons in the hypothalamus of males and females. Here we examine whether oestradiol (E2) regulates the hypothalamic Kiss1 expression in a similar way as described for spontaneously ovulating rodent species. By means of in situ hybridisation, we measured Kiss1 mRNA among groups of ovary-intact, ovariectomized (OVX) and OVX females treated with E2 (OVX + E2). In the arcuate nucleus (ARC), Kiss1 expression increased after ovariectomy and decreased with E2 treatment. In the preoptic region, Kiss1 expression after gonadectomy was similar to the level of wild-caught gonad-intact controls, but was dramatically upregulated with E2 treatment. The data suggest that, similar to other species, Kiss1 neurons in the ARC, which are inhibited by E2, play a role in the negative feedback control on GnRH release. The exact role of the Kiss1 neuron population in the preoptic region, which is stimulated by E2, remains to be determined.

Differential locomotor activity responses to day-time light intensity in juvenile and adult solitary Cape mole-rats, Georychus capensis (Rodentia: Bathyergidae)

The Cape mole-rat (Georychus capensis) is a solitary, strictly subterranean rodent that is responsive to light and entrains to photic cues despite having a reduced visual system. Circadian entrainment is maintained throughout life, but age can alter the amplitude of the response and re-entrainment time. Mole-rats are long-lived for their size which raises questions regarding the robustness of their circadian rhythms and how impacts their locomotor activity rhythms. The locomotor activity rhythms of juvenile and adult Cape mole-rats were investigated. They were exposed to pre-experimental and post-experimental control cycles under fluorescent lights, six 12 h light:12 h dark cycles of decreasing intensities and a constant dark cycle (DD). All animals exhibited more activity during the dark phases of all light regimes. Juveniles were more active than adults and displayed more variable activity during both the light and dark phases. Adults exhibited relatively stable levels of activity under all experimental conditions, whereas juvenile activity decreased as the light intensity was reduced. The amplitude of Cape mole-rat rhythms was consistently low, but similar across light regimes and between adults and juveniles. Cape mole-rats have functional circadian systems, are primarily nocturnal and respond differentially to light intensity depending on their age. Light intensity does not affect the locomotor activity responses of Cape mole-rats in a predictable manner, and could indicate more complex interactions with light wavelengths. The circadian systems of juveniles appear to be more sensitive than those of adults, although the mechanism of the light response remains unclear.

The Evolution and Ecology of Oxidative and Antioxidant Status: A Comparative Approach in African Mole-Rats

The naked mole-rat of the family Bathyergidae has been the showpiece for ageing research as they contradict the traditional understanding of the oxidative stress theory of ageing. Some other bathyergids also possess increased lifespans, but there has been a remarkable lack of comparison between species within the family Bathyergidae. This study set out to investigate how plasma oxidative markers (total oxidant status (TOS), total antioxidant capacity (TAC), and the oxidative stress index (OSI)) differ between five species and three subspecies of bathyergids, differing in their maximum lifespan potential (MLSP), resting metabolic rate, aridity index (AI), and sociality. We also investigated how oxidative markers may differ between captive and wild-caught mole-rats. Our results reveal that increased TOS, TAC, and OSI are associated with increased MLSP. This pattern is more prevalent in the social-living species than the solitary-living species. We also found that oxidative variables decreased with an increasing AI and that wild-caught individuals typically have higher antioxidants. We speculate that the correlation between higher oxidative markers and MLSP is due to the hypoxia-tolerance of the mole-rats investigated. Hormesis (the biphasic response to oxidative stress promoting protection) is a likely mechanism behind the increased oxidative markers observed and promotes longevity in some members of the Bathyergidae family.

T cell-derived interleukin-22 drives the expression of CD155 by cancer cells to suppress NK cell function and promote metastasis

Although T cells can exert potent anti-tumor immunity, a subset of T helper (Th) cells producing interleukin-22 (IL-22) in breast and lung tumors is linked to dismal patient outcome. Here, we examined the mechanisms whereby these T cells contribute to disease. In murine models of lung and breast cancer, constitutional and T cell-specific deletion of Il22 reduced metastases without affecting primary tumor growth. Deletion of the IL-22 receptor on cancer cells decreases metastasis to a degree similar to that seen in IL-22-deficient mice. IL-22 induced high expression of CD155, which bound to the activating receptor CD226 on NK cells. Excessive activation led to decreased amounts of CD226 and functionally impaired NK cells, which elevated the metastatic burden. IL-22 signaling was also associated with CD155 expression in human datasets and with poor patient outcomes. Taken together, our findings reveal an immunosuppressive circuit activated by T cell-derived IL-22 that promotes lung metastasis.

Socially Induced Infertility in Naked and Damaraland Mole-Rats: A Tale of Two Mechanisms of Social Suppression

Simple Summary

The naked and Damaraland mole-rats are group-living, subterranean mammals in which reproduction is distributed unequally among members of a social group, also referred to as reproductive skew. Only a single female per group, called the queen, produces offspring with the most dominant males of the group. The non-reproductive colony members are physiologically suppressed by the presence of the queen. This is reflected in their low concentration of luteinising hormone released from the pituitary and in their reduced responsiveness of the pituitary to stimulation with gonadotropin releasing hormone. Removal of the queen reverses these effects and leads to endocrine conditions in these females that are similar to those in reproductively active females. Regarding males, the extent of reproductive suppression is different between the two species. Non-reproductive male Damaraland mole-rats show hormonal profiles similar to the breeding males, whereas non-reproductive male naked mole-rats are physiologically suppressed similar to non-reproductive females. Thus, the two species represent ideal models to unravel the physiological, behavioural and neuroendocrine mechanisms regulating the hypothalamic-pituitary-gonadal axis. The recently discovered neuropeptides kisspeptin and RFamide-related peptide-3 are likely candidates to play an important role in the regulation of reproductive functions in the two mole-rat species.

