“Your zip code largely determined your public health protections,” says Massachusetts State Sen
and we were vulnerable as a commonwealth because of (them).”
The legislature moved to address these by passing the Statewide Accelerated Public Health for Every Community (SAPHE) Act
It provides funding for local health departments; allows for the creation of a new statewide data collection system and shared services; and requires the development of uniform credentialing systems for public health workers
The new law is “next-generation” public health legislation
executive director of the American Public Health Association
He calls it “a model for other states seeking to provide the legislative basis for public health system improvement efforts.”
Harvard Public Health’s Maura Kelly conducted separate interviews with Comerford and with Oami Amarasingham
deputy director of Massachusetts Public Health Alliance
Comerford: There is a moral and ethical responsibility to ensure equitable services to all residents of the commonwealth
we are less strong if we have weak pockets of resilience
That weakness appeared not only where we have seen weak public health protection and public health inequities—immigrant communities
We also saw real weakness in rural communities that did not have the infrastructure to launch a full-on response to the pandemic
Amarasingham: Covid made the case clearly to every individual and to every elected official that public health infrastructure is really important
Local public health officials have been trying to solve the problem of a lack of public health infrastructure
and statewide minimum standards for decades
We have one state department of public health and 351 local departments of health
whereas most states have county- and regional-level departments
Each local health department has been funded by the town or municipality and many have pretty limited resources
The city of Boston has a really big public health department
every public health department is much smaller
public health departments are open a few hours a week
HPH: Would this law have helped Massachusetts get through Covid better
Comerford: We have huge pockets without cell service here in western Massachusetts
We have almost no consistent internet service
We relied on unbelievably intrepid public health officials to go door to door [telling people about Covid
At the time we weren’t logging our work in a way that was consistent and usable information
There were a lot of gaps in information sharing
You can’t understand what you can’t measure and track
Amarasingham: We were not in great shape to respond in the most effective
What public health officials had during Covid was a PDF [containing the latest statistics]
You needed someone to convert that to an Excel spreadsheet if you wanted to use the data
It was not useful for data scientists or anyone who wanted to produce something with that data
When you have 351 separate entities reporting data
you want that data to be collected and compiled in a uniform way so that it can be combined and used
It was very frustrating not being able to quickly access and understand data in a rapidly evolving situation
HPH: Public health workers and officials came under attack during Covid
Comerford: By having performance standards and requiring a credentialing process as indicated in the law
the state is raising the level of credibility associated with public health officials
I hope that the workforce is much stronger as a result of this legislation
HPH: MPHA helped to develop this legislation
Did you take any lessons from other states
Amarasingham: We understand that other states have better systems for data collection
for instance,] how many food inspections have been done at restaurants
so that public health officials can have a full picture of who is responsible
The legislature appropriated nearly $100 million in ARPA [American Rescue Plan Act] funds to go towards building and maintaining a data system to integrate data collection between the local health departments and the state
HPH: If there is a single public health challenge looming in the future for Massachusetts that this bill will help to mitigate
Amarasingham: Almost anything you read about in the headlines has a local public health implication. So, for example, we’ve had these extreme weather events that dump a lot of water in a short period of time and overwhelm the sewer system—so then sewers get contaminated and it can be unsafe to swim on a beach or in a river
