Untangling the relationship between diet and visceral fat mass through blood metabolomics and gut microbiome profiling.

BACKGROUND/OBJECTIVES: Higher visceral fat mass (VFM) is associated with an increased risk for developing cardio-metabolic diseases. The mechanisms by which an unhealthy diet pattern may influence visceral fat (VF) development has yet to be examined through cutting-edge multi-omic methods. Therefore, our objective was to examine the dietary influences on VFM and identify gut microbiome and metabolite profiles that link food intakes to VFM. SUBJECTS/METHODS: In 2218 twins with VFM, food intake and metabolomics data available we identified food intakes most strongly associated with VFM in 50% of the sample, then constructed and tested the 'VFM diet score' in the remainder of the sample. Using linear regression (adjusted for covariates, including body mass index and total fat mass), we investigated associations between the VFM diet score, the blood metabolomics profile and the fecal microbiome (n=889), and confirmed these associations with VFM. We replicated top findings in monozygotic (MZ) twins discordant (⩾1 s.d. apart) for VFM, matched for age, sex and the baseline genetic sequence. RESULTS: Four metabolites were associated with the VFM diet score and VFM: hippurate, alpha-hydroxyisovalerate, bilirubin (Z,Z) and butyrylcarnitine. We replicated associations between VFM and the diet score (beta (s.e.): 0.281 (0.091); P=0.002), butyrylcarnitine (0.199 (0.087); P=0.023) and hippurate (-0.297 (0.095); P=0.002) in VFM-discordant MZ twins. We identified a single species, Eubacterium dolichum to be associated with the VFM diet score (0.042 (0.011), P=8.47 × 10-5), VFM (0.057 (0.019), P=2.73 × 10-3) and hippurate (-0.075 (0.032), P=0.021). Moreover, higher blood hippurate was associated with elevated adipose tissue expression neuroglobin, with roles in cellular oxygen homeostasis (0.016 (0.004), P=9.82x10-6). CONCLUSIONS: We linked a dietary VFM score and VFM to E. dolichum and four metabolites in the blood. In particular, the relationship between hippurate, a metabolite derived from microbial metabolism of dietary polyphenols, and reduced VFM, the microbiome and increased adipose tissue expression of neuroglobin provides potential mechanistic insight into the influence of diet on VFM.

Non-invasive evaluation of placental blood flow: lessons from animal models.

In human obstetrics, placental vascularisation impairment is frequent as well as linked to severe pathological events (preeclampsia and intrauterine growth restriction), and there is a need for reliable methods allowing non-invasive evaluation of placental blood flow. Uteroplacental vascularisation is complex, and animal models are essential for the technical development and safety assessment of these imaging tools for human clinical use; however, these techniques can also be applied in the veterinary context. This paper reviews how ultrasound-based imaging methods such as 2D and 3D Doppler can provide valuable insight for the exploration of placental blood flow both in humans and animals and how new approaches such as the use of ultrasound contrast agents or ultrafast Doppler may allow to discriminate between maternal (non-pulsatile) and foetal (pulsatile) blood flow in the placenta. Finally, functional magnetic resonance imaging could also be used to evaluate placental blood flow, as indicated by studies in animal models, but its safety in human pregnancy still requires to be confirmed.

Inspiratory muscle training during pulmonary rehabilitation in chronic obstructive pulmonary disease: A randomized trial.

Although recommended by international guidelines, the benefit of inspiratory muscle training (IMT) in addition to rehabilitation remains uncertain. The objective was to demonstrate the effectiveness of IMT on dyspnea using Borg scale and multidimensional dyspnea profile questionnaire at the end of a 6-minute walk test (6MWT) in patients with chronic obstructive pulmonary disease (COPD) with preserved average maximum inspiratory pressure (PImax) of 85 cm H2O (95% of predicted (pred.) value) and admitted for a rehabilitation program in a dedicated center. In a randomized trial, comparing IMT versus no IMT in 32 COPD patients without inspiratory muscle weakness (PImax >60 cm H2O) who were admitted for pulmonary rehabilitation (PR) for 3 weeks, we evaluated the effect of IMT on dyspnea, using both Borg scale and multidimensional dyspnea profile (MDP) at the end of the 6MWT, and on functional parameters included inspiratory muscle function (PImax) and 6MWT. All testings were performed at the start and the end of PR. In unadjusted analysis, IMT was not found to be associated with an improvement of either dyspnea or PImax. After adjustment on confounders (initial Borg score) and variables of interaction (forced expiratory volume in 1 second (FEV1)), we found a trend toward an improvement of "dyspnea sensory intensity", items from MDP and a significant improvement on the variation in the 2 items of MDP ("tight or constricted" and "breathing a lot"). In the subgroup of patients with FEV1 < 50% pred., 5 items of MDP were significantly improved, whereas no benefit was observed in patients with FEV1 > 50% pred. IMT did not significantly improve dyspnea or functional parameter in COPD patients with PImax > 60 cm H2O. However, in the subgroup of patients with FEV1 < 50% pred., MDP was significantly improved.