Abstract

The naked mole-rat (Heterocephalus glaber) and the Damaraland mole-rat (Fukomys damarensis) possess extreme reproductive skew with a single reproductive female responsible for reproduction. In this review, we synthesize advances made into African mole-rat reproductive patterns and physiology within the context of the social control of reproduction. Non-reproductive female colony members have low concentrations of luteinising hormone (LH) and a reduced response of the pituitary to a challenge with gonadotropin releasing hormone (GnRH). If the reproductive female is removed from the colony, an increase in the basal plasma LH and increased pituitary response to a GnRH challenge arises in the non-reproductive females, suggesting the reproductive female controls reproduction. Non-reproductive male Damaraland mole-rats have basal LH concentrations and elevated LH concentrations in response to a GnRH challenge comparable to the breeding male, but in non-breeding male naked mole-rats, the basal LH concentrations are low and there is a muted response to a GnRH challenge. This renders these two species ideal models to investigate physiological, behavioural and neuroendocrine mechanisms regulating the hypothalamic-pituitary-gonadal axis. The recently discovered neuropeptides kisspeptin and RFamide-related peptide-3 are likely candidates to play an important role in the regulation of reproductive functions in the two mole-rat species.

Systematic assessment of monogenic etiology in adult-onset kidney stone formers undergoing urological intervention-evidence for genetic pretest probability

Kidney stone disease (KSD) is a prevalent condition associated with high morbidity, frequent recurrence, and progression to chronic kidney disease (CKD). The etiology is multifactorial, depending on environmental and genetic factors. Although monogenic KSD is frequent in children, unbiased prevalence data of heritable forms in adults is scarce. Within 2 years of recruitment, all patients hospitalized for urological kidney stone intervention at our center were consecutively enrolled for targeted next generation sequencing (tNGS). Additionally, clinical and metabolic assessments were performed for genotype-phenotype analyses. The cohort comprised 155 (66%) males and 81 (34%) females, with a mean age at first stone of 47 years (4-86). The diagnostic yield of tNGS was 6.8% (16/236), with cystinuria (SLC3A1, SLC7A9), distal renal tubular acidosis (SLC4A1), and renal phosphate wasting (SLC34A1, SLC9A3R1) as underlying hereditary disorders. While metabolic syndrome traits were associated with late-onset KSD, hereditary KSD was associated with increased disease severity in terms of early-onset, frequent recurrence, mildly impaired kidney function, and common bilateral affection. By employing systematic genetic analysis to a less biased cohort of common adult kidney stone formers, we demonstrate its diagnostic value for establishing the underlying disorder in a distinct proportion. Factors determining pretest probability include age at first stone (<40 years), frequent recurrence, mild CKD, and bilateral KSD.

Thawing Yedoma permafrost is a neglected nitrous oxide source

In contrast to the well-recognized permafrost carbon (C) feedback to climate change, the fate of permafrost nitrogen (N) after thaw is poorly understood. According to mounting evidence, part of the N liberated from permafrost may be released to the atmosphere as the strong greenhouse gas (GHG) nitrous oxide (N₂O). Here, we report post-thaw N₂O release from late Pleistocene permafrost deposits called Yedoma, which store a substantial part of permafrost C and N and are highly vulnerable to thaw. While freshly thawed, unvegetated Yedoma in disturbed areas emit little N₂O, emissions increase within few years after stabilization, drying and revegetation with grasses to high rates (548 (133–6286) μg N m⁻² day⁻¹; median with (range)), exceeding by 1–2 orders of magnitude the typical rates from permafrost-affected soils. Using targeted metagenomics of key N cycling genes, we link the increase in in situ N₂O emissions with structural changes of the microbial community responsible for N cycling. Our results highlight the importance of extra N availability from thawing Yedoma permafrost, causing a positive climate feedback from the Arctic in the form of N₂O emissions.

During permafrost thaw, nitrogen can be released as the greenhouse gas nitrous oxide, but the magnitude of this flux is unknown. Nitrous oxide emissions from ice-rich permafrost deposits are reported here, showing that emissions increase after thawing and stabilization and could represent an unappreciated positive climate feedback in the Arctic.

Gene expression pattern of Kisspeptin and RFamide-related peptide (Rfrp) in the male Damaraland mole-rat hypothalamus

Damaraland mole-rats (Fukomys damarensis) are cooperatively breeding, subterranean mammals, which exhibit high reproductive skew. Reproduction is monopolized by the dominant female of the group, while subordinates are anovulatory. Similarly, male subordinates within the colony show no sexual behaviour although they have functional gonads and do not differ from reproductive males in circulating levels of pituitary hormones and testosterone. However, reproductive status affects the neuroendocrine phenotype of males with breeders possessing increased mRNA expression of androgen and progesterone receptors compared to non-breeders in several forebrain regions implicated in the regulation of reproductive behaviour. The RFamide peptides kisspeptin and RFRP-3, encoded by the Kiss1 and Rfrp gene, are considered potent regulators of gonadotropin release. In females, reproductive inhibition is associated with reduced Kiss1 expression within the arcuate nucleus (ARC) and increased Rfrp expression in the anterior hypothalamus. To assess whether differential gene expression of Kiss1 and Rfrp underlies the difference in reproductive behaviour of males, we studied the expression of both genes by means of in situ hybridisation in wild-caught male Damaraland mole-rats with different reproductive status. The distribution of Kiss1 and Rfrp within the hypothalamus was found to be similar to females. Quantification of the Kiss1 hybridisation signal revealed no significant differences in relation to reproductive status. However, there was a significant positive correlation between testis mass and the number of Kiss1-expressing cells in the ARC and the mRNA content per cell, respectively. Analysis of the Rfrp hybridisation signal along the rostro-caudal extent of the hypothalamus revealed that non-reproductive males possessed an increased number of Rfrp-expressing cells at the level of the dorsomedial hypothalamic nucleus (DMH) than reproductive males. These data suggest the Kiss1 expression within the ARC is not associated with reproductive quiescence in subordinate males but instead, inhibitory effects may be mediated by Rfrp-expressing cells in the DMH.