It can reach crisis level rapidly and you have to deal with it
and if you don’t have the public health infrastructure in place
then you are trying to build the infrastructure while addressing the crisis
the toll on the human beings who work in these understaffed systems can be overwhelming
HPH: Did this bill pass at an especially timely moment
Amarasingham: We know the health impacts of climate change are going to get worse
[Add to that] the uncertainty of what will happen with the incoming administration—it is the right time
Comerford: The Office of Senator Jo ComerfordAmarasingham: Mario Quiroz / Courtesy of MPHA
Metrics details
To achieve high power conversion efficiency in perovskite/silicon tandem solar cells
it is necessary to develop a promising wide-bandgap perovskite absorber and processing techniques in relevance
the performance of devices based on wide-bandgap perovskite is still limited mainly by carrier recombination at their electron extraction interface
we demonstrate assembling a binary two-dimensional perovskite by both alternating-cation-interlayer phase and Ruddlesden−Popper phase to passivate perovskite/C60 interface
The binary two-dimensional strategy takes effects not only at the interface but also in the bulk
which enables efficient charge transport in a wide-bandgap perovskite solar cell with a stabilized efficiency of 20.79% (1 cm2)
a monolithic perovskite/silicon tandem solar cell is fabricated with a steady-state efficiency of 30.65% assessed by a third party
the tandem devices retain 96% of their initial efficiency after 527 h of operation under full spectral continuous illumination
and 98% after 1000 h of damp-heat testing (85 °C with 85% relative humidity)
it is necessary to broaden the design horizon of 2D passivation for high-performance WBG perovskite and tandem solar cells
we propose a strategy by assembling 2D perovskite phases to reduce non-radiative recombination with improved charge extraction in a ~ 1.68 eV bandgap perovskite Cs0.235FA0.765Pb(I0.867Br0.133)3 with 5% MAPbCl3
we demonstrate a binary two-dimensional (B-2D) structure
which was realized by reacting a binary mixture of organic salts with 3D perovskite
The perovskite absorbers are effectively passivated by both phases at the surface
The resultant 2D/3D heterojunction showed an n-type surface and appropriate energy level alignment
ensuring effective electron extraction and reduced carrier recombination
1-cm2 single-junction PSCs showed a PCE of 20.95%
with a fill factor (FF) of 81.22% and open-circuit voltage (VOC) of 1.234 V
The tandem device based on this strategy achieved a steady-state efficiency of 30.65% at an independently accredited test center of Shanghai Institute of Micro-system and Information Technology (SIMIT)
the tandem devices retained 96% of their initial performance after 527 h of operation at maximum power point (MPP) under 1-Sun illumination in air (unencapsulated device with an initial PCE of 30.34%
and 98% after 1000 h of the damp-heat test at 85 °C and 85% RH
a Schematic illustration of B-2D strategy
showcasing dual passivation for perovskite bulk and surface
Evolution of XRD patterns (b) and steady-state PL spectra (c) for the perovskite films treated with varying concentrations of GACl
The tracked ions are positively charged monovalent fragments
g Ration of ratio of integral characteristic peak areas of ACI (12.96°) and 3D (14.13°) extracted from the GIXRD
The main characteristic diffraction peaks of the untreated film locate at 14.13° and 12.64° are corresponded to the (100) crystal plane of 3D perovskite and PbI2
For the sample treated by GACl with a concentration of 2 mg/mL
a new diffraction peak appears at about 12.96° instead of the PbI2 peak at 12.64°
and 6.73° appeared successively with the increasing concentration
These low-angle diffraction peaks suggest that the introduction of GACl results in the formation of 2D structures
we designate the films/devices samples treated by OAmI and GACl as RP and ACI
The strong and concentrated diffraction spots in the z direction are indicative of a highly lateral orientation of the B-2D perovskite layers
the distribution curve of FA+ imitates the trajectory of GA+ at the upper surface of perovskite in B-2D sample
This phenomenon is not observed in the Ref
