Aldosterone-independent regulation of K+ secretion in the distal nephron.

PURPOSE OF REVIEW: Maintenance of plasma K+ concentration within a narrow range is critical to all cellular functions. The kidneys are the central organ for K+ excretion, and robust renal excretory responses to dietary K+ loads are essential for survival. Recent advances in the field have challenged the view that aldosterone is at the center of K+ regulation. This review will examine recent findings and propose a new mechanism for regulating K+ secretion. RECENT FINDINGS: Local aldosterone-independent response systems in the distal nephron are increasingly recognized as key components of the rapid response to an acute K+ load, as well as playing an essential role in sustained responses to increased dietary K+. The master kinase mTOR, best known for its role in mediating the effects of growth factors and insulin on growth and cellular metabolism, is central to these aldosterone-independent responses. Recent studies have shown that mTOR, particularly in the context of the "type 2" complex (mTORC2), is regulated by K+ in a cell-autonomous fashion. SUMMARY: New concepts related to cell-autonomous K+ signaling and how it interfaces with aldosterone-dependent regulation are emerging. The underlying signaling pathways and effectors of regulated K+ secretion, as well as implications for the aldosterone paradox and disease pathogenesis are discussed.

Chip for dielectrophoretic microbial capture, separation and detection II: experimental study.

In our previous paper we have modelled a dielectrophoretic force (DEP) and cell particle behavior in a microfluidic channel (Weber MUet al2023 Chip for dielectrophoretic microbial capture, separation and detection I: theoretical basis of electrode designNanotechnologythis issue). Here we test and confirm the results of our modeling work by experimentally validating the theoretical design constraints of the ring electrode architecture. We have compared and tested the geometry and particle capture and separation performance of the two separate electrode designs (the ring and dot electrode structures) by investigating bacterial motion in response to the applied electric field. We have quantitatively evaluated the electroosmosis (EO) to positive DEP (PDEP) transition in both electrode designs and explained the differences in capture efficiency of the ring and dot electrode systems. The ring structure shows 99% efficiency of bacterial capture both for PDEP and for EO. Moreover, the ring structure shows an over 200 faster bacterial response to the electric field. We have also established that the ring electrode architecture, with appropriate structure periodicity and spacing, results in efficient capture and separation of microbial cells. We have identified several critical design constraints that are required to achieve high efficiency bacterial capture. We have established that the spacing between consecutive DEP traps smaller than the length of the depletion zone will ensure that the DEP force dominates bacterial motion over motility and Brownian motion.

Chip for dielectrophoretic microbial capture, separation and detection I: theoretical basis of electrode design.

We model the dielectrophoretic response ofE. colibacterial cells and red blood cells, upon exposure to an electric field. We model the separation, capture, and release mechanisms under flow conditions in a microfluidic channel and show under which conditions efficient separation of different cell types occurs. The modelling work is aimed to guide the separation electrode architecture and design for experimental validation of the model. The dielectrophoretic force is affected both by the geometry of the electrodes (the gradient of the electric field), the Re{CM(ω)} factor, and the permittivity of the medium ϵm. Our modelling makes testable predictions and shows that designing the electrode structure to ensure structure periodicity with spacing between consecutive traps smaller than the length of the depletion zone ensures efficient capture and separation. Such electrode system has higher capture and separation efficiency than systems with the established circular electrode architecture. The simulated, modelled microfluidic design allows for the separated bacteria, concentrated by dedicated dielectrophoretic regions, to be subsequently detected using label-free functionalized nanowire sensors. The experimental validation of the modelling work presented here and the validation of the theoretical design constraints of the chip electrode architecture is presented in the companion paper in the same issue (Weber MUet al2022 Chip for dielectrophoretic Microbial Capture, Separation and Detection II: Experimental Study).

Chemical Signatures of Seasonally Unique Anthropogenic Influences on Organic Aerosol Composition in the Central Amazon.