Coestimation of recombination, substitution and molecular adaptation rates by approximate Bayesian computation.

The estimation of parameters in molecular evolution may be biased when some processes are not considered. For example, the estimation of selection at the molecular level using codon-substitution models can have an upward bias when recombination is ignored. Here we address the joint estimation of recombination, molecular adaptation and substitution rates from coding sequences using approximate Bayesian computation (ABC). We describe the implementation of a regression-based strategy for choosing subsets of summary statistics for coding data, and show that this approach can accurately infer recombination allowing for intracodon recombination breakpoints, molecular adaptation and codon substitution rates. We demonstrate that our ABC approach can outperform other analytical methods under a variety of evolutionary scenarios. We also show that although the choice of the codon-substitution model is important, our inferences are robust to a moderate degree of model misspecification. In addition, we demonstrate that our approach can accurately choose the evolutionary model that best fits the data, providing an alternative for when the use of full-likelihood methods is impracticable. Finally, we applied our ABC method to co-estimate recombination, substitution and molecular adaptation rates from 24 published human immunodeficiency virus 1 coding data sets.

Evaluation of utero-placental vascularization using contrast-enhanced ultrasound: Early first trimester maternal perfusion of the intervillous space is confirmed.

INTRODUCTION: The objective was to confirm and semiquantify the maternal perfusion of the intervillous space between 8 and 13 + 6 gestational weeks (GW). METHODS: We conducted a prospective, multicenter, and nonrandomized open study. Women undergoing voluntary termination of pregnancy at three different gestational ages (Group 8 GW: 8 to 8 + 6 GW, Group 11GW: 11 to 11 + 6 GW and Group 13GW: 13 to 13 + 6 GW) were included, with 14 subjects per group. Women presenting with a personal risk of preeclampsia and/or intrauterine growth restriction were excluded. Contrast-enhanced ultrasound (CEUS) was performed with an intravenous bolus administration of 2.4 mL of microbubbles. The region of interest (ROI) was the entire placenta. The perfusion curves and kinetic parameters, including wash-in perfusion index, peak enhancement and mean transit time, were calculated. RESULTS: Of the 42 women initially included, interpretable perfusion curves could be obtained for 33. Regardless of the gestational age, contrast was observed in the entire placenta. No significant difference in perfusion parameters was observed between groups. There was an association between signal intensity and both maternal heart frequency and placental location. Signal intensity was decreased when the heart frequency increased (p < 0.05) and when the placenta was in a nonanterior position (p > 0.005). DISCUSSION: We confirmed the presence of maternal perfusion of the intervillous space as early as 8 GW. No significant increase in perfusion parameters was observed between 8 and 13 + 6 GW. Our observations, in accordance with the previous experiment published by Roberts et al.1, strongly challenge the classic trophoblastic plug theory.

Coprophagia in early life tunes expression of immune genes after weaning in rabbit ileum.

Coprophagia by suckling rabbits, i.e. ingestion of feces from their mother, reduces mortality after weaning. We hypothesized that this beneficial effect of coprophagia is immune-mediated at the intestinal level. Therefore, this study investigated immune development after weaning by analyzing the ileal transcriptome at day 35 and 49 in rabbits with differential access to coprophagia in early life. Rabbit pups had access between day 1 and 15 to (i) no feces (NF) or (ii) feces from unrelated does (Foreign Feces, FF) or (iii) feces from unrelated does treated with antibiotics (FFab). 350 genes were differentially expressed between day 35 and day 49 in suckling rabbits with access to coprophagia. These genes coded for antimicrobial peptides, a mucin, cytokines and chemokines, pattern recognition receptors, proteins involved in immunoglobulin A secretion and in interferon signaling pathway. Strikingly, prevention of coprophagia or access to feces from antibiotic-treated does in early life blunted immune development between day 35 et 49 in the ileum of rabbits. Thus, coprophagia might be crucial for the maturation of intestinal immunity in rabbits and could explain why this behavior improves survival.

