Perceptions of 3R implementation in European animal research: A systematic review, meta-analysis, and meta-synthesis of barriers and facilitators

OBJECTIVES

The purpose of this systematic review was to examine how the scientific community in Europe that is involved with research with animals perceives and experiences the implementation of 3R (Replace, Reduce, Refine).

METHODS

A systematic search of the literature published in the past ten years was performed in PubMed, Web of Science and Scopus. Publications were screened for eligibility using a priori inclusion criteria, and only empirical evidence (quantitative, qualitative, or mixed methodologies) was retained. Quantitative survey items were investigated by conducting a meta-analysis, and the qualitative data was summarized using an inductive meta-synthetic approach. Included publications were assessed using the Quality Assessment for Diverse Studies tool.

RESULTS

17 publications were included (eight quantitative, seven qualitative, two mixed-methods). The meta-analysis revealed that scientists are skeptical about achieving replacement, even if they believe that 3R improve the quality of experimental results. They are optimistic concerning the impact of 3R on research costs and innovation, and see education as highly valuable for the implementation of 3R. The meta-synthesis revealed four barriers (systemic dynamics, reification process, practical issues, insufficient knowledge) and four facilitators (efficient use of animals, caring for animals, regulatory uptake, supportive workplace environment).

CONCLUSION

These findings show actionable levers at the local and systemic levels, and may inform regulators and institutions in their 3R policies.

TRIAL REGISTRATION

The protocol was registered into the PROSPERO database under the number CRD42023395769.

Integrating physiological monitoring systems in military aviation: a brief narrative review of its importance, opportunities, and risks

Military pilots risk their lives during training and operations. Advancements in aerospace engineering, flight profiles, and mission demands may require the pilot to test the safe limits of their physiology. Monitoring pilot physiology (e.g. heart rate, oximetry, and respiration) inflight is in consideration by several nations to inform pilots of reduced performance capacity and guide future developments in aircraft and life-support system design. Numerous challenges, however, prevent the immediate operationalisation of physiological monitoring sensors, particularly their unreliability in the aerospace environment and incompatibility with pilot clothing and protective equipment. Human performance and behaviour are also highly variable and measuring these in controlled laboratory settings do not mirror the real-world conditions pilots must endure. Misleading or erroneous predictive models are unacceptable as these could compromise mission success and lose operator trust. This narrative review provides an overview of considerations for integrating physiological monitoring systems within the military aviation environment.Practitioner summary: Advancements in military technology can conflictingly enhance and compromise pilot safety and performance. We summarise some of the opportunities, limitations, and risks of integrating physiological monitoring systems within military aviation. Our intent is to catalyse further research and technological development.Abbreviations: AGS: anti-gravity suit; AGSM: anti-gravity straining manoeuvre; A-LOC: almost loss of consciousness; CBF: cerebral blood flow; ECG: electrocardiogram; EEG: electroencephalogram; fNIRS: functional near-infrared spectroscopy; G-forces: gravitational forces; G-LOC: gravity-induced loss of consciousness; HR: heart rate; HRV: heart rate variability; LSS: life-support system; NATO: North Atlantic Treaty Organisation; PE: Physiological Episode; PCO2: partial pressure of carbon dioxide; PO2: partial pressure of oxygen; OBOGS: on board oxygen generating systems; SpO2: peripheral blood haemoglobin-oxygen saturation; STANAG: North Atlantic Treaty Organisation Standardisation Agreement; UPE: Unexplained Physiological Episode; WBV: whole body vibration.

Recovery from acute hypoxia: A systematic review of cognitive and physiological responses during the 'hypoxia hangover'

Recovery of cognitive and physiological responses following a hypoxic exposure may not be considered in various operational and research settings. Understanding recovery profiles and influential factors can guide post-hypoxia restrictions to reduce the risk of further cognitive and physiological deterioration, and the potential for incidents and accidents. We systematically evaluated the available evidence on recovery of cognitive and basic physiological responses following an acute hypoxic exposure to improve understanding of the performance and safety implications, and to inform post-hypoxia restrictions. This systematic review summarises 30 studies that document the recovery of either a cognitive or physiological index from an acute hypoxic exposure. Titles and abstracts from PubMed (MEDLINE) and Scopus were searched from inception to July 2022, of which 22 full text articles were considered eligible. An additional 8 articles from other sources were identified and also considered eligible. The overall quality of evidence was moderate (average Rosendal score, 58%) and there was a large range of hypoxic exposures. Heart rate, peripheral blood haemoglobin-oxygen saturation and heart rate variability typically normalised within seconds-to-minutes following return to normoxia or hyperoxia. Whereas, cognitive performance, blood pressure, cerebral tissue oxygenation, ventilation and electroencephalogram indices could persist for minutes-to-hours following a hypoxic exposure, and one study suggested regional cerebral tissue oxygenation requires up to 24 hours to recover. Full recovery of most cognitive and physiological indices, however, appear much sooner and typically within ~2-4 hours. Based on these findings, there is evidence to support a 'hypoxia hangover' and a need to implement restrictions following acute hypoxic exposures. The severity and duration of these restrictions is unclear but should consider the population, subsequent requirement for safety-critical tasks and hypoxic exposure.

Cocoa flavanols protect cognitive function, cerebral oxygenation, and mental fatigue during severe hypoxia

We tested the hypothesis that ingestion of cocoa flavanols would improve cognition during acute hypoxia equivalent to 5,500 m altitude (partial pressure of end-tidal oxygen = 45 mmHg). Using placebo-controlled double-blind trials, 12 participants ingested 15 mg·kg-1 of cocoa flavanols 90 min before completing cognitive tasks during normoxia and either poikilocapnic or isocapnic hypoxia (partial pressure of end-tidal carbon dioxide uncontrolled or maintained at the baseline value, respectively). Cerebral oxygenation was measured using functional near-infrared spectroscopy. Overall cognition was impaired by poikilocapnic hypoxia (main effect of hypoxia, P = 0.008). Cocoa flavanols improved a measure of overall cognitive performance by 4% compared with placebo (effect of flavanols, P = 0.033) during hypoxia, indicating a change in performance from "low average" to "average." The hypoxia-induced decrease in cerebral oxygenation was two-fold greater with placebo than with cocoa flavanols (effect of flavanols, P = 0.005). Subjective fatigue was increased by 900% with placebo compared with flavanols during poikilocapnic hypoxia (effect of flavanols, P = 0.004). Overall cognition was impaired by isocapnic hypoxia (effect of hypoxia, P = 0.001) but was not improved by cocoa flavanols (mean improvement = 1%; effect of flavanols, P = 0.72). Reaction time was impaired by 8% with flavanols during normoxia and further impaired by 11% during isocapnic hypoxia (effect of flavanols, P = 0.01). Our findings are the first to show that flavanol-mediated improvements in cognition and mood during normoxia persist during severe oxygen deprivation, conferring a neuroprotective effect.NEW & NOTEWORTHY We show for the first time that cocoa flavanols exert a neuroprotective effect during severe hypoxia. Following acute cocoa flavanol ingestion, we observed improvements in cognition, cerebral oxygenation, and subjective fatigue during normoxia and severe poikilocapnic hypoxia. Cocoa flavanols did not improve cognition during severe isocapnic hypoxia, suggesting a possible interaction with carbon dioxide.