Aviation Contrail Cirrus and Radiative Forcing Over Europe During 6 Months of COVID-19

The COVID-19 pandemic led to a 72% reduction of air traffic over Europe in March-August 2020 compared to 2019. Modeled contrail cover declined similarly, and computed mean instantaneous radiative contrail forcing dropped regionally by up to 0.7 W m-2. Here, model predictions of cirrus optical thickness and the top-of-atmosphere outgoing longwave and reflected shortwave irradiances are tested by comparison to Meteosat-SEVIRI-derived data. The agreement between observations and modeled data is slightly better when modeled contrail cirrus contributions are included. The spatial distributions and diurnal cycles of the differences in these data between 2019 and 2020 are partially caused by differences in atmospheric and surface conditions, particularly for solar radiation in the spring of 2020. Aviation signals become discernible in the observed differences of these data between 2019 and 2020 when subtracting numerical weather prediction model results that approximate the atmosphere and surface conditions without contrails.

Epithelial-type systemic breast carcinoma cells with a restricted mesenchymal transition are a major source of metastasis

Carcinoma cells undergo epithelial-mesenchymal transition (EMT); however, contributions of EMT heterogeneity to disease progression remain a matter of debate. Here, we addressed the EMT status of ex vivo cultured circulating and disseminated tumor cells (CTCs/DTCs) in a syngeneic mouse model of metastatic breast cancer (MBC). Epithelial-type CTCs with a restricted mesenchymal transition had the strongest lung metastases formation ability, whereas mesenchymal-type CTCs showed limited metastatic ability. EpCAM expression served as a surrogate marker to evaluate the EMT heterogeneity of clinical samples from MBC, including metastases, CTCs, and DTCs. The proportion of epithelial-type CTCs, and especially DTCs, correlated with distant metastases and poorer outcome of patients with MBC. This study fosters our understanding of EMT in metastasis and underpins heterogeneous EMT phenotypes as important parameters for tumor prognosis and treatment. We further suggest that EpCAM-dependent CTC isolation systems will underestimate CTC numbers but will quantify clinically relevant metastatic cells.

Author Correction: The evolution of 17O-excess in surface water of the arid environment during recharge and evaporation

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.

Neural activation following offensive aggression in Japanese quail

Aggression is a fundamental part of animal social behaviour. In avian species, little is known about its neural representation. In particular, neural activity following offensive aggression has not been studied in detail. Here, we investigated the patterns of brain activation using immediate-early gene (IEG) expression in male Japanese quail that showed pronounced aggressive behaviours during a 30 min male–male interaction and compared them to those of males that did not interact with a conspecific. In aggressive males, we found a massive induction of the IEG ZENK in pallial brain structures such as the intermediate medial mesopallium, the caudomedial mesopallium and the intermediate medial nidopallium. To a lesser extent, activation was observed in subpallial areas such as the nucleus taeniae of the amygdala and in the medial portion of the bed nucleus of the stria terminalis. Our data suggest that the modulation of aggressive behaviour involves the integration of multisensory information.

Summary: The manuscript describes the pronounced activation of the immediate early gene ZENK in the pallium of male Japanese quails following offensive aggressive behaviour.

Reproductive status-dependent kisspeptin and RFamide-related peptide (Rfrp) gene expression in female Damaraland mole-rats

Damaraland mole rats (Fukomys damarensis) are cooperatively breeding, subterranean mammals that exhibit a high reproductive skew. Reproduction is monopolised by the dominant female of the group, whereas subordinates are physiologically suppressed to the extent that they are anovulatory. In these latter animals, it is assumed that normal gonadotropin-releasing hormone secretion from the hypothalamus is disrupted. The RFamide peptides kisspeptin (Kiss1) and RFamide-related peptide-3 (RFRP-3) are considered as potent regulators of gonadotropin release. To assess whether these neuropeptides are involved in the mechanism of reproductive suppression, we investigated the distribution and gene expression of Kiss1 and Rfrp by means of in situ hybridisation in wild-caught female Damaraland mole-rats with different reproductive status. In both reproductive phenotypes, substantial Kiss1 expression was found in the arcuate nucleus and only few Kiss1-expressing cells were detected in the anteroventral periventricular nucleus (AVPV), potentially as a result of low circulating oestradiol concentrations in breeding and nonbreeding females. Rfrp gene expression occurred in the dorsomedial nucleus, the paraventricular nucleus and the periventricular nucleus. While in female breeders and nonbreeders, plasma oestradiol levels were low and not significantly different, quantification of the hybridisation signal for both genes revealed significant differences in relation to reproductive status. Reproductively active females had more Kiss1-expressing cells and a higher number of silver grains per cell in the arcuate nucleus compared to nonreproductive females. This difference was most pronounced in the caudal part of the nucleus. No such differences were found in the AVPV. Furthermore, breeding status was associated with a reduced number of Rfrp-expressing cells in the anterior hypothalamus. This reproductive status-dependent expression pattern of Kiss1 and Rfrp suggests that both neuropeptides play a role in the regulation of reproduction in Damaraland mole-rats. Enhanced long-term negative feedback effects of oestradiol could be responsible for the lower Kiss1 expression in the arcuate nucleus of reproductively suppressed females.

Cement augmentation of humeral head screws reduces early implant-related complications after locked plating of proximal humeral fractures

Background

Cement augmentation (CA) of humeral head screws in locked plating of proximal humeral fractures (PHF) was found to be biomechanically beneficial. However, clinical outcomes of this treatment have not been well evaluated to date.

Objectives

To assess outcomes of locked plating of PHF with additional CA and to compare them with outcomes of conventional locked plating without CA.

Methods

24 patients (mean age, 74.2 ± 10.1 years; 22 female) with displaced PHF were prospectively enrolled and treated with locked plating and additional CA. The Constant score (CS), the Simple Shoulder Test (SST), and the Simple Shoulder Value (SSV) were assessed 3 and 12 months postoperatively. Fracture healing and potential complications were evaluated on postoperative radiographs. The CS and complications were compared with the outcomes of a matched group of 24 patients (mean age, 73.9 ± 9.4 years; 22 female) with locked plating of displaced PHF without CA.