Approximate Bayesian computation for modular inference problems with many parameters: the example of migration rates.

We propose a two-step procedure for estimating multiple migration rates in an approximate Bayesian computation (ABC) framework, accounting for global nuisance parameters. The approach is not limited to migration, but generally of interest for inference problems with multiple parameters and a modular structure (e.g. independent sets of demes or loci). We condition on a known, but complex demographic model of a spatially subdivided population, motivated by the reintroduction of Alpine ibex (Capra ibex) into Switzerland. In the first step, the global parameters ancestral mutation rate and male mating skew have been estimated for the whole population in Aeschbacher et al. (Genetics 2012; 192: 1027). In the second step, we estimate in this study the migration rates independently for clusters of demes putatively connected by migration. For large clusters (many migration rates), ABC faces the problem of too many summary statistics. We therefore assess by simulation if estimation per pair of demes is a valid alternative. We find that the trade-off between reduced dimensionality for the pairwise estimation on the one hand and lower accuracy due to the assumption of pairwise independence on the other depends on the number of migration rates to be inferred: the accuracy of the pairwise approach increases with the number of parameters, relative to the joint estimation approach. To distinguish between low and zero migration, we perform ABC-type model comparison between a model with migration and one without. Applying the approach to microsatellite data from Alpine ibex, we find no evidence for substantial gene flow via migration, except for one pair of demes in one direction.

[The role of the physiotherapist in the assessment and management of dyspnea]. / Le rôle du kinésithérapeute dans l'évaluation et la gestion de la dyspnée.

The role of the physiotherapist in the assessment and management of dyspnea. Dyspnea is the most common symptom in cardio-respiratory diseases. Recently improved comprehension of dyspnea mechanisms have underlined the need for three-faceted assessment. The three key aspects correspond to the "breathing, thinking, functioning" clinical model, which proposes a multidimensional - respiratory, emotional and functional - approach. Before initiating treatment, it is essential for several reasons to assess each specific case, determining the type of dyspnea affecting the patient, appraising the impact of shortness of breath, and estimating the effectiveness of the treatment applied. The physiotherapist has a major role to assume in the care of dyspneic patients, not only in assessment followed by treatment but also as a major collaborator in a multidisciplinary team, especially with regard to pulmonary rehabilitation. The aim of this review is to inventory the existing assessment tools and the possible physiotherapies for dyspnea, using a holistic approach designed to facilitate the choice of techniques and to improve quality of care by fully addressing the patient's needs.

Population divergence with or without admixture: selecting models using an ABC approach.

Genetic data have been widely used to reconstruct the demographic history of populations, including the estimation of migration rates, divergence times and relative admixture contribution from different populations. Recently, increasing interest has been given to the ability of genetic data to distinguish alternative models. One of the issues that has plagued this kind of inference is that ancestral shared polymorphism is often difficult to separate from admixture or gene flow. Here, we applied an approximate Bayesian computation (ABC) approach to select the model that best fits microsatellite data among alternative splitting and admixture models. We performed a simulation study and showed that with reasonably large data sets (20 loci) it is possible to identify with a high level of accuracy the model that generated the data. This suggests that it is possible to distinguish genetic patterns due to past admixture events from those due to shared polymorphism (population split without admixture). We then apply this approach to microsatellite data from an endangered and endemic Iberian freshwater fish species, in which a clustering analysis suggested that one of the populations could be admixed. In contrast, our results suggest that the observed genetic patterns are better explained by a population split model without admixture.

Challenges and pitfalls in the characterization of anonymous outlier AFLP markers in non-model species: lessons from an ocellated lizard genome scan.