Russell and Burch's 3Rs then and now: The case of Switzerland

Since Russell and Burch introduced and defined the 3Rs, i.e., the replacement, reduction, and refinement of animal use in research, in 1959, different definitions have emerged and been implemented in guidelines and policies. Switzerland is known for having some of the most restrictive legislation regarding the use of animals, in which the 3Rs are also defined and implemented. To our knowledge, the purpose and definitions of the 3Rs used in the Swiss Animal Welfare Act, Animal Protection Ordinance, and Animal Experimentation Ordinance have never been compared with Russell and Burch’s original purpose and definitions. In this paper we make this comparison with two aims: to reveal ethically relevant departures from the original purpose and definitions, and to provide an ethical evaluation of the current Swiss law regarding the 3Rs. In doing so, we first expose the similarity of purposes. We then identify one risky departure from the original definition of replacement in Swiss law, which shows a problematic focus on species. Finally, we address Swiss law’s failure to apply the 3Rs in the most effective way. With respect to this last point, we discuss the need for 3R conflict resolution, the timing of application of the 3Rs, problematic prioritizations and choices of convenience as well as a solution to apply the 3Rs more effectively using Russell and Burch’s concept of total sum of distress.

Natural killer cell subset count and antigen-stimulated activation in response to exhaustive running following adaptation to a ketogenic diet

NEW FINDINGS

What is the central question of this study? Does a ketogenic diet (KD) modulate circulating counts of natural killer (NK) cells, including CD56bright and CD56dim subsets, and their ability to activate (CD69 expression) following in vitro antigen stimulation in response to exhaustive moderate-intensity exercise? What is the main finding and its importance? The KD amplified the biphasic exercise-induced NK cell response due to a greater mobilisation of the cytotoxic CD56dim subset but did not alter NK cell CD69 expression. The KD appears to modulate exercise-induced circulating NK cell mobilisation and egress, but not antigen-stimulated circulating NK cell activation.

ABSTRACT

We investigated the effect of a 31-day ketogenic diet (KD) compared with a habitual, carbohydrate (CHO)-based diet on total circulating natural killer (NK) CD3- CD56+ , dim and bright subset count, and antigen-stimulated CD3- CD56+ cell activation (CD69+ ) in response to exhaustive running. In a randomised, repeated-measures, cross-over study, eight trained, male endurance athletes ingested a 31-day low-CHO KD or their habitual diet (HD). On day 31, participants ran to exhaustion at 70%V ̇ O 2 max $\dot{V}_{{\rm{O}}_{2}{\rm{max}}}$ (∼3.5-4 h, ∼45-50 km). A low-CHO (<10 g) meal was ingested prior to the KD trial, with fat ingested during exercise. A high-CHO (2 g kg-1 ) meal was ingested prior to the HD trial, with CHO (∼55 g h-1 ) ingested during exercise. Venous blood samples were collected at pre-exercise, post-exercise and 1 h post-exercise. The KD amplified the classical exercise-induced biphasic CD3- CD56+ cell response by increasing the post-exercise counts (P = 0.0004), which appeared to be underpinned by the cytotoxic CD3- CD56dim subset (main effect of time point, P < 0.0001). The KD had no effect on NK cells' expression of CD69 or their geometric mean fluorescence intensity of CD69 expression, either for unstimulated or for antigen-stimulated NK cells (all P > 0.05). In conclusion, adaptation to a KD may alter the number of circulating NK cells but not their ability to activate to an antigenic challenge.

The effect of acute normobaric hyperoxia on cognition: a systematic review, meta-analysis and meta-regression

This systematic review, meta-analysis and meta-regression examined the effect of acute normobaric hyperoxia breathing on cognition in healthy humans. 23 studies were included providing 76 effect estimates (EE). Hyperoxic breathing improved memory accuracy (22 EEs; g = 0.34) and speed (9 EEs; g = 0.59), attention accuracy (7 EEs; g = 0.59) and speed (7 EEs; g = 0.51), reaction speed (8 EEs; g = 0.82), crystallised intelligence (7 EEs; g = 0.73), executive function (6 EEs; g = 0.88) and information processing (10 EEs; g = 0.62). However, the overall quality of evidence was low (average Rosendal score of 47%) and there was a large range of study heterogeneity, with prediction intervals often crossing 0; therefore, reducing the reliability of the magnitude of these favourable effects. Oxygen percentage, 100% compared with 22-99% oxygen, temporal position of administration to task performance, and study quality did not influence the overall weighted mean effects for most cognitive domains. Altogether, despite beneficial results, further high quality research is required prior to recommending hyperoxic breathing to enhance cognition.

The effect of a 2 week ketogenic diet, versus a carbohydrate-based diet, on cognitive performance, mood and subjective sleepiness during 36 h of extended wakefulness in military personnel: An exploratory study

Extended wakefulness, or sleep deprivation, impairs cognitive performance and brain glucose metabolism. A ketogenic diet (KD) provides an alternative fuel source, ketone bodies, that could elicit a metabolic benefit during sleep deprivation. A randomised, cross-over trial was conducted with seven male military personnel. Participants ingested an iso-energetic ketogenic diet or carbohydrate-based diet for 14 days, immediately followed by 36 h of extended wakefulness and separated by a 12 day washout. Cognitive performance, mood, subjective sleepiness, capillary blood glucose, and D-β-hydroxybutyrate concentrations were measured every 2 h during extended wakefulness. Linear mixed models were used to analyse data. D-β-hydroxybutyrate was higher (p < 0.001) and glucose was lower (p < 0.01) on the KD compared with the carbohydrate-based diet. The KD improved psychomotor vigilance task performance (number of lapses, mean reciprocal response time, mean fastest 10% response time (RT), and mean slowest 10% RT; all p < 0.05), running memory continuous performance test performance (RT and number of correct responses per minute; both p < 0.01), and vigour, fatigue, and sleepiness (all, p ≤ 0.001) compared with the carbohydrate-based diet. In conclusion, a KD demonstrated beneficial effects on cognitive performance, mood, and sleepiness during 36 h of extended wakefulness compared with a carbohydrate-based diet.