Results

At the 3‑month follow-up, the mean CS was 59.9 ± 15.6 points, the mean SST was 7.5 ± 2.7 points, and the mean SSV was 63.9 ± 21.7%. All scores significantly improved by the 12-month follow-up (p < 0.05; CS, 72.9 ± 17.7; SST, 9.2 ± 3.2; SSV, 77.2 ± 17.3%). There were two cases (8%) of biological complications (n = 1 varus malunion and n = 1 humeral head necrosis). Compared with locked plating without CA, no significant differences were observed between the CS at the 3‑ (57.8 ± 13.4 points; p = 0.62) and 12-month (73.0 ± 12.8 points; p = 0.99) follow-up. However, patients without CA had a significantly increased risk of early loss of reduction and articular screw perforation (p = 0.037).

Conclusion

Locked plating of proximal humeral fractures with trauma cement augmentation of humeral head screws could be translated from the ex-vivo lab setting into the clinical situation without additional complications. Locked plating of displaced PHF with additional cement augmentation showed similar clinical outcomes but reduced the rate of early implant-related complications compared to locked plating without additional CA.

Neuroendocrine correlates of sex-role reversal in barred buttonquails

Sex differences in brain structure and behaviour are well documented among vertebrates. An excellent model exploring the neural mechanisms of sex differences in behaviour is represented by sex-role-reversed species. In the majority of bird species, males compete over access to mates and resources more strongly than do females. It is thought that the responsible brain regions are therefore more developed in males than in females. Because these behaviours and brain regions are activated by androgens, males usually have increased testosterone levels during breeding. Therefore, in species with sex-role reversal, certain areas of the female brain should be more developed or steroid hormone profiles should be sexually reversed. Here, I studied circulating hormone levels and gene expression of steroid hormone receptors and aromatase in a captive population of barred buttonquails (Turnix suscitator). While females performed courtship and agonistic behaviours, there was no evidence for sexually reversed hormone profiles. However, I found female-biased sex differences in gene expression of androgen receptors in several hypothalamic and limbic brain regions that were already in place at hatching. Such sex differences are not known from non-sex-role-reversed species. These data suggest that increased neural sensitivity to androgens could be involved in the mechanisms mediating sex-role-reversed behaviours.

Cancer cells induce interleukin-22 production from memory CD4+ T cells via interleukin-1 to promote tumor growth

IL-22 has been identified as a cancer-promoting cytokine that is secreted by infiltrating immune cells in several cancer models. We hypothesized that IL-22 regulation would occur at the interface between cancer cells and immune cells. Breast and lung cancer cells of murine and human origin induced IL-22 production from memory CD4+ T cells. In the present study, we found that IL-22 production in humans is dependent on activation of the NLRP3 inflammasome with the subsequent release of IL-1β from both myeloid and T cells. IL-1 receptor signaling via the transcription factors AhR and RORγt in T cells was necessary and sufficient for IL-22 production. In these settings, IL-1 induced IL-22 production from a mixed T helper cell population comprised of Th1, Th17, and Th22 cells, which was abrogated by the addition of anakinra. We confirmed these findings in vitro and in vivo in two murine tumor models, in primary human breast and lung cancer cells, and in deposited expression data. Relevant to ongoing clinical trials in breast cancer, we demonstrate here that the IL-1 receptor antagonist anakinra abrogates IL-22 production and reduces tumor growth in a murine breast cancer model. Thus, we describe here a previously unrecognized mechanism by which cancer cells induce IL-22 production from memory CD4+ T cells via activation of the NLRP3 inflammasome and the release of IL-1β to promote tumor growth. These findings may provide the basis for therapeutic interventions that affect IL-22 production by targeting IL-1 activity.

Gnrh mRNA expression in the brain of cooperatively breeding female Damaraland mole-rats

The Damaraland mole-rat (Fukomys damarensis) is a eusocial, subterranean rodent, in which breeding is limited to a single reproductive pair within each colony. Non-reproductive females, while in the confines of the colony, exhibit socially induced infertility. Anovulation is thought to be caused by a disruption in the normal gonadotropin-releasing hormone (GNRH) secretion from the hypothalamus. To assess whether social suppression is associated with alteredGnrhmRNA expression in the brain, we investigated the distribution and gene expression levels by means ofin situhybridization in female breeders and non-breeders from field captured colonies of the Damaraland mole-rat. We found expression ofGnrhmRNA as a loose network in several forebrain areas of female Damaraland mole-rats with the majority of labelling in the preoptic and anterior hypothalamus. The distribution matched previous findings using immunocytochemistry in this and other social mole-rat species. Quantification of the hybridisation signal revealed no difference between breeding and non-breeding females in the average optical density of the hybridization signal and the size of the total area covered byGnrhmRNA. However, analysis along the rostro-caudal axis revealed significantly elevatedGnrhmRNA expression in the rostral preoptic region of breeders compared to non-breeders, whereas the latter had increasedGnrhmRNA expression at the caudal level of the anterior hypothalamus. This study indicates that social suppression affects the expression ofGnrhmRNA in female Damaraland mole-rats. Furthermore, differential regulation occurs within different neuron subpopulations.

[Injuries of the acromioclavicular joint: Hook plate versus arthroscopy]

Acute acromioclavicular (AC) joint injuries are common in clinical practice. The hook plate is a well-established conventional operative treatment option for high grade instability; however, arthroscopically-assisted flexible double button techniques are increasingly being used. Both procedures lead to good or excellent results. The advantages of the hook plate are the simple surgical technique and the possibility of an early functional aftercare. The minimally invasive one-step procedure with the possibility of identification and treatment of frequently concomitant glenohumeral pathologies is advantageous for the arthroscopic technique but mobilization is more restrictive. Available comparative studies have shown no significant clinical differences but a tendency towards better results with a higher degree of acceptance among patients for the arthroscopic and minimally invasive non-rigid double button procedures.