In the last few years, dozens of studies have documented the detection of loci influenced by selection from genome scans in a wide range of non-model species. Many of those studies used amplified fragment length polymorphism (AFLP) markers, which became popular for being easily applicable to any organism. However, because they are anonymous markers, AFLPs impose many challenges for their isolation and identification. Most recent AFLP genome scans used capillary electrophoresis (CE), which adds even more obstacles to the isolation of bands with a specific size for sequencing. These caveats might explain the extremely low number of studies that moved from the detection of outlier AFLP markers to their actual isolation and characterization. We document our efforts to characterize a set of outlier AFLP markers from a previous genome scan with CE in ocellated lizards (Lacerta lepida). Seven outliers were successfully isolated, cloned and sequenced. Their sequences are noncoding and show internal indels or polymorphic repetitive elements (microsatellites). Three outliers were converted into codominant markers by using specific internal primers to sequence and screen population variability from undigested DNA. Amplification in closely related lizard species was also achieved, revealing remarkable interspecific conservation in outlier loci sequences. We stress the importance of following up AFLP genome scans to validate selection signatures of outlier loci, but also report the main challenges and pitfalls that may be faced during the process.

New insights into human functional ultrasound imaging.

Ultrasound imaging is a vital tool for exploring in vivo the placental function which is essential to understand pathological phenomena such as preeclampsia or intrauterine growth restriction. As technology advances including ready availability of three-dimensional (3D) probes and novel software, new markers of placental function become possible. The objective of this review was to provide an overview of the new ultrasound markers of placental function with a focus on the potential clinical application of three-dimensional power Doppler (3DPD). A broad-free text literature search was undertaken based on human placental studies and sixty full-text studies were included in this review. Three-dimensional power Doppler is a promising technique to predict preeclampsia in the first trimester. However, the influence of external factors such as body mass index, parameter standardisation and machine settings still need to be addressed. Contrast-enhanced ultrasound is currently reserved for research, because the required injected contrast mediums are not currently approved for use in pregnancy, although the safety data is reassuring.

Assessment of placental perfusion using contrast-enhanced ultrasound: A longitudinal study in pregnant rabbit.

OBJECTIVES: The main aim of the study was to quantitatively characterize placental perfusion using contrast-enhanced ultrasound in a longitudinal study performed in pregnant rabbits. As a secondary objective, we qualitatively assessed the placental perfusion. METHODS: Three pregnant rabbits were used. Contrast-enhanced ultrasound was performed twice for each dam, either on embryo development (ED) day 14, 21 or 28 of pregnancy, under general anesthesia. Both qualitative and quantitative analyses were performed based on ultrasound assessment. RESULTS: Altogether, data from 29 fetuses were analyzed: 10 at ED-14; 12 at ED-21, and 7 at ED-28. Placental vascularization was mainly peripheral at the earliest gestational age and became gradually homogeneous within the whole placenta as pregnancy progressed. Intensity parameters and relative blood flows significantly increased with gestational age. The wash-in and wash-out rates were correlated and a significant increase in wash-in compared to in wash-out rates was observed with increased gestational age. CONCLUSION: Contrast-enhanced ultrasound is feasible in animal models and allows qualitative and quantitative analysis of placental vascularization during pregnancy.

Association of Mc1r variants with ecologically relevant phenotypes in the European ocellated lizard, Lacerta lepida.

A comprehensive knowledge on the genetic basis of coloration is crucial to understand how new colour phenotypes arise and how they contribute to the emergence of new species. Variation in melanocortin-1 receptor (Mc1r), a gene that has been reported as a target for repeated evolution in a wide range of vertebrate taxa, was assessed in European ocellated lizards (Lacerta lepida) to search for associations with melanin-based colour phenotypes. Lacerta lepida subspecies' distribution is associated with the three major bio-climatic regions in the Iberian Peninsula. A nonconserved and derived substitution (T162I) was associated with the L. l. nevadensis phenotype (prevalence of brown scales). Another substitution (S172C) was associated with the presence of black scales in both L. l. lepida and L. l. iberica, but no mutations were found to be associated with the higher proportion of black in L. l. iberica. Extensive genotyping of Mc1r along the contact zone between L. l. nevadensis and L. l. lepida revealed low gene flow (only two hybrids detected). The implications of these findings are discussed in the context of previous knowledge about the evolutionary history of ocellated lizards.

Adaptive divergence and speciation among sexual and pseudoviviparous populations of Festuca.