which is likely caused by the formation of ACI phase that composes FA+ and GA+ alternatively in their spacer layers
Besides, we carried out X-ray photoelectron spectroscopy (XPS) to probe the chemical bonding information of the perovskite absorber at the surface (Supplementary Fig. 16)
The binding energy at ~400.3 eV is assigned to the NH2+ group in FA+ (N1) for the Ref film
And an additional peak locates at 402.0 eV for the NH3+ group from OAm+ (N2) in RP films
which again confirms OAm+ exists at the upper surface
When the perovskite film is treated with pure GACl
the Cl 2p peaks exhibit enhanced intensity
suggesting more Cl‒ retains at the surface of the perovskite film
Noted that the B-2D film presents a similar N 1s signal to that obtained from the RP film
It further exhibited an increased intensity of Cl 2p peak similar to that in GACl film
These results indicate the successful application of the B-2D passivator in our strategy
In situ PL contour plots of perovskite films undergoing surface treatment with IPA (a) or 2D reactants in IPA for the fabrication of RP (b)
The dashed box in PL spectra encloses the characteristic peaks of the ACI structure
The grounded lines indicate the absence of the ACI phases from the back side of the perovskite film
f Energy level scheme of perovskite films with and without 2D layers stacked extracted from IPES and UPS data
h The statistical distribution of surface potential
i–l TPC mapping of WBG devices with or without post-treatment
the evolution of PL spectra for perovskite by B-2D strategy includes both evolutionary features of individual OAmI and GACl treatment
the film by B-2D passivation shows the best luminescence intensity right after the lens effect (4–28 s)
a J-V curves under reverse scan for devices with and without 2D layers passivation
b Histogram of VOC and FF fitted with Gaussian distributions from a batch of 52 devices for Ref and B-2D PSCs
c J-V curves for the champion B-2D device (1 cm2)
The B-2D strategy was implemented using spin-coating or bath immersion methods
e Thermal stability at 85 °C in N2 and (f) long-term operational stability under 0.8-Sun illumination of WBG perovskite solar cells with and without post-treatment
devices obtained by bath soaking process exhibits comparable performance to spin-coating method
and the processing window is extended to about 10 s
a Schematic of the monolithic tandem structure based on a double-side textured silicon heterojunction cell
and PCE of the Ref and B-2D tandem solar cells
J-V curves (f) and SPO (g) of the champion B-2D tandem solar cell
including the performance parameters and a photograph of the tandem cell
h EQE spectra of the perovskite top cell and silicon bottom cell of the B-2D tandem device
i Evolution of PV performance of the encapsulated B-2D tandem device when subjected to a damp-heat test at 85 ˚С and 85% relative humidity
j Long-term operation track of unencapsulated B-2D tandem device under full spectrum continual AM 1.5 G illumination in air (~25% RH) at a temperature of 25 ˚С
The results indicate the 2D passivation would help to improve the reverse bias stability of perovskite/silicon tandem
Above results show the perovskite absorber with B-2D passivation is durable in these harsh stability tests
we have explored a promising B-2D strategy
by taking the advantages of both RP and ACI 2D phases
to reconcile the contradiction between defect passivation and efficient charge transport at the electron extraction interface
The ensemble effect of inhibition of non-radiative recombination
more n-type doping at the surface and well-matched interface energy level alignment boost the VOC and FF of single-junction WBG PSCs and relevant perovskite/silicon tandem devices
WBG single junction device with a stabilized PCE of 20.79% (1 cm2) have been obtained
the monolithic 2 T perovskite/silicon tandem device enables a stabilized PCE of 30.65% (measured by a third party)
The B-2D strategy improves the reverse bias stability of perovskite/silicon tandem
And the perovskite/silicon tandem devices with B-2D treatment also exhibited remarkable long-term stability
retaining 96% of their original PCE after 527 h of operation at MPP and 98% after 1000 h of damp-heat testing (85 °C with 85% RH)
We anticipate that these findings will open new avenues for developing high-performance perovskite-based PV technologies