Population pharmacokinetics of a new long-acting recombinant coagulation factor IX albumin fusion protein for patients with severe hemophilia B

Essentials The new recombinant factor IX (FIX) albumin fusion protein (rIX-FP) has a prolonged half-life. A population pharmacokinetic (PK) model was based on FIX activity levels of hemophilia B patients. The model was used to simulate different dosing scenarios of rIX-FP to help guide dosing. The population PK model supported prolonged dosing of rIX-FP with intervals of up to 2 weeks. Click to hear Prof.Makris's presentation on new treatments in hemophilia SUMMARY: Background The recombinant fusion protein linking recombinant coagulation factor IX with recombinant albumin (rIX-FP; Idelvion® ) exhibits a longer half-life than plasma-derived factor IX (FIX) and the commercially available recombinant FIX products. Objectives (i) Characterize the population pharmacokinetics (PK) of rIX-FP in hemophilia B patients, (ii) identify covariates that are potential determinants of rIX-FP PK variability and (iii) simulate different dosing scenarios of rIX-FP following single and steady-state dosing. Patients/Methods A population PK model was developed based on FIX activity levels of 104 patients who had received treatment with rIX-FP. Patients were aged 1-65 years with FIX activity ≤ 2 IU dL-1 . PK sampling was performed for up to 14 days (336 h). Results Simulation of a single intravenous infusion of rIX-FP (25-75 IU kg-1 ) predicted that the median trough exogenous FIX activity levels would remain > 5 IU dL-1 for up to 16 days in adolescents/adults aged ≥ 12 years, up to 12 days in children aged 6 to < 12 years, and up to 9.5 days in children aged < 6 years. For steady-state dosing, the median trough exogenous FIX activity levels were maintained at > 5 IU dL-1 for the duration of the dosing interval for the 25, 35 and 40 IU kg-1 weekly regimens and for 75 IU kg-1 every 14 days in adolescents/adults, and for the 35 and 40 IU kg-1 weekly regimens in children. Conclusion The population PK model developed here correlates well with observed clinical data and supports prolonged dosing of rIX-FP with intervals of up to 2 weeks.

[Prehospital analgesia by paramedics in Rhineland-Palatinate : Feasability, analgesic effectiveness and safety of intravenous paracetamol]

BACKGROUND

In contrast to the widespread practice in life-threatening emergencies, delegation of medical pain therapy to paramedics by the medical director  of Emergency Medical Services, EMS, are still the exception in Germany. This is due to the fact that in non-life-threatening situations, the expected benefit and potential side effects of drug therapy have to be carefully weighed. In addition, in Germany federal law generally restricts the administration of opiates to physicians.

METHODS

In 2011 the medical directors of EMS in the German state of Rhineland- Palatinate (4 million inhabitants) developed and implemented a standard operating procedure (SOP) for paramedics related to the prehospital parenteral administration of paracetamol for patients with isolated limb trauma. After a 2 h training session and examination, paramedics were authorized to administer 1 g of paracetamol to patients with a pain score > 5 points on an 11-point numerical rating scale (NRS). For purposes of quality management, every administration of paracetamol had to be prospectively documented on a specific electronic mission form.

RESULTS

A total of 416 mission forms could be analyzed. After administration of paracetamol the median NRS score decreased from 8 points (interquartile range: 6; 8) to 4 points (interquartile range: 3; 7). In 51.2 % of the patients the pain intensity was reduced by at least 3 NRS points and in 50.5 % of the patients the NRS was less than 5 points after treatment. The extent of pain reduction was positively correlated with the initial NRS value (r = 0.31, p < 0.0001). No serious side effects were noted. The percentage of patients with an initial heart rate > 100/min declined from 14.6 % to 5.2 % after the administration of paracetamol (p < 0.0001), 18.7 % of the patients received paracetamol for trauma not related to the extremities and 7 % of the patients for nontraumatic pain. An emergency physician was involved in 50 % of the EMS missions and 98.6 % of the patients were transported to a hospital for further diagnostics and treatment.

CONCLUSION

The prehospital intravenous administration of paracetamol by paramedics to patients with limb trauma is simple, safe and in 50 % of the patients effective in achieving a NRS value < 5; however, further improvements in prehospital pain therapy initiated by paramedics are desirable, especially in patients with an initial NRS value > 7.

Hatching late in the season requires flexibility in the timing of song learning

Most songbirds learn their songs from adult tutors, who can be their father or other male conspecifics. However, the variables that control song learning in a natural social context are largely unknown. We investigated whether the time of hatching of male domesticated canaries has an impact on their song development and on the neuroendocrine parameters of the song control system. Average age difference between early- and late-hatched males was 50 days with a maximum of 90 days. Song activity of adult tutor males decreased significantly during the breeding season. While early-hatched males were exposed to tutor songs for on average the first 99 days, late-hatched peers heard adult song only during the first 48 days of life. Remarkably, although hatching late in the season negatively affected body condition, no differences between both groups of males were found in song characteristics either in autumn or in the following spring. Similarly, hatching date had no effect on song nucleus size and circulating testosterone levels. Our data suggest that late-hatched males must have undergone accelerated song development. Furthermore, the limited tutor song exposure did not affect adult song organization and song performance.

Is there any advantage in placing an additional calcar screw in locked nailing of proximal humeral fractures?

BACKGROUND

The objective of this study was to evaluate the biomechanical effect of an additional unlocked calcar screw compared to a standard setting with three proximal humeral head screws alone for fixation of an unstable 2-part fracture of the surgical neck.

HYPOTHESIS

The additional calcar screw improves stiffness and failure load.

METHODS

Fourteen fresh frozen humeri were randomized into two equal sized groups. An unstable 2-part fracture of the surgical neck was simulated and all specimens were fixed with the MultiLoc(®)-nail. Group I represented a basic screw setup, with three locked head screws and two unlocked shaft screws. Group II was identical with a supplemental unlocked calcar screw (CS). Stiffness tests were performed in torsional loading, as well as in axial and in 20° abduction/20° adduction modes. Subsequently cyclic loading and load-to-failure tests were performed. Resulting stiffness, displacement under cyclic load and ultimate load were compared between groups using the t-test for independent variables (α=0.05).

RESULTS

No significant differences were observed between the groups in any of the biomechanical parameters. Backing out of the CS was observed in three cases.