Urbanization and fires perturb the quantities and composition of fine organic aerosol in the central Amazon, with ramifications for radiative forcing and public health. These disturbances include not only direct emissions of particulates and secondary organic aerosol (SOA) precursors but also changes in the pathways through which biogenic precursors form SOA. The composition of ambient organic aerosol is complex and incompletely characterized, encompassing millions of potential structures relatively few of which have been synthesized and characterized. Through analysis of submicron aerosol samples from the Green Ocean Amazon (GoAmazon2014/5) field campaign by two-dimensional gas chromatography coupled with machine learning, ∼1300 unique compounds were traced and characterized over two seasons. Fires and urban emissions produced chemically and interseasonally distinct impacts on product signatures, with only ∼50% of compounds observed in both seasons. Seasonally unique populations point to the importance of aqueous processing in Amazonian aerosol aging, but further mechanistic insights are impeded by limited product identity knowledge. Less than 10% of compounds were identifiable at an isomer-specific level. Overall, the findings (i) provide compositional characterization of anthropogenic influence on submicron organic aerosol in the Amazon, (ii) identify key season-to-season differences in chemical signatures, and (iii) highlight high-priority knowledge gaps in current speciated knowledge.

Ultra-deep long-read sequencing detects IS-mediated gene duplications as a potential trigger to generate arrays of resistance genes and a mechanism to induce novel gene variants such as blaCTX-M-243.

BACKGROUND: Extended-spectrum ß-lactamases (ESBLs) are enzymes that can render their hosts resistant to various ß-lactam antibiotics. CTX-M-type enzymes are the most prevalent ESBLs and the main cause of resistance to third-generation cephalosporins in Enterobacteriaceae. The number of described CTX-M types is continuously rising, currently comprising over 240 variants. During routine screening we identified a novel blaCTX-M gene. OBJECTIVES: To characterize a novel blaCTX-M variant harboured by a multidrug-resistant Escherichia coli isolate of sequence type ST354. METHODS: Antibiotic susceptibilities were determined using broth microdilution. Genome and plasmid sequences were reconstructed using short- and long-read sequencing. The novel blaCTX-M locus was analysed using long-read and Sanger sequencing. Plasmid polymorphisms were determined in silico on a single plasmid molecule level. RESULTS: The novel blaCTX-M-243 allele was discovered alongside a nearly identical blaCTX-M-104-containing gene array on a 219 kbp IncHI2A plasmid. CTX-M-243 differed from CTX-M-104 by only one amino acid substitution (N109S). Ultra-deep (2300-fold coverage) long-read sequencing revealed dynamic scaling of the blaCTX-M genetic contexts from one to five copies. Further antibiotic resistance genes such as blaTEM-1 also exhibited sequence heterogeneity but were stable in copy number. CONCLUSIONS: We identified the novel ESBL gene blaCTX-M-243 and illustrate a dynamic system of varying blaCTX-M copy numbers. Our results highlight the constant emergence of new CTX-M family enzymes and demonstrate a potential evolutionary platform to generate novel ESBL variants and possibly other antibiotic resistance genes.

Electrocatalytic Hydrogenation of Biomass-Derived Organics: A Review.

Sustainable energy generation calls for a shift away from centralized, high-temperature, energy-intensive processes to decentralized, low-temperature conversions that can be powered by electricity produced from renewable sources. Electrocatalytic conversion of biomass-derived feedstocks would allow carbon recycling of distributed, energy-poor resources in the absence of sinks and sources of high-grade heat. Selective, efficient electrocatalysts that operate at low temperatures are needed for electrocatalytic hydrogenation (ECH) to upgrade the feedstocks. For effective generation of energy-dense chemicals and fuels, two design criteria must be met: (i) a high H:C ratio via ECH to allow for high-quality fuels and blends and (ii) a lower O:C ratio in the target molecules via electrochemical decarboxylation/deoxygenation to improve the stability of fuels and chemicals. The goal of this review is to determine whether the following questions have been sufficiently answered in the open literature, and if not, what additional information is required:(1)What organic functionalities are accessible for electrocatalytic hydrogenation under a set of reaction conditions? How do substitutions and functionalities impact the activity and selectivity of ECH?(2)What material properties cause an electrocatalyst to be active for ECH? Can general trends in ECH be formulated based on the type of electrocatalyst?(3)What are the impacts of reaction conditions (electrolyte concentration, pH, operating potential) and reactor types?

Aging of Volatile Organic Compounds in October 2017 Northern California Wildfire Plumes.