Genome-wide association study identifies novel risk loci for apical periodontitis

Apical periodontitis (AP) is a common consequence of root canal infection leading to periapical bone resorption. Microbial and host genetic factors, and their interactions, have been shown to play a role in AP development and progression. Variations in a few genes have been reported in association with AP, however, the lack of genome-wide studies has hindered progress in understanding the mechanisms involved in AP. Here, we report the first genome-wide association study of AP in a well-characterized population. Male and female adults (n=932) presenting with deep caries with AP (cases) or without AP (controls) were included. Genotyping was performed using the Illumina Expanded Multi-Ethnic Genotyping Array. Single-variant association testing was performed adjusting for sex and five principal components. Subphenotype association testing, analyses of genetically regulated gene expression, polygenic risk score and phenome-wide association (PheWAS) analyses were also performed. Eight loci reached near-genome-wide significant association with AP (p < 5 x 10-6); gene-focused analyses replicated three previously reported associations (p < 8.9 x 10-5). Sex-specific and subphenotype analyses revealed additional significant associations with variants genome-wide. Functionally oriented gene-based analyses revealed eight genes significantly associated with AP (p < 5 x 10-5), and PheWAS analysis revealed 33 phecodes associated with AP risk score (p < 3.08 x 10-5). This study identified novel genes/loci contributing to AP and revealed specific contributions to AP risk in males and females. Importantly, we identified additional systemic conditions significantly associated with AP risk. Our findings provide strong evidence for host-mediated effects on AP susceptibility.

A smarter perspective: Learning with and from AI-cases

Artificial intelligence (AI) has only partially (or not at all) been integrated into medical education, leading to growing concerns regarding how to train healthcare practitioners to handle the changes brought about by the introduction of AI. Programming lessons and other technical information into healthcare curricula has been proposed as a solution to support healthcare personnel in using AI or other future technology. However, integrating these core elements of computer science knowledge might not meet the observed need that students will benefit from gaining practical experience with AI in the direct application area. Therefore, this paper proposes a dynamic approach to case-based learning that utilizes the scenarios where AI is currently used in clinical practice as examples. This approach will support students' understanding of technical aspects. Case-based learning with AI as an example provides additional benefits: (1) it allows doctors to compare their thought processes to the AI suggestions and critically reflect on the assumptions and biases of AI and clinical practice; (2) it incentivizes doctors to discuss and address ethical issues inherent to technology and those already existing in current clinical practice; (3) it serves as a foundation for fostering interdisciplinary collaboration via discussion of different views between technologists, multidisciplinary experts, and healthcare professionals. The proposed knowledge shift from AI as a technical focus to AI as an example for case-based learning aims to encourage a different perspective on educational needs. Technical education does not need to compete with other essential clinical skills as it could serve as a basis for supporting them, which leads to better medical education and practice, ultimately benefiting patients.

Cognitive, Sleep, and Autonomic Responses to Induction of a Ketogenic Diet in Military Personnel: A Pilot Study

BACKGROUND: This pilot study examined the effect of a 2-wk ketogenic diet (KD) compared with a carbohydrate (CHO) diet in military personnel on cognitive performance, mood, sleep, and heart rate variability (HRV).METHODS: A randomized-controlled, cross-over trial was conducted with eight male military personnel (age, 36 ± 7 yr; body mass, 83.7 ± 9.2 kg; BMI, 26.0 ± 2.3 kg · m−2). Subjects ingested their habitual diet for 7 d (baseline), then an iso-energetic KD (∼25 g CHO/d) or CHO diet (∼285 g CHO/d) for 14 d (adaptation), separated by a 12-d washout. HRV, fasting capillary blood D-βHB, and glucose concentration, mood, and sleep were measured daily. Cognitive performance was measured on the 7th day of baseline and the 7th and 14th days of adaptation. Data were analyzed using a series of linear mixed models.RESULTS: Mean weekly D-βHB was higher (95% CI, +0.34 to +2.38 mmol · L−1) and glucose was lower (−0.45 to −0.21 mmol · L−1) in the KD compared with the CHO diet. Cognitive performance (Psychomotor Vigilance Task, 2-choice reaction time, and running memory continuous performance test) and mean weekly fatigue, vigor, and sleep (sleep duration, sleep efficiency, and sleep onset latency) were similar between diets. A diet × week interaction for HRV approached significance, with exploratory analyses suggesting HRV was lower compared with baseline during week-2 adapt (−27 to +4 ms) in the KD.DISCUSSION: A 2-wk induction to a KD in male military personnel does not appear to affect cognitive performance, mood, or sleep, but may lower HRV, indicating increased physiological stress.Shaw DM, Henderson L, van den Berg M. Cognitive, sleep, and autonomic responses to induction of a ketogenic diet in military personnel: a pilot study. Aerosp Med Hum Perform. 2022; 93(6):507–516.

Avoiding a crisis at Christmas: a systematic review of adverse health effects or 'Chrishaps' caused by traditional hazard sources and COVID-19

OBJECTIVE

To complement the 2020 ANZJPH editorial "How COVID-safe Santa can save Christmas". In addition to a concise update regarding SARS-CoV-2/COVID-19, we aimed to explore some risks of Christmas in terms of adverse health effects, which we call 'Chrishaps'. Our overall study question was "which hazards have been scientifically associated with old Christmas essentials such as decoration, gifts, menus, and Santa himself, as well as new challenges associated with COVID-19?"

METHOD

We searched the PubMed, Web of Science, and Open Grey databases systematically and Google unsystematically.

RESULTS

Thirty-six pertinent articles - most of them case reports or retrospective analyses - documented Chrishaps.

CONCLUSION

Overall results suggested that Chrishaps come in different shapes and guises. Implications for public health: Chrishaps pose a potential minor public health threat that should be borne in mind every festive season. Assessing and discussing specific public health implications of Chrishaps requires systematic risk research to be conducted.