Pseudovivipary is an environmentally induced flowering abnormality in which vegetative shoots replace seminiferous (sexual) inflorescences. Pseudovivipary is usually retained in transplantation experiments, indicating that the trait is not solely induced by the growing environment. Pseudovivipary is the defining characteristic of Festuca vivipara, and arguably the only feature separating this species from its closest seminiferous relative, Festuca ovina. We performed phylogenetic and population genetic analysis on sympatric F. ovina and F. vivipara samples to establish whether pseudovivipary is an adaptive trait that accurately defines the separation of genetically distinct Festuca species. Chloroplast and nuclear marker-based analyses revealed that variation at a geographical level can exceed that between F. vivipara and F. ovina. We deduced that F. vivipara is a recent species that frequently arises independently within F. ovina populations and has not accumulated significant genetic differentiation from its progenitor. We inferred local gene flow between the species. We identified one amplified fragment length polymorphism marker that may be linked to a pseudovivipary-related region of the genome, and several other markers provide evidence of regional local adaptation in Festuca populations. We conclude that F. vivipara can only be appropriately recognized as a morphologically and ecologically distinct species; it lacks genetic differentiation from its relatives. This is the first report of a 'failure in normal flowering development' that repeatedly appears to be adaptive, such that the trait responsible for species recognition constantly reappears on a local basis.

[Inspiratory muscle training during pulmonary rehabilitation]. / L'entraînement des muscles inspiratoires en réhabilitation respiratoire.

INTRODUCTION: Inspiratory muscle training (IMT) is part of the management of patients with pulmonary diseases during rehabilitation. Since the last recommendations of the Société de pneumologie de langue française, several studies have focused on the role of inspiratory muscle training during pulmonary rehabilitation. BACKGROUND: IMT, in comparison to standard care or sham-IMT, improves the strength and endurance of the inspiratory muscles, decreases dyspnoea during the activities of daily living, improves walking distance and quality of life. However, the different studies did not show an additional effect of IMT during a pulmonary rehabilitation program compared to a rehabilitation program without IMT, with regard to improvement of exercise capacity and quality of life. OUTLOOK: One study showed an improvement in dyspnoea of effort, but these results are yet to be confirmed. Finally, it seems appropriate to associate IMT with an exercise-training program before chest or abdominal surgery, even if further studies are necessary. CONCLUSION: During a pulmonary rehabilitation program, IMT does not provide additional benefits. However, when patients cannot perform a global exercise training, IMT has shown benefit. IMT provides additional benefits in pre-operative programs.

Comparison of the cardio-respiratory response of a training session on cycloergometer or treadmill versus an Adapted Physical Activity session on Nintendo Wii, in patients with chronic respiratory disease.

OBJECTIVES: During a pulmonary rehabilitation program (PRP), patients frequently report that the classically proposed activities (as cycloergometer or treadmill) are not playful. The goal of adapted physical activities is to maintain physical activity that is more playful for patients. The Nintendo Wii Gaming Console allows a playful physical activity. However, it seems important to know if this tool allows physical activity with an effective cardiorespiratory effect. The objective was to compare the cardiorespiratory response of a 30-minute training session on cycloergometer (C) and treadmill (T) versus a 30-minute training session with Wii. METHODS: Patients admitted to the PR unit of Brest University Hospital (France) were eligible for this randomized study if they had a chronic pulmonary disease. The endpoints were heart rate (HR), pulse oxymetry, dyspnea, lower limb penibility and pleasure felt. RESULTS: Twenty patients were prospectively included. HR was significantly higher at the end of the Wii session in comparison with C session (P=0.001); there was no significant difference in HR between Wii and T. We found no significant difference for dyspnea and lower limb penibility between Wii and C (respectively P=0.8 and P=0.7) and between Wii and T (respectively P=0.96 and P=0.5). The pleasure felt was significantly greater during Wii compared to C and T (respectively P=0.001 and P=0.001). CONCLUSIONS: Exercise training using Wii with identifiable games require higher HR at the end of the session compared to C and a similar cardiorespiratory response compared to T with the same dyspnea and lower limb exertion and with a pleasure felt significantly higher. Wii can be used for exercise training during PRP.

Possible observation of the signature of the bad metal phase and its crossover to a Fermi liquid in κ-(BEDT-TTF)2Cu(NCS)2 bulk and nanoparticles by Raman scattering.