DISCUSSION

The use of an additional unlocked calcar screw does not provide mechanical benefit in locked nailing of an unstable 2-part fracture of the surgical neck.

Results of a phase I/II open-label, safety and efficacy trial of coagulation factor IX (recombinant), albumin fusion protein in haemophilia B patients

Introduction

rIX-FP is a coagulation factor IX (recombinant), albumin fusion protein with more than fivefold half-life prolongation over other standard factor IX (FIX) products available on the market.

Aim

This prospective phase II, open-label study evaluated the safety and efficacy of rIX-FP for the prevention of bleeding episodes during weekly prophylaxis and assessed the haemostatic efficacy for on-demand treatment of bleeding episodes in previously treated patients with haemophilia B.

Methods

The study consisted of a 10–14 day evaluation of rIX-FP pharmacokinetics (PK), and an 11 month safety and efficacy evaluation period with subjects receiving weekly prophylaxis treatment. Safety was evaluated by the occurrence of related adverse events, and immunogenic events, including development of inhibitors. Efficacy was evaluated by annualized spontaneous bleeding rate (AsBR), and the number of injections to achieve haemostasis.

Results

Seventeen subjects participated in the study, 13 received weekly prophylaxis and 4 received episodic treatment only. No inhibitors were detected in any subject. The mean and median AsBR were 1.25, and 1.13 respectively in the weekly prophylaxis arm. All bleeding episodes were treated with 1 or 2 injections of rIX-FP. Three prophylaxis subjects who were treated on demand prior to study entry had >85% reduction in AsBR compared to the bleeding rate prior to study entry.

Conclusion

This study demonstrated the efficacy for weekly routine prophylaxis of rIX-FP to prevent spontaneous bleeding episodes and for the treatment of bleeding episodes. In addition no safety issues were detected during the study and an improved PK profile was demonstrated.

[Suprapectoral mini-open biceps tenodesis - functional and sonographic results]

BACKGROUND

Aim of this study was to evaluate the effectiveness of a suprapectoral mini-open tenodesis of the long head of the biceps (LHB) tendon with ultrasound assessment. Secondary aim was to compare the results of an extraosseous fixation (group I) to those of an intraosseous fixation technique (group II).

PATIENTS AND METHODS

25 patients (10 female, 15 male) aged 54 ± 8 (36 to 68) years were followed-up 21 ± 4.7 (13 to 32) months postoperatively. Tenodesis fixation was extraosseous in 12 (group I) and intraosseous in 13 patients (group II). Preoperative shoulder function and intraoperative findings were recorded. At the time of follow-up the fixation of the biceps tendon was evaluated by ultrasound examination. Furthermore, the shoulder function, the simple shoulder test (SST), the Constant-Murley score (CMS) and the "long head of the biceps (LHB) score" were assessed.

RESULTS

Failure of tenodesis fixation was observed in 3/12 cases (25 %) of group I and 1/13 cases (8 %) of group II. Shoulder flexion (p < 0.001), abduction (p < 0.001), external rotation (p < 0.001) and the pain level (p < 0.001) improved significantly compared to the preoperative status. At time of follow-up the CMS averaged 79.4 ± 13 points, the age and gender related CMS averaged 95.7 ± 16.4 %. Mean SST was 10.6 ± 2.1 points. No significant difference (p = 0.064) could be observed between the LHB of the affected (88.1 ± 9.7) versus the non-affected shoulder (92.7 ± 13.6 points). Age and gender related CMS (p = 0.96), LHB score (p = 0.16) and SST (p = 0.94) of both groups revealed no significant differences.

CONCLUSION

The intraosseous fixation technique seems favourable with less fixation failure compared to the extraosseous suspension technique. The suprapectoral mini-open tenodesis of the LHB is a valuable alternative tenodesis technique with good to excellent clinical results.

[Corrective osteosynthesis of proximal humeral fractures. Technique and prospective results]

BACKGROUND

Fracture sequelae of proximal humeral fractures arise following nonoperative and operative forms of treatment. Due to a painful restricted range of motion, in most cases shoulder prostheses are implanted. There is a need for joint-preserving alternatives especially for younger patients.

OBJECTIVES

The aim of this study was to evaluate the surgical techniques and prospective results of fracture sequelae of proximal humeral fractures following corrective osteosynthesis.

MATERIAL AND METHODS

A total of 11 patients (4 female) with an average age of 53 years (range 29-71 years) and a mean follow-up of 19.5 months were included prospectively. The preoperative and postoperative ranges of motion of the affected shoulder were compared by statistical means. At the time of follow-up the constant score (CS), the simple shoulder test (SST) and the simple shoulder value (SSV) were assessed.

RESULTS

Fracture sequelae were classified as type II in four patients, as type III in two and as type IV in five patients using the Boileau classification. Shoulder flexion (p = 0.006), abduction (p = 0.003) and external rotation (p = 0.02) improved significantly in the postoperative course. The mean age and gender-adapted CS was 74.8 ± 19.9 % at the time of follow-up, 10.1 out of 12 points were reached in the SST and the mean SSV was 77 %.

CONCLUSION

Corrective osteosynthesis of fracture sequelae (Boileau types II-IV) of proximal humeral fractures appears to be a good alternative to implantation of shoulder prostheses, especially in younger patients (< 60 years of age).

[Unicentre Results in Surgery of Primary Hyperparathyroidism with Postoperative Long-Term Follow-Up and Value of Intraoperative Quick Parathormone Test]

BACKGROUND

The increasing use of focussed parathyroidectomy is attributed to introduction of intraoperative parathyroid hormone measurement (ioPTH) and novel preoperative imaging techniques. This study assesses the early postoperative and long-term outcomes of surgery and the value of standardised ioPTH in patients undergoing surgery for primary hyperparathyroidism (pHPT).

METHODS

From 01/01/1996 to 09/30/2011, all consecutive patients undergoing surgery for pHPT were documented. Data of this observational study were retrospectively evaluated. Patients were subdivided into 2 groups: A.) use of Quick Intraoperative Intact PTH Assay (n = 142; "ioPTH group") vs. B.) control group ("CG", n = 44). For clinical long-term follow-up, also pre- and postoperative signs, symptoms and findings of the initial 43 patients obtained during the first 4 years of the study were semiquantitatively compared.