bathocuproine (BCP) and Poly(bis(4-phenyl) (2,4,6trimethylphenyl)-amine) (PTAA) were all purchased from Xi’an Polymer L.T
Formamidium iodide (FAI) was purchased from Greatcell Solar Materials
anhydrous) were all purchased from Sigma Aldrich
All materials were directly used without post-treatment
The 1.4 M Cs0.235FA0.765Pb(I0.867Br0.133)3 with additional 5% MAPbCl3 (relative to 1.4 M Pb
formulated by mixing MACl and PbCl2) perovskite precursor solution was prepared by dissolving a mixture of FAI (184.2 mg)
and PbCl2 (19.5 mg) in a mixed solvent of DMF and DMSO with a volume ratio of 3:1
0.5% PEAI relative to 1.4 M Pb was further added in precursor
the precursor solution was stirred at 50 °C until clarified and then filtered via a 0.22 μm PTFE membrane
The configuration of the single-junction device is ITO/HTL (hole transport layer)/Perovskite/C60/BCP/Ag
The ITO substrate was successively cleaned with ultrapure water
All the spin-coating processes were conducted in a nitrogen-filled atmosphere
After 15 minutes of UV-Ozone treatments on the ITO surface
4 mg/mL in CB) was spin-coated on the substrate at 4000 rpm for 30 s
A pure DMF was then spin-coated at 5000 rpm for 20 s followed by spin-coating the perovskite layer
The WBG perovskite precursor was spin-coated at 1000 rpm for 5 s with an acceleration of 200 rpm/s
then followed by 5000 rpm for 20 s with an acceleration of 1000 rpm/s
Chlorobenzene of 100 μL was dropped in the center of the substrates 8 s before the end of the spin-coating process
The substrates were then annealed for 20 minutes on a hotplate at 110 °C
or GACl/OAmI were all dissolved in IPA with different concentrations and spin-coated onto the cooled perovskite surface at a spin rate of 5000 rpm for 30 s
the rate ramp to get 5000 rpm is 5000 rpm/s
followed by thermal annealing at 100 °C for 5 min
the immediate rotation of the substrate when the post-treatment solutions contact the perovskite surface is necessary to ensure an appropriate degree of reaction
30 nm C60 and 6 nm BCP were thermally evaporated at a respective rate of 0.2 and 0.1 Å s-1 onto the perovskite films sequentially
The devices were finished by thermal evaporation of 100 nm Ag under vacuum
Silicon heterojunction (SHJ) bottom solar cells were made from 300 μm thick float-zone (FZ) n-type crystalline silicon (c-Si) wafers
Both sides of the wafer were treated with alkaline solution for textured surfaces
the wafers were cleaned in RCA solutions and dipped in hydrofluoric acid to remove the silicon oxide layer
and 15 nm p-type a-Si:H were deposited by plasma-enhanced chemical vapor deposition (PECVD)
ITO layers were sputtered from an In2O3 target onto both sides of cells
with 20 nm acting as the recombination layer and 70 nm on the rear contact through a shadow mask to define 1 cm×1 cm square cells
A 250 nm thick Ag was thermal evaporated through the same shadow mask on the rear surface
the wafers were laser-cut (Huzhou Phoenixolar Co
Ltd) into 2.2 cm × 2.2 cm square substrates for tandem fabrication
The processes for HTL and 2D passivation layers are the same as that on single-junction perovskite devices
Perovskite precursor with an enhanced concentration from 1.4 to 1.7 M was conducted to completely cover the texture silicon substrate
The precursor was spin-coated at 300 rpm for 5 s with an acceleration of 300 rpm/s
then followed by 3500 rpm for 20 s with an acceleration of 500 rpm/s
Chlorobenzene of 200 μL was dropped in the center of the substrate 8 s before the end of the spin-coating process
The C60 ETL layer thickness is reduced to 15 nm to decrease the parasitic absorption in the top cell
The 6.6 nm SnO2 was then deposited by atomic layer deposition (ALD) with N2 as the gas carrier
the substrate temperature was maintained at 85 °C and tetrakis(dimethylamino)tin(IV) (TDMASn) precursor source at 55 °C and the H2O source at room temperature
The dosing and purging time for TDMASn is 0.3 and 12 s
a 70 nm ITO layer was then sputtered with 60 W power (3-inch target) on top of the SnO2
and 1μm of Ag fingers and busbars were thermally evaporated on top of the ITO
a 110 nm MgF2 layer through thermal evaporation was used as the antireflective coating
The black butyl rubber sealant is used at the edges in a sandwiched construction of Glass/Tandems/Glass
This configuration was vacuum-laminated in an industrial laminator (WYT500-2 Wei Yi Te (Hebei) energy-saving Equipment Technology Co.