κ-(BEDT-TTF)2Cu(NCS)2 has been investigated by Raman scattering in both bulk and nanoparticle compounds. Phonon modes from 20 to 1600 cm-1 have been assigned. Focusing on the unexplored low frequency phonons, a plateau in frequencies is observed in the bulk phonons between 50 and 100 K and assigned to the signature of the bad metal phase. Nanoparticles of κ-(BEDT-TTF)2Cu(NCS)2 exhibit anomalies at 50 K associated to the crossover from a bad metal to a Fermi liquid whose origins are discussed.

Design and evaluation of an abbreviated pixelwise dynamic contrast enhancement analysis protocol for early extracellular volume fraction estimation.

INTRODUCTION: T1-based method is considered as the gold standard for extracellular volume fraction (ECV) mapping. This technique requires at least a 10 min delay after injection to acquire the post injection T1 map. Quantitative analysis of Dynamic Contrast Enhancement (DCE) images could lead to an earlier estimation of an ECV like parameter (2 min). The purpose of this study was to design a quantitative pixel-wise DCE analysis workflow to assess the feasibility of an early estimation of ECV. METHODS: Fourteen patients with mitral valve prolapse were included in this study. The MR protocol, performed on a 3 T MR scanner, included MOLLI sequences for T1 maps acquisition and a standard SR-turboFlash sequence for dynamic acquisition. DCE data were acquired for at least 120 s. We implemented a full DCE analysis pipeline with a pre-processing step using an innovative motion correction algorithm (RC-REG algorithm) and a post-processing step using the extended Tofts Model (ECVETM). Estimated ECVETM maps were compared to standard T1-based ECV maps (ECVT1) with both a Pearson correlation analysis and a group-wise analysis. RESULTS: Image and map quality assessment showed systematic improvements using the proposed workflow. Strong correlation was found between ECVETM, and ECVT1 values (r-square = 0.87). CONCLUSION: A DCE analysis workflow based on RC-REG algorithm and ETM analysis can provide good quality parametric maps. Therefore, it is possible to extract ECV values from a 2 min-long DCE acquisition that are strongly correlated with ECV values from the T1 based method.

Inferring introduction routes of invasive species using approximate Bayesian computation on microsatellite data.

Determining the routes of introduction provides not only information about the history of an invasion process, but also information about the origin and construction of the genetic composition of the invading population. It remains difficult, however, to infer introduction routes from molecular data because of a lack of appropriate methods. We evaluate here the use of an approximate Bayesian computation (ABC) method for estimating the probabilities of introduction routes of invasive populations based on microsatellite data. We considered the crucial case of a single source population from which two invasive populations originated either serially from a single introduction event or from two independent introduction events. Using simulated datasets, we found that the method gave correct inferences and was robust to many erroneous beliefs. The method was also more efficient than traditional methods based on raw values of statistics such as assignment likelihood or pairwise F(ST). We illustrate some of the features of our ABC method, using real microsatellite datasets obtained for invasive populations of the western corn rootworm, Diabrotica virgifera virgifera. Most computations were performed with the DIYABC program (http://www1.montpellier.inra.fr/CBGP/diyabc/).

Contribution of the gut microbiota to the regulation of host metabolism and energy balance: a focus on the gut-liver axis.

This review presents mechanistic studies performed in vitro and in animal models, as well as data obtained in patients that contribute to a better understanding of the impact of nutrients interacting with the gut microbiota on metabolic and behavioural alterations linked to obesity. The gut microbiota composition and function are altered in several pathological conditions including obesity and related diseases i.e. non-alcoholic fatty liver diseases (NAFLD). The gut-liver axis is clearly influenced by alterations of the gut barrier that drives inflammation. In addition, recent papers propose that specific metabolites issued from the metabolic cooperation between the gut microbes and host enzymes, modulate inflammation and gene expression in the liver. This review illustrates how dietary intervention with prebiotics or probiotics influences host energy metabolism and inflammation. Indeed, intervention studies are currently underway in obese and NAFLD patients to unravel the relevance of the changes in gut microbiota composition in the management of metabolic and behavioural disorders by nutrients interacting with the gut microbiota. In conclusion, diet is among the main triggers of NAFLD and the gut microbiota is modified accordingly, underlining the importance of the concomitant study of the nutrients and microbial impact on liver health and metabolism, in order to propose innovative, clinically relevant, therapeutic approaches.