Re-focusing explainability in medicine

Using artificial intelligence to improve patient care is a cutting-edge methodology, but its implementation in clinical routine has been limited due to significant concerns about understanding its behavior. One major barrier is the explainability dilemma and how much explanation is required to use artificial intelligence safely in healthcare. A key issue is the lack of consensus on the definition of explainability by experts, regulators, and healthcare professionals, resulting in a wide variety of terminology and expectations. This paper aims to fill the gap by defining minimal explainability standards to serve the views and needs of essential stakeholders in healthcare. In that sense, we propose to define minimal explainability criteria that can support doctors’ understanding, meet patients’ needs, and fulfill legal requirements. Therefore, explainability need not to be exhaustive but sufficient for doctors and patients to comprehend the artificial intelligence models’ clinical implications and be integrated safely into clinical practice. Thus, minimally acceptable standards for explainability are context-dependent and should respond to the specific need and potential risks of each clinical scenario for a responsible and ethical implementation of artificial intelligence.

Upper respiratory tract symptom risk in elite field hockey players during a dry run for the Tokyo Olympics

ABSTRACTThe primary aim of this study was to examine if biomarker and/or self-reported data could predict upper respiratory tract symptom (URTS) risk in elite field hockey players. The secondary aim was to investigate the effect of the additional stressor 'repeated heat exposure' on measures of thermoregulation and immunity. A prospective cohort repeated measures study design was used to collect URTS, household illness, self-reported wellness, biomarker and thermoregulatory data from elite male field hockey players (n = 19), during an 8-week training and competition period that simulated the preparatory and competition phases of the 2020 Tokyo Olympics. Heat response testing (HRT) was performed at the beginning of the study period, following heat acclimation (HA) and following an intensified competition period (ICP) played in hot and humid conditions (27-37°C and 53-80% relative humidity). Univariate frailty analysis demonstrated that illness in players' households (Hazard ratio (HR: 4.90; p < 0.001)) and self-reported stress (HR: 0.63; p = 0.043) predicted players' risk for URTS. Additionally, low baseline resting salivary secretory immunoglobulin A (SIgA) concentration predicted players' "potential" URTS risk (p = 0.021). The additional stressor "repeated heat exposure" was found to facilitate partial thermoregulatory adaptation without attenuating resting immune functions. In conclusion, lifestyle and behavioural factors (i.e. household illness and stress) influenced players risk for URTS more so than sport-related stressors. Furthermore, repeated heat exposure did not appear to compromise players resting immunity. To assess athletes' risk for URTS, baseline screening of SIgA concentration and regular monitoring of self-reported lifestyle and behavioural data are recommended.

Advance Car-Crash Planning: Shared Decision Making between Humans and Autonomous Vehicles

In this article we summarise some previously described proposals for ethical governance of autonomous vehicles ('smart cars'), critique them, and offer an alternative solution. Rather than programming cars to react to crash situations in the same way as humans, having humans program pre-set responses for a wide range of different potential scenarios, or applying particular ethical theories, we suggest that decisions should be made jointly between humans and cars. Given that humans lack the requisite processing capacity, and computers lack the necessary ethical capacity, the medical paradigm of advance care planning can be retooled for this new context. Advance car-crash planning provides a way to combine humans' ethical preferences with the advanced data processing capacities of computers to enable shared decision making in collision situations.

Risk, Responsibility, Rudeness, and Rules: The Loneliness of the Social Distance Warrior

We have a responsibility to obey COVID-19 rules, in order to minimize risk. Yet it is still seen as rude to challenge people who do not respect those rules, when in fact the opposite is true; it is rude to increase risk to others. In this paper I analyse the relationship between risk, responsibility, and rudeness by analysing the evolution of the main governmental slogans and rules and explore the complex relationship between simplicity, safety, and perceived fairness of these rules, and how these features in turn influence the extent to which we act responsibly. I begin by exploring the relationship between rudeness and risk in our interactions about coronavirus, before going on to analyse the importance of clear rules in minimizing tension between us, illustrating the argument with various slogans including "stay at home," "stay alert," and the now infamous "rule of six," which is actually at least three different rules. Ultimately, we are faced with a paradox: people annoyed about complex/unfair rules are less likely to obey them, even if that means rules will apply for longer and even though it was noncompliance with earlier simpler rules that means new rules are necessary. And if rules make less or no sense it is harder to try to get people to follow them in your own capacity as a citizen; it is hard to police rules that are seen as arbitrary or unfair.

Towards a good work-life balance: 10 recommendations from 10 Nobel Laureates (1996-2013)

It can be hard to get the work-life balance right in research and academia. There is no one-size-fits-all recommendation for 'the best work-life balance', as we all have different work-life priorities. But for scientists, at least, Nobel Laureates' thoughts on the matter may prove useful. As such, we describe and discuss, ten recommendations toward a good work-life balance voiced by ten 1996-2013 nobel laureates. "[Peter Medawar] told his young bride, pretentiously, that she had first claim on his love, but not on his time, made her buy her own wedding ring and often also her own Christmas presents. So preoccupied was he with his work that Jean had to be both father and mother to their four children". -Max Perutz (Perutz 2002).

Hypoxic Hypoxia and Brain Function in Military Aviation: Basic Physiology and Applied Perspectives

Acute hypobaric hypoxia (HH) is a major physiological threat during high-altitude flight and operations. In military aviation, although hypoxia-related fatalities are rare, incidences are common and are likely underreported. Hypoxia is a reduction in oxygen availability, which can impair brain function and performance of operational and safety-critical tasks. HH occurs at high altitude, due to the reduction in atmospheric oxygen pressure. This physiological state is also partially simulated in normobaric environments for training and research, by reducing the fraction of inspired oxygen to achieve comparable tissue oxygen saturation [normobaric hypoxia (NH)]. Hypoxia can occur in susceptible individuals below 10,000 ft (3,048 m) in unpressurised aircrafts and at higher altitudes in pressurised environments when life support systems malfunction or due to improper equipment use. Between 10,000 ft and 15,000 ft (4,572 m), brain function is mildly impaired and hypoxic symptoms are common, although both are often difficult to accurately quantify, which may partly be due to the effects of hypocapnia. Above 15,000 ft, brain function exponentially deteriorates with increasing altitude until loss of consciousness. The period of effective and safe performance of operational tasks following exposure to hypoxia is termed the time-of-useful-consciousness (TUC). Recovery of brain function following hypoxia may also lag beyond arterial reoxygenation and could be exacerbated by repeated hypoxic exposures or hyperoxic recovery. This review provides an overview of the basic physiology and implications of hypoxia for military aviation and discusses the utility of hypoxia recognition training.