were used to connect the upper and lower electrodes of the tandem devices; and were extended to the outside of the cover glass
The damp heat test was conducted by placing the tandem devices inside an environmental chamber with a temperature of 85 °C and relative humidity of 85%
then retrieving them for periodic J-V measurements
The operation stability of tandem devices was performed at MPP under a full spectrum 1Ssun irradiation (WaveLabs Sinus 220) in the air with a controlled temperature of 25 °C and relative humidity of about 25%
The sample structure used for electrical bias aging tests is ITO/perovskite/BCP/Ag
A bias voltage of 1 V is applied to the device using an electrochemical workstation
The crystal structure of perovskites with and without 2D passivation was analyzed using X-ray diffraction (XRD) measured by PANalytical X’Pert Pro X-ray powder diffractometer with Cu Kα radiation (λ = 1.54050 Å)
Grazing incidence x-ray diffraction (GIXRD) data were measured using a Bruker D8 Advanced
equipped with Cu Kα radiation (λ = 1.54060 Å)
The optical properties of the perovskite-based films/devices were obtained by a UV–visible diffuse reflectance spectrophotometer (UV–vis DRS
The steady-state photoluminescence (PL) and time-resolved PL (TRPL) spectra were characterized by FLS1,000 (Edinburgh Instruments Ltd.)
equipped with a Xe lamp and photomultiplier tube (PMT) detector
The feature of perovskite surface structure after 2D passivation was investigated by 2D synchrotron radiation grazing incidence wide-angle X-ray scattering (GIWAXS) at the BL14B beamline
The processes of kinetic formation and passivation effects for 2D perovskites were monitored by in situ PL spectra with an excitation at 375 nm recorded on a Du-100 dynamic spectrum (Puguangweishi Co.Ltd)
The PLQY was conducted on the samples by using a commercialized system (LQE-100-EL
Enlitech) with laser excitation from a 405 nm LED
Scanning electron microscope (SEM) images were obtained by Hitachi S4800 field-emission scanning electron microscopy
Ultraviolet photoelectron spectroscopy (UPS) measurement was carried out on an XPS AXIS Ultra DLD (Kratos Analytical)
Atomic force microscope (AFM) and kelvin probe force microscopy (KPFM) measurements were conducted to investigate the surface morphology and potential of perovskite films with and without 2D passivation using an MFP-3D bio (Oxford Instruments Asylum Research) with an NSG01/Pt probe
AFM-IR (Nano-FTIR) experiments were carried out at the Bruker Dimension Icon IR using the PRUM-TNIR-D-10 probe
High-resolution scanning transmission electron microscopy (HR-STEM) images were obtained on a FEI Talos F200X G2 electron microscope operated at an accelerating voltage of 200 kV and equipped with a field emission source
Cross-sectional electron-transparent lamella for the HR-STEM study was prepared using a focused ion beam (FIB) on the FEI Helios G4 UC dual beam system
1H NMR spectra were measured using a Bruker AVANCE III 300 MHz NMR Spectrometer in the designated deuterated solvent
ToF-SIMS measurements were conducted with a PHI nano ToF II (ULVAC-PHI Inc.