In the western United States, the number and severity of large wildfires have been growing for decades. Biomass burning (BB) is a major source of volatile organic compounds (VOCs) to the atmosphere both globally and regionally. Following emission, BB VOCs are oxidized while being transported downwind, producing ozone, secondary organic aerosols, and secondary hazardous VOCs. In this research, we measured VOCs using proton transfer reaction time-of-flight mass spectrometry (PTR-ToF-MS) in an urban area 55-65 km downwind of the October 2017 Northern California wildfires. Nonaromatic oxygenated compounds were the dominant component of BB VOCs measured. In the smoke plumes, the VOCs account for 70-75% of the total observed organic carbon, with the remainder being particulate matter (with a diameter of <2.5 µm, PM2.5). We show that the correlation of VOCs with furan (primary BB VOC) and maleic anhydride (secondary BB VOC) can indicate the origin of the VOCs. This was further confirmed by the diurnal variations of the VOCs and their concentration-weighted trajectories. Oxidation during transport consumed highly reactive compounds including benzenoids, furanoids, and terpenoids and produced more oxygenated VOCs. Furthermore, wildfire VOCs altered the ozone formation regime and raised the O3 levels in the San Francisco Bay Area.

Anthropogenic and Biogenic Contributions to the Organic Composition of Coastal Submicron Sea Spray Aerosol.

The organic composition of coastal sea spray aerosol is important for both atmospheric chemistry and public health but remains poorly characterized. Coastal waters contain an organic material derived from both anthropogenic processes, such as wastewater discharge, and biological processes, including biological blooms. Here, we probe the chemical composition of the organic fraction of sea spray aerosol over the course of the 2019 SeaSCAPE mesocosm experiment, in which a phytoplankton bloom was facilitated in natural coastal water from La Jolla, California. We apply untargeted two-dimensional gas chromatography to characterize submicron nascent sea spray aerosol samples, reporting ∼750 unique organic species traced over a 19 day phytoplankton bloom experiment. Categorization and quantitative compositional analysis reveal three major findings. First, anthropogenic species made up 30% of total submicron nascent sea spray aerosol organic mass under the pre-bloom condition. Second, biological activity drove large changes within the aerosolized carbon pool, decreasing the anthropogenic mass fraction by 89% and increasing the biogenic and biologically transformed fraction by a factor of 5.6. Third, biogenic marine organics are underrepresented in mass spectral databases in comparison to marine organic pollutants, with more than twice as much biogenic aerosol mass attributable to unlisted compounds.

Failure of Vitek2 to reliably detect vanB-mediated vancomycin resistance in Enterococcus faecium.

OBJECTIVES: The increasing prevalence of VRE necessitates their reliable detection, especially for low-level resistance mediated by vanB in Enterococcus faecium. In this prospective study we analysed if vanB-mediated vancomycin resistance can be reliably detected by Vitek2. METHODS: One thousand, three hundred and forty-four enterococcal isolates from routine clinical specimens were tested by Vitek2 (bioMérieux, Nürtingen, Germany). Additionally, a bacterial suspension (with a turbidity equivalent to that of a 0.5 McFarland standard) was inoculated on chromID VRE screening agar (bioMérieux) and incubated for 48 h. If vancomycin tested susceptible by Vitek2 but growth was detected on the screening agar, PCR for vanA/vanB was performed (GeneXpert vanA/B test, Cepheid, Frankfurt, Germany). For isolates that tested susceptible to vancomycin by Vitek2 but were vanA/B positive, MICs were determined before and after cultivation in broth with increasing concentrations of vancomycin. RESULTS: One hundred and fifty-six out of 491 E. faecium were VRE and were predominantly vanB positive (81.0%). Of these, Vitek2 did not identify 14 as VRE (sensitivity 91.0%). By broth microdilution 9/14 isolates demonstrated high MICs (≥32 mg/L) and 5/14 showed low vancomycin MICs, which did not increase despite vancomycin exposure. Three of the 14 isolates demonstrated growth on chromID VRE; after vancomycin exposure seven additional isolates were able to grow on chromID VRE. CONCLUSIONS: Vitek2 fails to detect vanB-mediated vancomycin resistance consistently, especially, but not limited to, low-level resistance. As this may lead to treatment failure and further dissemination of vanB VRE, additional methods (e.g. culture on VRE screening agar or PCR) are necessary to reliably identify vanB-positive enterococci in clinical routine.

Highly Resolved Composition during Diesel Evaporation with Modeled Ozone and Secondary Aerosol Formation: Insights into Pollutant Formation from Evaporative Intermediate Volatility Organic Compound Sources.