RESULTS

186 consecutive operations for pHPT were performed - in particular, 73 sole parathyroidectomies; 113 combined thyroid and parathyroid resections. Mean operation time was 87 (SD ± 48) min for parathyroidectomy and 120 (SD ± 49) min for combined resections. A persisting hypercalcaemia was found in 16 patients (8.6%) while postoperative elevation of serum calcium and parathormone occurred in 7 patients (3.8%). Postoperative hypocalcaemia was present in 35 patients (18.8%). Differences between both groups regarding hypocalcaemia (p = 1.0), hypercalcaemia (p = 0.67), hyperparathyrinaemia (p = 0.12) and rate of reintervention (p = 0.055) were not significant. Thirty nine of the initial 43 patients reported one or more signs of pHPT (90.7%). Most frequent symptoms were nephrolithiasis (41.9%), back pain (51.2%), discomfort in the upper abdomen (41.9%), fatigue (41.9%) and general weakness (61.1%). Follow-up investigations (mean, 4.7 [range, 3.2-6.5] years) revealed that 65 % of patients reported improvement of general condition, 27% had no change and 8% reported deterioration.

CONCLUSIONS

IoPTH is now standard in parathyroid surgery. Value of ioPTH correlates directly with selected centre-specific intraoperative criteria. The stricter the criteria the more reliable is the exclusion of multiglandular disease. Surgery for pHPT was performed with a very low complication rate. Through the long-term follow-up, nearly two thirds of patients benefited from the operation.

Breeding status and social environment differentially affect the expression of sex steroid receptor and aromatase mRNA in the brain of female Damaraland mole-rats

Introduction

The Damaraland mole-rat (Fukomys damarensis) is a eusocial, subterranean mammal, which exhibits an extreme reproductive skew with a single female (queen) monopolizing reproduction in each colony. Non-reproductive females in the presence of the queen are physiologically suppressed to the extent that they are anovulatory. This blockade is thought to be caused by a disruption in the normal gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus. In order to understand the underlying physiological mechanisms of reproductive suppression in subordinate females we studied the expression of steroid hormone receptors and the androgen-converting enzyme aromatase in forebrain regions involved in the control of reproductive behaviour in female breeders and non-breeders from intact colonies. Additionally, we included in our analysis females that experienced the release from social suppression by being removed from the presence of the queen.

Results

We found expression of androgen receptor, estrogen receptor α and aromatase in several forebrain regions of female Damaraland mole-rats. Their distribution matches previous findings in other mammals. Quantification of the hybridisation signal revealed that queens had increased expression of androgen receptors compared to non-breeders and removed non-breeders in most brain regions examined, which include the medial preoptic area (MPOA), the principal nucleus of the bed nucleus of the stria terminalis (BSTp), the ventromedial nucleus of the hypothalamus (VMH), the arcuate nucleus (ARC) and the medial amygdala (MeA). Furthermore, breeders had increased estrogen receptor α expression in the anteroventral periventricular nucleus (AVPV) and in the MeA, while aromatase expression in the AVPV was significantly reduced compared to non-breeders. Absence of social suppression was associated with increased androgen receptor expression in the ARC, increased estrogen receptor α expression in the MeA and BSTp and reduced aromatase expression in the AVPV.

Conclusion

This study shows that social suppression and breeding differentially affect the neuroendocrine phenotype of female Damaraland mole-rats. The differential expression pattern of estrogen receptor α and aromatase in the AVPV between breeders and non-breeders supports the view that this region plays an important role in mediating the physiological suppression in subordinate females.

[Applications of numerical simulation in musculoskeletal research and its impact on orthopedic surgery]

Finite element analyses (FEA) as well as multibody system dynamics (MSD) are the main tools used for numerical simulation in the field of musculoskeletal research. While FEA is utilized for field problems, such as calculation of stress and strain distribution, MSD is applied for solving kinematic analyses, such as calculation of muscle and joint forces. Depending on the focus of investigation, modelling of biological tissue may vary from simple homogeneous behavior to modelling biochemical processes on the microscale and nanoscale. An important milestone in biomechanical research was the analysis of stress shielding, which led to further research on bone remodelling. Various models of implant-bone fixation used for the prediction of micromotion have been published. New possibilities for biomechanical analyses are achieved by consideration of complex muscle forces which are generated by MSD simulation and imported into FEA models as limiting conditions. A numerical model always requires experimental validation. If the results are confirmed experimentally, various advantages of numerical simulation apply and problems can be analysed isolated from many influencing factors. Therefore, straightforward parameter variation is possible, enabling studies which would be impossible in an experimental or clinical setup.

Influence of rupture patterns of the medial patellofemoral ligament (MPFL) on the outcome after operative treatment of traumatic patellar dislocation

PURPOSE

Patellar dislocation usually occurs to the lateral side, leading to ruptures of the medial patellofemoral ligament (MPFL) in about 90 % of all cases. Reliable prognostic factors for the stability of the patellofemoral joint after MPFL surgery and satisfaction of the patient have not been established as yet.

METHODS

This multicentric study retrospectively included 40 patients with a mean age of 22.4 ± 8.1 years (range 9-48) from 5 German Trauma Departments with first-time traumatic patellar dislocation and operative treatment. Surgery was limited to soft tissue repairs, and a preoperative magnetic resonance imaging (MRI) was performed in all cases. Evaluation of the MRI included sulcus angle, dysplasia of the trochlea, depth and facet asymmetry of the trochlea, Insall-Salvati index, Tibial tuberosity to trochlear groove (TTTG) distance, and rupture patterns of the MPFL. Patients were interrogated after 2 years about recurrent dislocation, satisfaction, and the Kujala score.

