Elder abuse geriatrics: describing an important new medical specialist.

Elder mistreatment, including elder abuse and neglect, is a difficult diagnosis to make and manage for most providers. To address this, two elder abuse consultation teams were developed for patients in the hospital and emergency department settings. As these teams have developed, the providers involved have obtained specialized training and experience that we believe contributes to a new field of elder abuse geriatrics, a corollary to the well-established field of child abuse pediatrics. Providers working in this field require specialized training and have a specialized scope of practice that includes forensic evaluation, evaluation of cognition and capacity, care coordination and advocacy for victims of abuse, and collaboration with protective services and law enforcement. Here we describe the training, scope of practice, ethical role, and best practices for elder mistreatment medical consultation. We hope this will serve as a starting point for this new and important medical specialty.

Immunologic basis for development of keratoconjunctivitis sicca in systemic autoimmune diseases: Role of innate immune sensors.

The literature is filled with citations reporting an increased incidence of chronic dry eye disease, also known as keratoconjunctivitis sicca, in patients with systemic autoimmune diseases such as rheumatoid arthritis, Sjögren's Syndrome, systemic sclerosis and lupus. As the most environmentally exposed mucosal surface of the body, the conjunctiva constantly responds to environmental challenges which are typically self limited, but when persistent and unresolved may provoke pathogenic innate and adaptive immune reactions. Our understanding of the pathophysiological mechanisms by which systemic autoimmune diseases cause dry eye inducing ocular surface inflammation continues to evolve. Conjunctival immune tone responds to self or foreign danger signals (including desiccating stress) on the ocular surface with an initial non-specific innate inflammatory response. If unchecked, this can lead to activation of dendritic cells that present antigen and prime T and B cells resulting in an adaptive immune reaction. These reactions generally resolve, but dysfunctional, hyper-responsive immune cells found in systemic autoimmune diseases that are recruited to the ocular surface can amplify inflammatory stress responses in the ocular surface and glandular tissues and result in autoimmune reactions that disrupt tear stability and lead to chronic dry eye disease. We here propose that unique features of the ocular surface immune system and the impact of systemic immune dysregulation in autoimmune diseases, can predispose to development of dry eye disease, and exacerbate severity of existing dry eye.

Localization of nitric oxide-producing hemocytes in Aedes and Culex mosquitoes infected with bacteria.

Mosquitoes are significant vectors of various pathogens. Unlike vertebrates, insects rely solely on innate immunity. Hemocytes play a crucial role in the cellular part of the innate immune system. The gaseous radical nitric oxide (NO) produced by hemocytes acts against pathogens and also functions as a versatile transmitter in both the immune and nervous systems, utilizing cyclic guanosine monophosphate (cGMP) as a second messenger. This study conducted a parallel comparison of NO synthase (NOS) expression and NO production in hemocytes during Escherichia coli K12 infection in four vector species: Aedes aegypti, Aedes albopictus, Culex pipiens molestus, and Culex pipiens quinquefasciatus. Increased NOS expression by NADPH diaphorase (NADPHd) staining and NO production by immunofluorescence against the by-product L-citrulline were observed in infected mosquito hemocytes distributed throughout the abdomens. NADPHd activity and citrulline labeling were particularly found in periostial hemocytes near the heart, but also on the ventral nerve chord (VNC). Pericardial cells of Ae. aegypti and Cx. p. molestus showed increased citrulline immunofluorescence, suggesting their involvement in the immune response. Oenocytes displayed strong NADPHd and citrulline labeling independent of infection status. This comparative study, consistent with findings in other species, suggests a widespread phenomenon of NO's role in hemocyte responses during E. coli infection. Found differences within and between genera highlight the importance of species-specific investigations.

Motor neuron activity enhances the proteomic stress caused by autophagy defects in the target muscle.