As stricter regulations continue to reduce vehicular emissions, other emission sources such as evaporative emissions from road building and volatile consumer products have become more important in overall pollutant forming emissions in many urban areas. Emission regulations have historically targeted volatile organic compounds (VOCs) to reduce ozone, but intermediate volatility organic compounds (IVOCs) also contribute to ozone formation and the formation of secondary organic aerosol (SOA) that often dominates fine particulate matter. Emission rates and pollutant formation from IVOCs are not well constrained in current inventories and models. This study uses diesel fuel as a representative IVOC mixture in evaporation tests performed in a wind tunnel under varying wind speeds and liquid diesel temperatures. Comprehensive composition measurements guided the development of a model to determine rates of evaporation and estimate pollutant production. Results show that reducing IVOC emissions can result in significant reductions in ozone formation, in addition to the expected reductions in SOA formation, and that IVOC emissions can continue over the course of a month. Ozone formation from IVOC emissions is equal to that from VOCs after 3 days of evaporation at 0.65 g-ozone/g-diesel released. SOA formation is dominated by IVOCs, reaching 0.2 g-SOA/g-diesel released after 30 days.

High-Resolution Exposure Assessment for Volatile Organic Compounds in Two California Residences.

Time spent in residences substantially contributes to human exposure to volatile organic compounds (VOCs). Such exposures have been difficult to study deeply, in part because VOC concentrations and indoor occupancy vary rapidly. Using a fast-response online mass spectrometer, we report time-resolved exposures from multi-season sampling of more than 200 VOCs in two California residences. Chemical-specific source apportionment revealed that time-averaged exposures for most VOCs were mainly attributable to continuous indoor emissions from buildings and their static contents. Also contributing to exposures were occupant-related activities, such as cooking, and outdoor-to-indoor transport. Health risk assessments are possible for a subset of observed VOCs. Acrolein, acetaldehyde, and acrylic acid concentrations were above chronic advisory health guidelines, whereas exposures for other assessable species were typically well below the guideline levels. Studied residences were built in the mid-20th century, indicating that VOC emissions even from older buildings and their contents can substantially contribute to occupant exposures.

Atmospheric Benzothiazoles in a Coastal Marine Environment.

Organic emissions from coastal waters play an important but poorly understood role in atmospheric chemistry in coastal regions. A mesocosm experiment focusing on facilitated biological blooms in coastal seawater, SeaSCAPE (Sea Spray Chemistry and Particle Evolution), was performed to study emission of volatile gases, primary sea spray aerosol, and formation of secondary marine aerosol as a function of ocean biological and chemical processes. Here, we report observations of aerosol-phase benzothiazoles in a marine atmospheric context with complementary measurements of dissolved-phase benzothiazoles. Though previously reported dissolved in polluted coastal waters, we report the first direct evidence of the transfer of these molecules from seawater into the atmosphere. We also report the first gas-phase observations of benzothiazole in the environment absent a direct industrial, urban, or rubber-based source. From the identities and temporal dynamics of the dissolved and aerosol species, we conclude that the presence of benzothiazoles in the coastal water (and thereby their emissions into the atmosphere) is primarily attributable to anthropogenic sources. Oxidation experiments to explore the atmospheric fate of gas-phase benzothiazole show that it produces secondary aerosol and gas-phase SO2, making it a potential contributor to secondary marine aerosol formation in coastal regions and a participant in atmospheric sulfur chemistry.

Thirty years of VRE in Germany - "expect the unexpected": The view from the National Reference Centre for Staphylococci and Enterococci.