RESULTS

Trochlea facet asymmetry was significantly lower in patients with redislocation (23.5 ± 18.8) than in patients without redislocation (43.1 ± 16.5, p = 0.03). Patients with a patellar-based rupture were significantly younger (19.5 ± 7.2 years) than patients without patellar-based rupture (25.4 ± 8.1 years, p < 0.02). Patients with femoral-based ruptures were significantly older (25.7 ± 9.2 years) than patients without femoral-based rupture (19.7 ± 6.1 years, p < 0.02), and had a significantly higher TTTG distance (10.2 ± 6.9 vs. 4.5 ± 5.5, p < 0.02). Patients with incomplete ruptures of the MPFL had a significantly lower Insall-Salvati index (1.2 ± 0.2 vs. 1.4 ± 0.2, p = 0.05). The Kujala score in patients with redislocations was significantly lower (81.0 ± 10.5 points) than in patients without redislocation (91.9 ± 9.2 points, p < 0.02).

CONCLUSION

Younger patients more often sustain patellar-based ruptures following first-time traumatic patella dislocation, while older patients more often sustain femoral-based ruptures of the MPFL. Incomplete MPFL ruptures are correlated with lower Insall-Salvati indices. Low trochlear facet asymmetry is correlated with higher rates of redislocation. These results may be of relevance for the operative and postoperative treatment in the future.

LEVEL OF EVIDENCE

Prognostic study, Level IV.

Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial

INTRODUCTION

Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Even though several prognostic factors for patellofemoral instability have been identified so far, the appropriate therapy for patients with patellar dislocation remains a controversial issue. The purpose of this study was to compare the outcome after conservative or operative treatment in patients after first-time patellar dislocation.

PATIENTS AND METHODS

This randomized controlled clinical trial was designed multicentric including patients from six German orthopaedic and trauma departments. Twenty patients with a mean age of 24.6 years with first-time traumatic patella dislocation were included and randomized into either a conservative arm or an operative arm. Plain X-ray images of the knee joint (a.p. and lateral view and tangential view of both patellae) were performed in all cases prior to therapy to exclude osteochondral fragments requiring refixation. An MRI was recommended, but not compulsory. Patients were consulted after 6, 12, and 24 months with a questionnaire including the criteria of the Kujala score, recurrent dislocation, and satisfaction.

RESULTS

The mean Kujala score of the conservative vs operative treatment group was 78.6 vs 80.3 after 6 months (p = 0.842), 79.9 vs 88.9 after 12 months (p = 0.165), and 81.3 vs 87.5 after 24 months (p = 0.339). Redislocation rate after 24 months was 37.5 % in the conservative group and 16.7 % in the operative group (p = 0.347). Due to the small number of patients that could be included, no significant difference between the groups could be detected. We see a tendency towards better results after operative treatment.

CONCLUSION

Our multicentric prospective randomized controlled trial revealed no significant difference between conservative and operative treatment for patients after first-time traumatic patellar dislocation. However, a tendency towards a better Kujala score and lower redislocation rates for patients with operative treatment was observed. The small number of patients is a limiting factor of the study, leading to results without statistical significance. A meta-analysis including other study's level I data is desirable for the future.

Testosterone-dependency of male solo song in a duetting songbird--evidence from females

For male songbirds of the temperate zone there is a tight link between seasonal song behaviour and circulating testosterone levels. Such a relationship does not seem to hold for tropical species where singing can occur year-round and breeding seasons are often extended. White-browed sparrow weavers (Plocepasser mahali) are cooperatively breeding songbirds with a dominant breeding pair and male and female subordinates found in eastern and southern Africa. Each group defends an all-purpose territory year-round. While all group members sing duets and choruses, the most dominant male additionally sings a solo song that comprises a distinct and large syllable repertoire. Previous studies suggested this type of song being associated with reproduction but failed to support a relationship with males' circulating testosterone levels. The present study aimed to investigate the steroid hormone sensitivity of the solo song in more detail. We found that dominant males had significantly higher circulating testosterone levels than subordinates during the early and late breeding seasons. No changes in solo song characteristics were found between both time points. Further, experimental implantation of captive adult females with exogenous testosterone induced solo singing within one week of treatment. Such females produced male-typical song regarding overall structure and syllable composition. Sex differences existed, however, concerning singing activity, repertoire size and temporal organisation of song. These results suggest that solo singing in white-browed sparrow weavers is under the control of gonadal steroid hormones. Moreover, the behaviour is not male-specific but can be activated in females under certain conditions.

Impact of 5-lipoxygenase inhibitors on the spatiotemporal distribution of inflammatory cells and neuronal COX-2 expression following experimental traumatic brain injury in rats

The inflammatory response following traumatic brain injury (TBI) contributes to neuronal death with poor outcome. Although anti-inflammatory strategies were beneficial in the experimental TBI, clinical translations mostly failed, probably caused by the complexity of involved cells and mediators. We recently showed in a rat model of controlled cortical impact (CCI) that leukotriene inhibitors (LIs) attenuate contusion growth and improve neuronal survival. This study focuses on spatiotemporal characteristics of macrophages and granulocytes, typically involved in inflammatory processes, and neuronal COX-2 expression. Effects of treatment with LIs (Boscari/MK-886), started prior trauma, were evaluated by quantifying CD68(+), CD43(+) and COX-2(+) cells 24h and 72 h post-CCI in the parietal cortex (PC), CA3 region, dentate gyrus (DG) and visual/auditory cortex (v/aC). Correlations were applied to identify intercellular relationships. At 24h, untreated animals showed granulocyte invasion in all regions, decreasing towards 72 h. Macrophages increased from 24h to 72 h post-CCI in PC and v/aC. COX-2(+) neurones showed no temporal changes, except of an increase in the CA3 region at 72 h. Treatment reduced granulocytes at 24h in the pericontusional zone and hippocampus, and macrophages at 72 h in the PC and v/aC. COX-2 expression remained unaffected by LIs, except of time-specific changes in the DG (increase/decrease at 24/72 h). Interrelations confirmed concomitant cellular reactions beyond the initial trauma site. In conclusion, LIs attenuated the cellular inflammatory response following CCI. Future studies have to clarify region-specific effects and explore the potential of a clinically more relevant therapeutic approach applying LIs after CCI.