Several lines of evidence demonstrate that increased neuronal excitability can enhance proteomic stress. For example, epilepsy can enhance the proteomic stress caused by the expression of certain aggregation-prone proteins implicated in neurodegeneration. However, unanswered questions remain concerning the mechanisms by which increased neuronal excitability accomplishes this enhancement. Here we test whether increasing neuronal excitability at a particular identified glutamatergic synapse, the Drosophila larval neuromuscular junction, can enhance the proteomic stress caused by mutations in the ER fusion/GTPase gene atlastin (atl). It was previously shown that larval muscle from the atl2 null mutant is defective in autophagy and accumulates protein aggregates containing ubiquitin (poly-UB aggregates). To determine if increased neuronal excitability might enhance the increased proteomic stress caused by atl2, we activated the TrpA1-encoded excitability channel within neurons. We found that TrpA1 activation had no effect on poly-UB aggregate accumulation in wildtype muscle, but significantly increased poly-UB aggregate number in atl2 muscle. Previous work has shown that atl loss from either neuron or muscle increases muscle poly-UB aggregate number. We found that neuronal TrpA1 activation enhanced poly-UB aggregate number when atl was removed from muscle, but not from neuron. Neuronal TrpA1 activation enhanced other phenotypes conferred by muscle atl loss, such as decreased pupal size and decreased viability. Taken together, these results indicate that the proteomic stress caused by muscle atl loss is enhanced by increasing neuronal excitability.

Atl (atlastin) regulates mTor signaling and autophagy in Drosophila muscle through alteration of the lysosomal network.

ABBREVIATIONS: atl atlastin; ALR autophagic lysosome reformation; ER endoplasmic reticulum; GFP green fluorescent protein; HSP hereditary spastic paraplegia; Lamp1 lysosomal associated membrane protein 1 PolyUB polyubiquitin; RFP red fluorescent protein; spin spinster; mTor mechanistic Target of rapamycin; VCP valosin containing protein.

A novel conceptual model of heart rate autonomic modulation based on a small-world modular structure of the sinoatrial node.

The present view on heartbeat initiation is that a primary pacemaker cell or a group of cells in the sinoatrial node (SAN) center paces the rest of the SAN and the atria. However, recent high-resolution imaging studies show a more complex paradigm of SAN function that emerges from heterogeneous signaling, mimicking brain cytoarchitecture and function. Here, we developed and tested a new conceptual numerical model of SAN organized similarly to brain networks featuring a modular structure with small-world topology. In our model, a lower rate module leads action potential (AP) firing in the basal state and during parasympathetic stimulation, whereas a higher rate module leads during ß-adrenergic stimulation. Such a system reproduces the respective shift of the leading pacemaker site observed experimentally and a wide range of rate modulation and robust function while conserving energy. Since experimental studies found functional modules at different scales, from a few cells up to the highest scale of the superior and inferior SAN, the SAN appears to feature hierarchical modularity, i.e., within each module, there is a set of sub-modules, like in the brain, exhibiting greater robustness, adaptivity, and evolvability of network function. In this perspective, our model offers a new mainframe for interpreting new data on heterogeneous signaling in the SAN at different scales, providing new insights into cardiac pacemaker function and SAN-related cardiac arrhythmias in aging and disease.

Strategies for dissemination of ED/hospital elder mistreatment response team model.

Interdisciplinary Emergency Department/hospital-based teams represent a promising care model to improve identification of and intervention for elder mistreatment. Two institutions, Weill Cornell Medicine/NewYork-Presbyterian Hospital and the University of Colorado Anschutz Medical Campus have launched such programs and are exploring multiple strategies for effective dissemination. These strategies include: (1) program evaluation research, (2) framing as a new model of geriatric care, (3) understanding the existing incentives of health systems, EDs, and hospitals to align with them, (4) connecting to ongoing ED/hospital initiatives, (5) identifying and collaborating with communities with strong elder mistreatment response that want to integrate the ED/hospital, (6) developing and making easily accessible high-quality, comprehensive protocols and training materials, (7) offering technical assistance and support, (8) communications outreach to raise awareness, and (9) using an existing framework to inform implementation in new hospitals and health systems.

Initial steps in addressing the challenges of elder mistreatment evaluation: Protocol for evaluating the Vulnerable Elder Protection Team.

INTRODUCTION: Although many programmes have been developed to address elder mistreatment, high-quality, rigorous evaluations to assess their impact are lacking. This is partly due to challenges in conducting programme evaluation for such a complex phenomenon. We describe here the development of a protocol to mitigate these challenges and rigorously evaluate a first-of-its-kind emergency department/hospital-based elder mistreatment intervention, the Vulnerable Elder Protection Team (VEPT). METHODS AND ANALYSIS: We used a multistep process to develop an evaluation protocol for VEPT: (1) creation of a logic model to describe programme activities and relevant short-term and long-term outcomes, (2) operationalisation of these outcome measures, (3) development of a combined outcome and (4) design of a protocol using telephone follow-up at multiple time points to obtain information about older adults served by VEPT. This protocol, which is informing an ongoing evaluation of VEPT, may help researchers and health system leaders design evaluations for similar elder mistreatment programmes. ETHICS AND DISSEMINATION: This project has been reviewed and approved by the Weill Cornell Medicine Institutional Review Board, protocol #20-02021422. We aim to disseminate our results in peer-reviewed journals at national and international conferences and among interested patient groups and the public.