Exogenous Ketone Supplementation and Keto-Adaptation for Endurance Performance: Disentangling the Effects of Two Distinct Metabolic States

Ketone bodies (KB) provide an alternative energy source and uniquely modulate substrate metabolism during endurance exercise. Nutritional ketosis (blood KBs > 0.5 mM) can be achieved within minutes via exogenous ketone supplementation or days-to-weeks via conforming to a very low-carbohydrate, ketogenic diet (KD). In contrast to short-term (< 2 weeks) KD ingestion, chronic adherence (> 3 weeks) leads to a state of keto-adaptation. However, despite elevating blood KBs to similar concentrations, exogenous ketone supplementation and keto-adaptation are not similar metabolic states as they elicit diverse and distinct effects on substrate availability and metabolism during exercise; meaning that their influence on endurance exercise performance is different. In contrast to contemporary, high(er)-carbohydrate fuelling strategies, inducing nutritional ketosis is rarely ergogenic irrespective of origin and, in fact, can impair endurance performance. Nonetheless, exogenous ketone supplementation and keto-adaptation possess utility for select endurance events and individuals, thus warranting further research into their performance effects and potential strategies for their optimisation. It is critical, however, that future research considers the limitations of measuring blood KB concentrations and their utilisation, and assess the effect of nutritional ketosis on performance using exercise protocols reflective of real-world competition. Furthermore, to reliably assess the effects of keto-adaptation, rigorous dietary-training controls of sufficient duration should be prioritised.

Predictors of upper respiratory tract symptom risk: Differences between elite rugby union and league players

This study examined possible predictors of upper respiratory tract symptom (URTS) episodes in elite rugby union and league players (n = 51) during intensive pre-season training. Baseline saliva and blood samples were collected in the first week of pre-season training for analysis of salivary secretory immunoglobulin A (SIgA) and cytomegalovirus. Thereafter, SIgA, URTS, internal training load and self-reported wellness data were repeatedly measured throughout a 10-week pre-season training period. Univariate frailty model analysis, which included 502 observations, was performed for each rugby code for the following independent predictor variables: SIgA concentration, internal training load, total wellness, sleep quantity, sleep quality and stress. Rugby union and league players experienced a similar number of URTS episodes; however, predictors of URTS episodes differed between the codes. No biomarkers or self-reported measures significantly predicted URTS risk in rugby union players, while reductions in self-reported total wellness (HR: 0.731, p = 0.004) and sleep quality (HR: 0.345, p = 0.001) predicted increased URTS risk in rugby league players. The findings from this study highlight that factors influencing URTS risk are perhaps sport specific and this may be attributed to different sporting demands and/or different management of players by team-practitioners.

Synthesis of legonmycins A and B, C(7a)-hydroxylated bacterial pyrrolizidines

A one-flask, two-step procedure from 3-amino-2-methyl-5,6,7,7a-tetrahydro-1H-pyrrolizin-1-one affords the Streptomyces secondary metabolites legonmycins A and B - three operations overall from methyl N-Boc-prolinate. The key step proceeds in each case via N,O-diacylation, then selective oxidative hydrolysis of the intermediate bicyclic pyrrole and establishes a precedent for the synthesis of related C(7a)-hydroxylated pyrrolizidines.

Household illness is the strongest predictor of upper respiratory tract symptom risk in elite rugby union players

OBJECTIVES

To identify periods of increased risk for upper respiratory tract symptom (URTS) episodes, and examine whether biomarkers and/or self-reported lifestyle and wellness data can predict URTS risk in elite rugby union players.

DESIGN

Prospective, longitudinal and repeated-measures study.

METHODS

Salivary secretory immunoglobulin A (SIgA), salivary cortisol, URTS, internal training load and self-reported lifestyle and wellness data including household illness, stress, mood, fatigue, muscle soreness and sleep quality were repeatedly measured in elite Southern hemisphere rugby union players (n=28) throughout a season. Univariate frailty model analysis, which included 495 observations, was used to determine predictors of URTS risk.

RESULTS

Surprisingly, the highest incidence of URTS occurred after rest weeks, namely the Christmas break and bye weeks (i.e., no scheduled trainings or matches); whereas URTS risk was reduced during weeks involving international travel (Hazard ratio (HR): 0.43, p<0.001)). Household illness was the strongest predictor of URTS risk; players were almost three-fold more at risk for an URTS episode when illness in the household was present (HR: 2.90, p=0.002). A non-significant, but potentially important trend for an inverse association between SIgA concentration and URTS incidence was also observed (HR: 0.99, p=0.070).

CONCLUSIONS

Rest weeks were identified as periods of increased risk for URTS; while international travel did not appear to increase players risk for URTS. Incidence of household illness and SIgA concentration independently predicted URTS risk, with household illness being the strongest predictor. These findings can assist practitioners monitoring and management of athletes to potentially reduce URTS risk.

Invisible Enemies: Coronavirus and Other Hidden Threats

To say that coronavirus is highly visible is a massive understatement in terms of its omnipresence in our lives and media coverage concerning it, yet also clearly untrue in terms of the virus itself. COVID-19 is our invisible enemy, changing our lives radically without ever revealing itself directly. In this paper I explore its invisibility and how it relates to and exposes other invisible enemies we are and have been fighting, in many cases without even realizing. First, I analyse the virus itself and how its stealthy nature has transformed our lives. Second, I describe how the invisible epidemic of social media sharing of fake news about the virus worsens the situation further. Third, I explore how the virus has revealed to us what really matters in our lives and has forced us to re-evaluate our priorities. Fourth, I go on to explore the underlying structural weaknesses and disparities in society that have been exposed by the virus but previously remained unconsidered for so long that they too have become camouflaged, even if their effects are all too apparent; like the virus, neoliberal capitalism is an invisible enemy that has made prisoners of us all. I conclude by suggesting that the coronavirus pandemic represents a hidden opportunity to overcome perhaps the biggest invisible enemy of all: the moral distance that separates us from others. Only by rendering the rest of humanity morally visible to ourselves can we overcome capitalism and stop treating other people as invisible enemies.

The plight of the skyscraper wean: public health and the Jeely Piece Song

In this Chekhov's Corner article, I explore the public health lessons of a famous Scottish folk song. The Jeely Piece Song uses humour to highlight the health inequalities and other challenges facing children in one of Glasgow's new townships in the 1960s, some of which still persist today.