Enterococci are commensals of the intestinal tract of many animals and humans. Of the various known and still unnamed new enterococcal species, only isolates of Enterococcus faecium and Enterococcus faecalis have received increased medical and public health attention. According to textbook knowledge, the majority of infections are caused by E. faecalis. In recent decades, the number of enterococcal infections has increased, with the increase being exclusively associated with a rising number of nosocomial E. faecium infections. This increase has been accompanied by the dissemination of certain hospital-acquired strain variants and an alarming progress in the development of antibiotic resistance namely vancomycin resistance. With this review we focus on a description of the specific situation of vancomycin resistance among clinical E. faecium isolates in Germany over the past 30 years. The present review describes three VRE episodes in Germany, each of which is framed by the beginning and end of the respective decade. The first episode is specified by the first appearance of VRE in 1990 and a country-wide spread of specific vanA-type VRE strains (ST117/CT24) until the late 1990s. The second decade was initially marked by regional clusters and VRE outbreaks in hospitals in South-Western Germany in 2004 and 2005, mainly caused by vanA-type VRE of ST203. Against the background of a certain "basic level" of VRE prevalence throughout Germany, an early shift from the vanA genotype to the vanB genotype in clinical isolates already occurred at the end of the 2000s without much notice. With the beginning of the third decade in 2010, VRE rates in Germany have permanently increased, first in some federal states and soon after country-wide. Besides an increase in VRE prevalence, this decade was marked by a sharp increase in vanB-type resistance and a dominance of a few, novel strain variants like ST192 and later on ST117 (CT71, CT469) and ST80 (CT1065). The largest VRE outbreak, which involved about 2,900 patients and lasted over three years, was caused by a novel and until that time, unknown strain type of ST80/CT1013 (vanB). Across all periods, VRE outbreaks were mainly oligoclonal and strain types varied over space (hospital wards) and time. The spread of VRE strains obviously respects political borders; for instance, both vancomycin-variable enterococci which were highly prevalent in Denmark and ST796 VRE which successfully disseminated in Australia and Switzerland, were still completely absent among German hospital patients, until to date.

Paracrine costimulation of IFN-γ signaling by integrins modulates CD8 T cell differentiation.

The cytokine IFN-γ is a critical regulator of immune system development and function. Almost all leukocytes express the receptor for IFN-γ, yet each cell type elicits a different response to this cytokine. Cell type-specific effects of IFN-γ make it difficult to predict the outcomes of the systemic IFN-γ blockade and limit its clinical application, despite many years of research. To better understand the cell-cell interactions and cofactors that specify IFN-γ functions, we focused on the function of IFN-γ on CD8 T cell differentiation. We demonstrated that during bacterial infection, IFN-γ is a dominant paracrine trigger that skews CD8 T cell differentiation toward memory. This skewing is preferentially driven by contact-dependent T cell-T cell (T-T) interactions and the localized IFN-γ secretion among activated CD8 T cells in a unique splenic microenvironment, and is less sensitive to concurrent IFN-γ production by other immune cell populations such as natural killer (NK) cells. Modulation of CD8 T cell differentiation by IFN-γ relies on a nonconventional IFN-γ outcome that occurs specifically within 24 hours following infection. This is driven by IFN-γ costimulation by integrins at T-T synapses, and leads to synergistic phosphorylation of the proximal STAT1 molecule and accelerated IL-2 receptor down-regulation. This study provides evidence of the importance of context-dependent cytokine signaling and gives another example of how cell clusters and the microenvironment drive unique biology.

Focal Vibration Alters Human Digital Sensory Nerve Action Potentials: A Pilot Study.

Introduction: We studied the impact of vibratory stimulation on the electrophysiological features of digital sensory nerve action potential (SNAP). Methods: The antidromic digit 3 SNAP was recorded in 19 healthy adults before, during, and after applying a vibration to either 3rd or 5th metacarpal phalangeal joint (MCPJ) at 60 Hz and amplitude of 2 mm. 100% supramaximal stimulus intensity was performed in 5 subjects (randomly selected from the 19 subjects) where the SNAP sizes were recorded. Results: The amplitude of digit 3 SNAP declined to 58.9 ± 8.6% when a vibration was applied to MCPJ digit 3. These impacts did not change by increasing the electrical stimulus intensity. The SNAP regained its baseline value immediately after the cessation of vibration stimulation. The magnitude of size reduction of digit 3 SNAP was less when vibration was moved to from MCPJ of digit 3 to MCPJ of digit 5. Discussion. The marked drop of the SNAP size during vibratory stimulation reflects the decreased responsiveness of Aß afferents to electrical stimulation, which deserve further investigation in the study of focal vibration in neurorehabilitation.

Leadership Approaches to Staff Health and Wellness During COVID-19 Pandemic.