Elementary intracellular Ca signals approximated as a transition of release channel system from a metastable state.

Cardiac muscle contraction is initiated by an elementary Ca signal (called Ca spark) which is achieved by collective action of Ca release channels in a cluster. The mechanism of this synchronization remains uncertain. We approached Ca spark activation as an emergent phenomenon of an interactive system of release channels. We constructed a weakly lumped Markov chain that applies an Ising model formalism to such release channel clusters and probable open channel configurations and demonstrated that spark activation is described as a system transition from a metastable to an absorbing state, analogous to the pressure required to overcome surface tension in bubble formation. This yielded quantitative estimates of the spark generation probability as a function of various system parameters. We performed numerical simulations to find spark probabilities as a function of sarcoplasmic reticulum Ca concentration, obtaining similar values for spark activation threshold as our analytic model, as well as those reported in experimental studies. Our parametric sensitivity analyses also showed that the spark activation threshold decreased as Ca sensitivity of RyR activation and RyR cluster size increased.

Influence of RVFV Infection on Olfactory Perception and Behavior in Drosophila melanogaster.

In blood-feeding dipterans, olfaction plays a role in finding hosts and, hence, in spreading pathogens. Several pathogens are known to alter olfactory responses and behavior in vectors. As a mosquito-borne pathogen, Rift Valley Fever Virus (RVFV) can affect humans and cause great losses in livestock. We test the influence of RVFV infection on sensory perception, olfactory choice behavior and activity on a non-biting insect, Drosophila melanogaster, using electroantennograms (EAG), Y-maze, and locomotor activity monitor. Flies were injected with RVFV MP12 strain. Replication of RVFV and its persistence for at least seven days was confirmed by quantitative reverse transcription-PCR (RT-qPCR). One day post injection, infected flies showed weaker EAG responses towards 1-hexanol, vinegar, and ethyl acetate. In the Y-maze, infected flies showed a significantly lower response for 1-hexanol compared to uninfected flies. At days six or seven post infection, no significant difference between infected and control flies could be found in EAG or Y-maze anymore. Activity of infected flies was reduced at both time points. We found an upregulation of the immune-response gene, nitric oxide synthase, in infected flies. An infection with RVFV is able to transiently reduce olfactory perception and attraction towards food-related odors in Drosophila, while effects on activity and immune effector gene expression persist. A similar effect in blood-feeding insects could affect vector competence in RVFV transmitting dipterans.

Design and Implementation of the Surveys of Women: Protocol for an Address-Based Sampling Multimodal Study.

BACKGROUND: Studies conducted in the United States such as the National Survey of Family Growth (NSFG) and the Pregnancy Risk Assessment Monitoring System (PRAMS) collect data on pregnancy intentions to aid in improving health education, services, and programs. PRAMS collects data from specific sites, and NSFG is a national household-based survey. Like NSFG, the Surveys of Women was designed to survey participants residing in households using an address-based sample and a multimode data collection approach. The Surveys of Women collects data from eligible participants in 9 states within the United States on contraception use, reproductive health, and pregnancy intentions. In this paper, we focus on the baseline data collection protocol, including sample design, data collection procedures, and data processing. We also include a brief discussion on the follow-up and endline survey methodologies. Our goal is to inform other researchers on methods to consider when fielding a household-level reproductive health survey. OBJECTIVE: The Surveys of Women was developed to support state-specific research and evaluation projects, with an overall goal of understanding contraceptive health practices among women aged 18-44 years. The project collects data from respondents in 9 different states (Arizona, Alabama, Delaware, Iowa, Maryland, New Jersey, Ohio, South Carolina, and Wisconsin) over multiple rounds. METHODS: Households were selected at random using address-based sampling methods. This project includes a cross-sectional baseline survey, 2 or 3 follow-up surveys with an opt-in panel of respondents, and a cross-sectional endline survey. Each round of data collection uses a multimode design through the use of a programmed web survey and a formatted hard copy questionnaire. Participants from the randomly selected households access their personalized surveys through a web survey or mail in a hard copy questionnaire. To maximize responses, these surveys follow a rigorous schedule of various prompts bolstering the survey implementation design, and the participants received a modest monetary incentive. RESULTS: This is an ongoing project with results published separately by the evaluation teams involved with data analysis. CONCLUSIONS: The methods used in the first baseline survey informed modifications to the methods used in subsequent statewide surveys. Data collected from this project will provide insight into women's reproductive health, contraceptive use, and abortion attitudes in the 9 selected states. The long-term goal of the project is to use a data collection methodology that collects data from a representative sample of participants to assess changes in reproductive health behaviors over time. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40675.