Adaptation to a ketogenic diet modulates adaptive and mucosal immune markers in trained male endurance athletes

This study examined the effect of short-term adaptation to a ketogenic diet (KD) on resting and post-exercise immune markers. Using a randomized, repeated-measures, crossover design, eight trained, male, endurance athletes ingested a 31-day low carbohydrate (CHO), KD (energy intake: 4% CHO; 78% fat) or their habitual diet (HD) (energy intake: 43% CHO; 38% fat). On days 0 and 31, participants ran to exhaustion at 70% VO_2max . A high-CHO (2 g·kg^-1 ) meal was ingested prior to the pre-HD, post-HD, and pre-KD trials, with CHO (~55 g·h^-1 ) ingested during exercise, whereas a low-CHO (<10 g) meal was ingested prior to the post-KD trial, with fat ingested during exercise. Blood and saliva samples were collected at pre-exercise, exhaustion, and 1 hour post-exhaustion. T-cell-related cytokine gene expression within peripheral blood mononuclear cells (PBMCs) and whole-blood inflammatory cytokine production were determined using 24-hour multi-antigen-stimulated whole-blood cultures. Multi-antigen-stimulated PBMC IFN-γ mRNA expression and the IFN-γ/IL-4 mRNA expression ratio were higher at exhaustion in the post-KD compared with pre-KD trial (P = 0.003 and P = 0.004); however, IL-4 and IL-10 mRNA expression were unaltered (P > 0.05). Multi-antigen-stimulated whole-blood IL-10 production was higher in the post-KD compared with pre-KD trial (P = 0.028), whereas IL-1β, IL-2, IL-8, and IFN-γ production was lower in the post-HD compared with pre-HD trial (P < 0.01). Salivary immunoglobulin A (SIgA) secretion rate was higher in the post-KD compared with pre-KD trial (P < 0.001). In conclusion, short-term adaptation to a KD in endurance athletes may alter the pro- and anti-inflammatory immune cell cytokine response to a multi-antigen in vitro and SIgA secretion rate.

Allonymous science: the politics of placing and shifting credit in public-private nutrition research

Ideally, guidelines reflect an accepted position with respect to matters of concern, ranging from clinical practices to researcher behaviour. Upon close reading, authorship guidelines reserve authorship attribution to individuals fully or almost fully embedded in particular studies, including design or execution as well as significant involvement in the writing process. These requirements prescribe an organisation of scientific work in which this embedding is specifically enabled. Drawing from interviews with nutrition scientists at universities and in the food industry, we demonstrate that the organisation of research labour can deviate significantly from such prescriptions. The organisation of labour, regardless of its content, then, has consequences for who qualifies as an author. The fact that fewer food industry employees qualify is actively used by the food industry to manage the credibility and ownership of their knowledge claims as allonymous science: the attribution of science assisted by authorship guidelines blind to all but one organisational frame.

Effect of a Ketogenic Diet on Submaximal Exercise Capacity and Efficiency in Runners

PURPOSE

We investigated the effect of a 31-d ketogenic diet (KD) on submaximal exercise capacity and efficiency.

METHODS

A randomized, repeated-measures, crossover study was conducted in eight trained male endurance athletes (V˙O2max, 59.4 ± 5.2 mL⋅kg⋅min). Participants ingested their habitual diet (HD) (13.1 MJ, 43% [4.6 g⋅kg⋅d] carbohydrate and 38% [1.8 g⋅kg⋅d] fat) or an isoenergetic KD (13.7 MJ, 4% [0.5 g·kg⋅d] carbohydrate and 78% [4 g⋅kg⋅d] fat) from days 0 to 31 (P < 0.001). Participants performed a fasted metabolic test on days -2 and 29 (~25 min) and a run-to-exhaustion trial at 70% V˙O2max on days 0 and 31 following the ingestion of a high-carbohydrate meal (2 g⋅kg) or an isoenergetic low-carbohydrate, high-fat meal (<10 g CHO), with carbohydrate (~55 g⋅h) or isoenergetic fat (0 g CHO⋅h) supplementation during exercise.

RESULTS

Training loads were similar between trials and V˙O2max was unchanged (all, P > 0.05). The KD impaired exercise efficiency, particularly at >70% V˙O2max, as evidenced by increased energy expenditure and oxygen uptake that could not be explained by shifts in respiratory exchange ratio (RER) (all, P < 0.05). However, exercise efficiency was maintained on a KD when exercising at <60% V˙O2max (all, P > 0.05). Time-to-exhaustion (TTE) was similar for each dietary adaptation (pre-HD, 237 ± 44 vs post-HD, 231 ± 35 min; P = 0.44 and pre-KD, 239 ± 27 vs post-KD, 219 ± 53 min; P = 0.36). Following keto-adaptation, RER >1.0 vs <1.0 at V˙O2max coincided with the preservation and reduction in TTE, respectively.

CONCLUSION

A 31-d KD preserved mean submaximal exercise capacity in trained endurance athletes without necessitating acute carbohydrate fuelling strategies. However, there was a greater risk of an endurance decrement at an individual level.

(Side) effects of the rule of the road and neurophysiology on traffic safety: A hypothesis

Nowadays, the roots of left-hand traffic (LHT) and right-hand traffic (RHT) - including fighting on horse-back and whipping horses that are drawing carriages - are at an all-time low; thus, it is time to assess and appreciate the nexus of road-safety practices and human neurophysiology. We hypothesize that safety of LHT and RHT can be associated with neurophysiology. We summarize scattered empirical research into plausible links between neurophysiological aspects such as handedness, eye movement bias, and hemispheric lateralisation and how safe, in theory, LHT vs. RHT may be for whom. The scarcity and limitations of empirical data into road traffic accidents associated with LHT or RHT are surprising. Even though it was claimed that countries with LHT have lower collision rates than countries with RHT some 50 years ago, we lack informative analyses of traffic accidents in countries with either LHT or RHT which consider plausibly associated neurophysiology. Overall, we predict that LHT (with the driver sitting on the right) is safer than RHT. As 'the rule of the road' and neurophysiology may have important unrecognized "side" effects, we suggest that (and how) this rationale should be tested.

The side effects of deemed consent: changing defaults in organ donation

In this Current Controversy article, I describe and analyse the imminent move to a system of deemed consent for deceased organ donation in England and similar planned changes in Scotland, in light of evidence from Wales, where the system changed in 2015. Although the media has tended to focus on the potential benefits and ethical issues relating to the main change from an opt-in default to an opt-out one, other defaults will also change, while some will remain the same. Interaction of these other defaults with the principal one raise several ethical issues that may complicate efforts to use deemed consent to increase donation rates. Most significantly, changing the main default will have the effect of changing the default for patients' families, who play a vital role in the consent process.

Intensive care for organ preservation: A four-stage pathway

Objective

Intensive care for organ preservation (ICOP) is defined as the initiation or pursuit of intensive care not to save the patient's life, but to protect and optimize organs for transplantation.