Background: COVID-19 disease as caused by a coronavirus called SARS-CoV-2 has taken the world by storm with upwards of 8 million confirmed infections in more than 190 countries. At the writing of this article, over 2 million Americans are confirmed infected and 117,000 have died. Rapid changes to manage COVID-19 care creates significant physical and emotional stress for healthcare employees, including pharmacy staff. Objective: This article provides pharmacy leaders with advice in leading through COVID-19 to promote staff resiliency. Methods: The specific leadership strategies include: (1) identifying and addressing fundamental needs; (2) communicating updated and reliable information; and (3) providing psychological and mental health support. Conclusion: Using various techniques described will help to preserve workforce resilience in providing patient-centered pharmacy services. After reading this article, pharmacy directors will have strategies and resources to maintain employee resiliency during this difficult time.

Guidelines for Leading a Safe Medication Error Reporting Culture.

Background: A safe medication error reporting culture is one that promotes, fosters, and rewards the reporting of errors and events across the spectrum of harm (none to significant harm). For this culture to develop, leaders must key department cultural norms. These cultural norms include making employees feel psychologically safe to report errors, and to establish a culture of error review and follow-up that complies with best practices. Objective: This article reviews how pharmacy leaders can establish this environment by describing (1) setting an appropriate vision for safety as a priority; (2) establishing and actively supporting the concept of psychological safety; and (3) implementing medication error review that support an effective safety culture. Finally, the article discusses a case where the relationships between psychological safety, safety culture, and reporting culture are described. Methods: This article reviews the literature and authors' experiences in designing a safety culture for a pharmacy department. Concluson: A safe reporting culture requires leaders to be humble, engage their staff in dialogue, objectively measure culture, consistently provide feedback, and empower its people. Employing these leadership traits with best practices can improve overall medication safety and the quality of patient-centered pharmacy services.

Pain Management Stewardship Programs, Part I: A Review of Legislative and Regulatory Changes.

Background: Opioid use is classified as an epidemic by many due to the impact of these medications on society. Federal and state laws for prescribing and dispensing opioids have changed rapidly in a short period of time to hopefully balance proper pain control with their use. Pharmacy directors must be informed of these rapid changes to effectively work as part of any opioid stewardship team. Objective: The objective of this study was to provide foundational leadership guidance to pharmacy directors on current opioid legislation, literature, and best practices to assist in improving opioid use. Methods: A review of the literature from 2003 to the present was conducted along with collating important up to date resources and other publications that provide foundational information to help support a comprehensive management of opioid use. A summary of these data has been collated into an easy to use table and summarized throughout this article. Conclusion: The information provided in this article helps to properly inform pharmacy leaders to the resources available to improve the prescribing, dispensing, and monitoring of opioids and alternatives.

Dissecting the stem cell niche with organoid models: an engineering-based approach.

For many tissues, single resident stem cells grown in vitro under appropriate three-dimensional conditions can produce outgrowths known as organoids. These tissues recapitulate much of the cell composition and architecture of the in vivo organ from which they derive, including the formation of a stem cell niche. This has facilitated the systematic experimental manipulation and single-cell, high-throughput imaging of stem cells within their respective niches. Furthermore, emerging technologies now make it possible to engineer organoids from purified cellular and extracellular components to directly model and test stem cell-niche interactions. In this Review, we discuss how organoids have been used to identify and characterize stem cell-niche interactions and uncover new niche components, focusing on three adult-derived organoid systems. We also describe new approaches to reconstitute organoids from purified cellular components, and discuss how this technology can help to address fundamental questions about the adult stem cell niche.

Motor unit number index in quantitatively assessing motor root lesions and monitoring treatment outcomes in patients with lumbosacral radiculopathy.

INTRODUCTION: We investigated the feasibility of motor unit number index (MUNIX) in quantitatively assessing motor root lesions and tracking different treatment outcomes in lumbosacral radiculopathy (LR). METHODS: Bilateral MUNIX was recorded from the abductor hallucis, extensor digitorum brevis, and tibialis anterior in 44 normal controls and 108 patients with LR, and this was repeated approximately 12 months after treatment in 60 patients with LR. RESULTS: More abnormalities were observed when side-to-side differences of MUNIX measurements were used to evaluate LR (P < .05). Motor unit number index measurements worsened without progression of muscle weakness after conservative treatment, and MUNIX measurements improved with or without increased muscle strength after surgical treatment (P < .05). DISCUSSION: Motor unit number index may identify a specific L5 or S1 motor root lesion even before muscle weakness occurs, especially when side-to-side differences are used. Changes in MUNIX were larger than those in motor function measures after treatments for LR.