Mitragyna speciosa (Kratom) poisoning: Findings from ten cases.

Kratom is a mixture of compounds that are present in the leaves of the tropical tree Mitragyna speciosa. It is used as a psychoactive agent with both opiate and stimulant-like effects. In this case series we describe the signs, symptoms, and the management of kratom overdose in the prehospital setting and in intensive care. We retrospectively searched for cases in the Czech Republic. Over 36 months we found 10 cases of kratom poisoning, which healthcare records were analyzed and reported as per CARE guidelines. The dominant symptoms in our series were neurological and included quantitative (n = 9) or qualitative (n = 4) disorder of consciousness. Signs and symptoms of vegetative instability [hypertension (n = 3) and tachycardia (n = 3) vs. bradycardia/cardiac arrest (n = 2), mydriasis (n = 2) vs. miosis (n = 3)] were noticed. Prompt response to naloxone in two cases and lack of response in one patient were observed. All patients survived and the effect of intoxication wore off within two days. Kratom overdose toxidrome is variable and, in keeping with its receptor physiology, consists of signs and symptoms of opioid-like overdose, sympathetic overactivation and serotonin-like syndrome. Naloxone can help to avoid intubation in some cases.

Culex Y Virus: A Native Virus of Culex Species Characterized In Vivo.

Mosquitoes are vectors of various pathogens that cause diseases in humans and animals. To prevent the outbreak of mosquito-borne diseases, it is essential to control vector populations, as treatment or vaccination for mosquito-borne diseases are often unavailable. Insect-specific viruses (ISVs) have previously been described as being potentially helpful against arboviral disease outbreaks. In this study, we present the first in vivo characterization of the ISV Culex Y virus (CYV). CYV was first isolated from free-living Culex pipiens mosquitoes in 2010; then, it was found in several mosquito cell lines in a further study in 2018. For mammalian cells, we were able to confirm that CYV does not replicate as it was previously described. Additionally, we found that CYV does not replicate in honey bees or locusts. However, we detected replication in the Culex pipiens biotype molestus, Aedes albopictus, and Drosophila melanogaster, thus indicating dipteran specificity. We detected significantly higher mortality in Culex pipiens biotype molestus males and Drosophila melanogaster, but not in Aedes albopictus and female Culex pipiens biotype molestus. CYV could not be transmitted transovarially to offspring, but we detected venereal transmission as well as CYV in mosquitos' saliva, indicating that an oral route of infection would also be possible. CYV's dipteran specificity, transmission routes, and killing effect with respect to Culex males may be used as powerful tools with which to destabilize arbovirus vector populations in the future.

The paradigm shift: Heartbeat initiation without "the pacemaker cell".

The current dogma about the heartbeat origin is based on "the pacemaker cell," a specialized cell residing in the sinoatrial node (SAN) that exhibits spontaneous diastolic depolarization triggering rhythmic action potentials (APs). Recent high-resolution imaging, however, demonstrated that Ca signals and APs in the SAN are heterogeneous, with many cells generating APs of different rates and rhythms or even remaining non-firing (dormant cells), i.e., generating only subthreshold signals. Here we numerically tested a hypothesis that a community of dormant cells can generate normal automaticity, i.e., "the pacemaker cell" is not required to initiate rhythmic cardiac impulses. Our model includes 1) non-excitable cells generating oscillatory local Ca releases and 2) an excitable cell lacking automaticity. While each cell in isolation was not "the pacemaker cell", the cell system generated rhythmic APs: The subthreshold signals of non-excitable cells were transformed into respective membrane potential oscillations via electrogenic Na/Ca exchange and further transferred and integrated (computed) by the excitable cells to reach its AP threshold, generating rhythmic pacemaking. Cardiac impulse is an emergent property of the SAN cellular network and can be initiated by cells lacking intrinsic automaticity. Cell heterogeneity, weak coupling, subthreshold signals, and their summation are critical properties of the new pacemaker mechanism, i.e., cardiac pacemaker can operate via a signaling process basically similar to that of "temporal summation" happening in a neuron with input from multiple presynaptic cells. The new mechanism, however, does not refute the classical pacemaker cell-based mechanism: both mechanisms can co-exist and interact within SAN tissue.