Analysis

When a patient has devastating brain injury that might progress to organ donation this can be conceptualized as evolving through four consecutive stages: (1) instability, (2) stability, (3) futility and (4) finality. ICOP might be applied at any of these stages, raising different ethical issues. Only in the stage of finality is the switch from neurointensive care to ICOP ethically justified.

Conclusion

The difference between the stages is that during instability, stability and futility the focus must be neurointensive care which seeks the patient's recovery or an accurate neurological prognostication, while finality focuses on withdrawal of life-sustaining therapy and commencement of comfort care, which may include ICOP for deceased donation.

Unethical Aspects of Open Access

In this article, we identify and discuss several ethically problematic aspects of open access scientific publishing. We conclude that, despite some positive effects, paid open access has at least three unethical aspects: it discriminates against researchers, creates an editorial conflict of interest, and diverts funding from the actual conduct of research. To be truly open access, all researchers must be able to access its benefits.

Positive HIV Test Results from Deceased Organ Donors: Should We Disclose to Next of Kin?

In the context of deceased organ donation, donors are routinely tested for HIV, to check for suitability for organ donation. This article examines whether a donor's HIV status should be disclosed to the donor's next of kin. On the one hand, confidentiality requires that sensitive information not be disclosed, and a duty to respect confidentiality may persist after death. On the other hand, breaching confidentiality may benefit third parties at risk of having been infected by the organ donor, as it may permit them to be tested for HIV and seek treatment in case of positive results. We conclude that the duty to warn third parties surpasses the duty to respect confidentiality. However, in order to minimize risks linked to the breach of confidentiality, information should be restrained to only concerned third parties, that is, those susceptible to having been infected by the donor.

Practical Considerations in Donation After Circulatory Determination of Death in Switzerland

Faced with similar issues of organ scarcity to its neighbors, Switzerland has developed donation after circulatory determination of death (DCDD) as a way to expand the organ pool since 1985. Here, we analyze the history, practical considerations, and ethical issues relating to the Swiss donation after circulatory death programs. In Switzerland, determination of death for DCDD requires a stand-off period of 10 minutes. This time between cardiac arrest and the declaration of death is mandated in the guidelines of the Swiss Academy of Medical Sciences. As in other DCDD programs, safeguards are put to avoid physicians denying lifesaving treatment to savable patients because of being influenced by receivers' interest. An additional recommendation could be made: Recipients should be transparently informed of the worse graft outcomes with DCDD programs and given the possibility to refuse such organs.

Small groups, open doors: Fostering individual and group creativity within research communities

While abundant publications attempt to analyze and understand what makes humans creative, much less attention is being paid to institutional conditions which may enhance or impede creative work. On the basis of evidence from Cambridge and AT&T's Bell Laboratories, and as a condensation of the Janelia Experiment, an institutional focus on "small groups" and "open doors" may foster individual and group creativity. The evidence suggests that small organizational units of up to seven scientists and open door concepts could nurture interactions within and between groups and enhance the critical mass for individual and group creativity.

T-cells and their cytokine production: The anti-inflammatory and immunosuppressive effects of strenuous exercise

Strenuous exercise bouts and heavy training are associated with a heightened anti-inflammatory state and a transient suppression of several immune components. In turn, many athletes are susceptible to illness, particularly upper respiratory symptoms (e.g. cough, sore throat, running nose). T-lymphocytes (T-cells) are important for orchestrating the immune response and can be categorised into subsets according to their phenotypical characteristics resulting from polarisation (i.e. type-1, type-2 and regulatory T-cells). Each T-cell subset has a unique functional role, including their capacity to produce pro- and anti-inflammatory cytokines in response to an immune challenge. Prolonged and exhaustive exercise typically reduces peripheral blood type-1 T-cell number and their capacity to produce the pro-inflammatory cytokine, interferon-γ. Moreover, heavy training loads are associated with elevated numbers of resting peripheral blood type-2 and regulatory T-cells, which characteristically produce the anti-inflammatory cytokines, interleukin-4 and interleukin-10, respectively. This appears to increase the risk of upper respiratory symptoms, potentially due to the cross-regulatory effect of interleukin-4 on interferon-γ production and immunosuppressive action of IL-10. Catecholamines significantly influence the number of peripheral blood T-cells in response to exercise. Whereas, glucocorticoids and prostaglandin E2 promote the production of anti-inflammatory cytokines by T-cells. In summary, strenuous exercise bouts and heavy training shifts T-cell immunity towards an anti-inflammatory state. This impairs the ability of the immune system to mount an inflammatory response to an immune challenge, which may weaken defences against intracellular pathogens (e.g. viruses), and increase the risk of infection and viral reactivation.

A means of improving public health in low- and middle-income countries? Benefits and challenges of international public-private partnerships

OBJECTIVE

In the last two decades international public-private partnerships have become increasingly important to improving public health in low- and middle-income countries. Governments realize that involving the private sector in projects for financing, innovation, development, and distribution can make a valuable contribution to overcoming major health challenges. Private-public partnerships for health can generate numerous benefits but may also raise some concerns. To guide best practice for public-private partnerships for health to maximize benefits and minimize risks, the first step is to identify potential benefits, challenges, and motives. We define motives as the reasons why private partners enter partnerships with a public partner.

STUDY DESIGN

We conducted a systematic review of the literature using the PRISMA guidelines.

METHOD

We reviewed the literature on the benefits and challenges of public-private partnerships for health in low- and middle-income countries provided by international pharmaceutical companies and other health-related companies. We provide a description of these benefits, challenges, as well as of motives of private partners to join partnerships. An approach of systematic categorization was used to conduct this research.

RESULT

We identified six potential benefits, seven challenges, and three motives. Our main finding was a significant gap in the available academic literature on this subject. Further empirical research using both qualitative and quantitative approaches is required. From the limited information that is readily available, we conclude that public-private partnerships for health imply several benefits but with some noticeable and crucial limitations.

CONCLUSION

In this article, we provide a description of these benefits and challenges, discuss key themes, and conclude that empirical research is required to determine the full extent of the challenges addressed in the literature.

The Consequences of Vagueness in Consent to Organ Donation

In this article I argue that vagueness concerning consent to post-mortem organ donation causes considerable harm in several ways. First, the information provided to most people registering as organ donors is very vague in terms of what is actually involved in donation. Second, the vagueness regarding consent to donation increases the distress of families of patients who are potential organ donors, both during and following the discussion about donation. Third, vagueness also increases the chances that the patient's intention to donate will not be fulfilled due to the family's distress. Fourth, the consequent reduction in the number of donated organs leads to avoidable deaths and increased suffering among potential recipients, and distresses them and their families. There are three strategies which could be used to reduce the harmful effects of this vagueness. First, recategorizing the reasons (commonly referred to as 'overrules' under the current system) given by families who refuse donation from registered donors would bring greater clarity to donation discussions. Second, people who wish to donate their organs should be encouraged to discuss their wishes in detail with their families, and to consider recording their wishes in other ways. Finally, the consent system for organ donation could be made more detailed, ensuring both that more information is provided to potential donors and that they have more flexibility in how their intentions are indicated; this last strategy, however, could have the disadvantage of discouraging some potential donors from registering.