The Drosophila melanogaster attP40 docking site and derivatives are insertion mutations of msp-300.

The ɸC31 integrase system is widely used in Drosophila melanogaster to allow transgene targeting to specific loci. Over the years, flies bearing any of more than 100 attP docking sites have been constructed. One popular docking site, termed attP40, is located close to the Nesprin-1 orthologue msp-300 and lies upstream of certain msp-300 isoforms and within the first intron of others. Here we show that attP40 causes larval muscle nuclear clustering, which is a phenotype also conferred by msp-300 mutations. We also show that flies bearing insertions within attP40 can exhibit decreased msp-300 transcript levels in third instar larvae. Finally, chromosomes carrying certain "transgenic RNAi project" (TRiP) insertions into attP40 can confer pupal or adult inviability or infertility, or dominant nuclear clustering effects in certain genetic backgrounds. These phenotypes do not require transcription from the insertions within attP40. These results demonstrate that attP40 and insertion derivatives act as msp-300 insertional mutations. These findings should be considered when interpreting data from attP40-bearing flies.

Viral Shedding 1 Year Following First-Episode Genital HSV-1 Infection.

Importance: Herpes simplex virus type 1 (HSV-1) is the leading cause of first-episode genital herpes in many countries. Objective: To inform counseling messages regarding genital HSV-1 transmission, oral and genital viral shedding patterns among persons with first-episode genital HSV-1 infection were assessed. The trajectory of the development of HSV-specific antibody and T-cell responses was also characterized. Design, Setting, and Participants: Prospective cohort followed up for up to 2 years, with 82 participants followed up between 2013 and 2018. Participants were recruited from sexual health and primary care clinics in Seattle, Washington. Persons with laboratory-documented first-episode genital HSV-1 infection, without HIV infection or current pregnancy, were referred for enrollment. Exposures: First-episode genital HSV-1 infection. Main Outcomes and Measures: Genital and oral HSV-1 shedding and lesion rates at 2 months, 11 months, and up to 2 years after initial genital HSV-1 infection. Participants self-collected oral and genital swabs for HSV polymerase chain reaction testing for 30 days at 2 and 11 months and up to 2 years after diagnosis of genital HSV-1. Blood samples were collected at serial time points to assess immune responses to HSV-1. Primary HSV-1 infection was defined as absent HSV antibody at baseline or evolving antibody profile using the University of Washington HSV Western Blot. HSV-specific T-cell responses were detected using interferon γ enzyme-linked immunospot. Results: Among the 82 participants, the median (range) age was 26 (16-64) years, 54 (65.9%) were women, and 42 (51.2%) had primary HSV-1 infection. At 2 months, HSV-1 was detected from the genital tract in 53 participants (64.6%) and in the mouth in 24 participants (29.3%). Genital HSV-1 shedding was detected on 275 of 2264 days (12.1%) at 2 months and declined significantly to 122 of 1719 days (7.1%) at 11 months (model-predicted rate, 6.2% [95% CI, 4.3%-8.9%] at 2 months vs 3.2% [95% CI, 1.8%-5.7%] at 11 months; relative risk, 0.52 [95% CI, 0.29-0.93]). Genital lesions were rare, reported on 65 of 2497 days (2.6%) at 2 months and 72 of 1872 days (3.8%) at 11 months. Oral HSV-1 shedding was detected on 88 of 2247 days (3.9%) at 2 months. Persons with primary HSV-1 infection had a higher risk of genital shedding compared with those with nonprimary infection (model-predicted rate, 7.9% [95% CI, 5.4%-11.7%] vs 2.9% [95% CI, 1.7%-5.0%]; relative risk, 2.75 [95% CI, 1.40-5.44]). Polyfunctional HSV-specific CD4+ and CD8+ T-cell responses were maintained during the follow-up period. Conclusions and Relevance: Genital HSV-1 shedding was frequent after first-episode genital HSV-1, particularly among those with primary infection, and declined rapidly during the first year after infection.

A scoping review of the unassisted physical exam conducted over synchronous audio-video telemedicine.

BACKGROUND: This scoping review aims to provide a broad overview of the research on the unassisted virtual physical exam performed over synchronous audio-video telemedicine to identify gaps in knowledge and guide future research. METHODS: Searches for studies on the unassisted virtual physical exam were conducted in 3 databases. We included primary research studies in English on the virtual physical exam conducted via patient-to-provider synchronous, audio-video telemedicine in the absence of assistive technology or personnel. Screening and data extraction were performed by 2 independent reviewers. RESULTS: Seventy-four studies met inclusion criteria. The most common components of the physical exam performed over telemedicine were neurologic (38/74, 51%), musculoskeletal (10/74, 14%), multi-system (6/74, 8%), neuropsychologic (5/74, 7%), and skin (5/74, 7%). The majority of the literature focuses on the telemedicine physical exam in the adult population, with only 5% of studies conducted specifically in a pediatric population. During the telemedicine exam, the patients were most commonly located in outpatient offices (28/74, 38%) and homes and other non-clinical settings (25/74, 34%). Both patients and providers in the included studies most frequently used computers for the telemedicine encounter. CONCLUSIONS: Research evaluating the unassisted virtual physical exam is at an early stage of maturity and is skewed toward the neurologic, musculoskeletal, neuropsychologic, and skin exam components. Future research should focus on expanding the range of telemedicine exam maneuvers studied and evaluating the exam in the most relevant settings, which for telemedicine is trending toward exams conducted through mobile devices and in patients' homes.

Disorder in Ca2+ release unit locations confers robustness but cuts flexibility of heart pacemaking.

Excitation-contraction coupling kinetics is dictated by the action potential rate of sinoatrial-nodal cells. These cells generate local Ca releases (LCRs) that activate Na/Ca exchanger current, which accelerates diastolic depolarization and determines the pace. LCRs are generated by clusters of ryanodine receptors, Ca release units (CRUs), residing in the sarcoplasmic reticulum. While CRU distribution exhibits substantial heterogeneity, its functional importance remains unknown. Using numerical modeling, here we show that with a square lattice distribution of CRUs, Ca-induced-Ca-release propagation during diastolic depolarization is insufficient for pacemaking within a broad range of realistic ICaL densities. Allowing each CRU to deviate randomly from its lattice position allows sparks to propagate, as observed experimentally. As disorder increases, the CRU distribution exhibits larger empty spaces and simultaneously CRU clusters, as in Poisson clumping. Propagating within the clusters, Ca release becomes synchronized, increasing action potential rate and reviving pacemaker function of dormant/nonfiring cells. However, cells with fully disordered CRU positions could not reach low firing rates and their ß-adrenergic-receptor stimulation effect was substantially decreased. Inclusion of Cav1.3, a low-voltage activation L-type Ca channel isoform into ICaL, strongly increases recruitment of CRUs to fire during diastolic depolarization, increasing robustness of pacemaking and complementing effects of CRU distribution. Thus, order/disorder in CRU locations along with Cav1.3 expression regulates pacemaker function via synchronization of CRU firing. Excessive CRU disorder and/or overexpression of Cav1.3 boosts pacemaker function in the basal state, but limits the rate range, which may contribute to heart rate range decline with age and disease.

The Role of Spin-Flip Collisions in a Dark-Exciton Condensate.

We show that a Bose-Einstein condensate consisting of dark excitons forms in GaAs coupled quantum wells at low temperatures. We find that the condensate extends over hundreds of micrometers, well beyond the optical excitation region, and is limited only by the boundaries of the mesa. We show that the condensate density is determined by spin-flipping collisions among the excitons, which convert dark excitons into bright ones. The suppression of this process at low temperature yields a density buildup, manifested as a temperature-dependent blueshift of the exciton emission line. Measurements under an in-plane magnetic field allow us to preferentially modify the bright exciton density and determine their role in the system dynamics. We find that their interaction with the condensate leads to its depletion. We present a simple rate-equations model, which well reproduces the observed temperature, power, and magnetic-field dependence of the exciton density.