Reasons why nurses decline influenza vaccination: a qualitative study

Background

To explore reasons of non-vaccinated nursing staff for declining seasonal influenza vaccination. The annual influenza vaccination of healthcare workers reduces morbidity and mortality among vulnerable patients. Still, vaccination rates remain very low, particularly in nursing staff. While several studies have explored barriers for healthcare workers to get vaccinated, most have used a quantitative approach.

Methods

Data were collected by in-depth individual semi-structured interviews with 18 nurses from a range of fields, positions in organizational hierarchy, work experience and hospitals in two German-speaking cantons in Switzerland. Interviews were transcribed and analysed using conventional content analysis.

Results

Three interconnected themes explaining why nurses decline influenza vaccination were identified: Firstly, the idea of maintaining a strong and healthy body, which was a central motif for rejecting the vaccine. Secondly, the wish to maintain decisional autonomy - especially over one's body and health. Thirdly, nurses' perception of being surrounded by an untrustworthy environment, which restricts their autonomy and seemingly is in opposition to their goal of maintaining a strong and healthy body.

Conclusion

Nurses tend to rely on conventional health beliefs rather than evidence based medicine when making their decision to decline influenza vaccination. Interventions to increase influenza vaccination should be tailored specifically for nurses. Empowering nurses by promoting decision-making skills and by strengthening their appraisal may be important factors to consider when planning future interventions to improve vaccination rates. The teaching of evidence-based decision-making should be integrated on different levels, including nurses' training curricula, their workspace and further education.

Ford and Edison in a modern regulatory environment: the first-in-human trial of night-work and artificial light

A thought experiment places Henry Ford and Thomas Alva Edison in a modern regulatory environment. In a utopian occupational world devoid of night-shifts or artificial light, Ford wants to experiment with "working through the night". To support Ford's project, Edison offers his patented electric lamps to "turn nights into days". An ethics committee [EC] does not approve the night-work experiment and Utopia's Food and Drug Administration [FDA] does not approve the potential medical device as safe for use by humans. According to the EC and FDA, complex effects on circadian biology and thus safety of work and light at night are not understood. The thought experiment conveys that we should pay more attention to possible risks of work and light at chronobiologically unusual times.

Stakeholder views on participant selection for first-in-human trials in cancer nanomedicine

BACKGROUND

Participant selection for first-in-human (fih) trials involves complex decisions. The trial design makes it unlikely that participants will receive clinically relevant therapeutic benefit, but they are likely to experience risks of various magnitudes and types. The aim of the present paper was to describe and discuss the views of investigators and ethics committee members about the choice of trial participants for fih trials in cancer nanomedicine.

METHODS

We drew insights from an exploratory qualitative study involving thematic analysis of 46 in-depth interviews with key stakeholders in Europe and North America involved in fih nanomedicine trials. The present work draws on subset of 21 interviews with investigators and ethics committee members who have either conducted or reviewed a fih cancer nanomedicine trial or are planning one.

RESULTS

Investigators and ethics committee members are aware of the ethics standards for recruiting patients with end-stage cancer into fih trials, but they nonetheless question the practice and provide reasons against it.

CONCLUSIONS

Although it is a standard and ethically accepted practice to enrol patients with end-stage cancer and no treatment options into fih trials of investigational chemotherapeutic molecules, doing so can threaten the validity and generalizability of the trials, thereby weakening translational research. Another possibility is to stratify and include patients with less advanced disease who demonstrate certain biomarkers or cancer genotypes and who have a disease profile similar to that tested in preclinical studies. The latter approach could be a step toward personalized medical research and targeted drug development. Such a patient selection approach requires multi-stakeholder discussion to reach scientific and ethics consensus.

Effectiveness and Duration of Effect of Open-Label Lisdexamfetamine Dimesylate in Adults With ADHD

OBJECTIVES

(a) Evaluate the efficacy and duration of effect of lisdexamfetamine dimesylate (LDX) in adult ADHD. (b) Assess the reliability and validity of the Adult ADHD Medication Smoothness of Effect Scale (AMSES) and Adult ADHD Medication Rebound Scale (AMRS).

METHOD

Adults ( N = 40) with ADHD were treated with LDX for up to 12 weeks. The primary efficacy measure was the ADHD Rating Scale (ADHD-RS). The psychometric properties of the AMSES and AMRS are analyzed and compared with the ADHD-RS, ADHD Self-Report Scale (ASRS) v1.1 Symptom Checklist, and Time-Sensitive ADHD Symptom Scale (TASS).

RESULTS

ADHD-RS scores were significantly improved with LDX. The AMSES and AMRS had high internal consistency and were correlated with the ADHD-RS, ASRS v1.1 Symptom Checklist, and TASS.

CONCLUSION

LDX is effective in treating adult ADHD and has a smooth drug effect throughout the day with limited symptom rebound. The AMSES and AMRS are valid and reliable measures.

Defining Nano, Nanotechnology and Nanomedicine: Why Should It Matter?

Nanotechnology, which involves manipulation of matter on a 'nano' scale, is considered to be a key enabling technology. Medical applications of nanotechnology (commonly known as nanomedicine) are expected to significantly improve disease diagnostic and therapeutic modalities and subsequently reduce health care costs. However, there is no consensus on the definition of nanotechnology or nanomedicine, and this stems from the underlying debate on defining 'nano'. This paper aims to present the diversity in the definition of nanomedicine and its impact on the translation of basic science research in nanotechnology into clinical applications. We present the insights obtained from exploratory qualitative interviews with 46 stakeholders involved in translational nanomedicine from Europe and North America. The definition of nanomedicine has implications for many aspects of translational research including: fund allocation, patents, drug regulatory review processes and approvals, ethical review processes, clinical trials and public acceptance. Given the interdisciplinary nature of the field and common interest in developing effective clinical applications, it is important to have honest and transparent communication about nanomedicine, its benefits and potential harm. A clear and consistent definition of nanomedicine would significantly facilitate trust among various stakeholders including the general public while minimizing the risk of miscommunication and undue fear of nanotechnology and nanomedicine.