Bi3 + + beam (30 kV) was used as the primary beam to detect the samples and the sputter etching was performed using an Ar+ gun (2 kV
100 nA) to obtain the desired depth profile
The area of analysis was 50 × 50 μm2 while the sputtering area was 400 × 400 μm2
XPS measurement was carried out on a STARPES system (Specs) with a monochromatic SPECS XR-MF Microwave X-Ray Source (Al Ka = 1486.7 eV). The measurement geometric diagram of angle-resolved XPS is shown in Supplementary Fig. 17
where λ is the mean diffusion length of electrons in perovskite film
increasing with the decrease of takeoff angle
indicating that the larger take-off angle can be applied to reflect the elemental composition closer to the film surface
The TPV/TPC Mapping setup primarily consisted of three parts: a continuous/transient light module
The light module integrated both an intensity-tunable white light (~0.6-sun equivalent) and a pulse laser (~0.06-sun equivalent)
The Pulse Width Modulation (PWM) mapping motors were fixed in three dimensions
allowing height adjustment to match the laser’s focus spot and horizontal movement for sample mapping
achieving a high resolution of up to 0.5 ns in timescale
A scanning speed of 200 mV/s and a range of –0.2 to 1.9 V were set and no preconditioning was used in this work
A mask with an aperture area of 1.0 cm2 for tandem devices was used
Light intensity was calibrated with a National Institute of Metrology (China) calibrated Si reference cell
The stabilized power output (SPO) of tandem devices was measured by recording the continuous current output at the maximum power point (MPP) of J-V scans
The external quantum efficiency (EQE) curves were recorded by an Enli Technology (Taiwan) EQE measurement system
The light intensity for EQE measurement at different wavelengths has been calibrated with standard single-crystal Si (300‒1100 nm) and Ge (800‒1200 nm) reference solar cells
EQE spectra of perovskite top cell or Si bottom cell were measured independently by saturating the bottom/top cell with continuous biased light from a white light equipped with a long-pass (850 nm)/short-pass (550 nm) filter
Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article
The primary data from this study are available in the Supplementary Information/Source Data file. Additional data supporting the findings can be requested from the corresponding authors. Source data accompany this paper. Source data are provided with this paper
National Renewable Energy Laboratory, Best research-cell efficiency chart; www.nrel.gov/pv/cell-efficiency.html
Metal-halide perovskites for photovoltaic and light-emitting devices
A review on organic–inorganic halide perovskite photodetectors: device engineering and fundamental physics
Lead halide perovskite nanowire lasers with low lasing thresholds and high quality factors
A mixed-cation lead mixed-halide perovskite absorber for tandem solar cells
Buried-interface engineering of conformal 2D/3D perovskite heterojunction for efficient perovskite/silicon tandem solar cells on industrially textured silicon
Heterojunction formed via 3D-to-2D perovskite conversion for photostable wide-bandgap perovskite solar cells
Double-side 2D/3D heterojunctions for inverted perovskite solar cells
Quantum barriers engineering toward radiative and stable perovskite photovoltaic devices
Front-contact passivation through 2D/3D perovskite heterojunctions enables efficient bifacial perovskite/silicon tandem solar cells
Ligand-bridged charge extraction and enhanced quantum efficiency enable efficient n–i–p perovskite/silicon tandem solar cells
Damp heat–stable perovskite solar cells with tailored-dimensionality 2D/3D heterojunctions
Intact 2D/3D halide junction perovskite solar cells via solid-phase in-plane growth
Quantum-size-tuned heterostructures enable efficient and stable inverted perovskite solar cells
Molecular engineering of organic–inorganic hybrid perovskites quantum wells
New type of 2D perovskites with alternating cations in the interlayer space
Dynamical transformation of two-dimensional perovskites with alternating cations in the interlayer space for high-performance photovoltaics
Compositional control in 2D perovskites with alternating cations in the interlayer space for photovoltaics with efficiency over 18%
Revealing the origin of voltage loss in mixed-halide perovskite solar cells
Performance-limiting formation dynamics in mixed-halide perovskites
Layered 2D halide perovskites beyond the ruddlesden–popper phase: tailored interlayer chemistries for high-performance solar cells
Stable 2D alternating cation perovskite solar cells with power conversion efficiency >19% via solvent engineering
Nanoscale hybrid multidimensional perovskites with alternating cations for high performance photovoltaic
Component distribution of nano-carbon materials assisted by Time of Flight-Secondary Ion Mass
Dual-layered interfacial evolution of lithium metal anode: SEI analysis via TOF-SIMS technology
Effects of CsPbBr3 nanocrystals concentration on electronic structure and surface composition of perovskite films
Crystallization in one-step solution deposition of perovskite films: Upward or downward
High-performance tin–lead mixed-perovskite solar cells with vertical compositional gradient
Surface reconstruction of halide perovskites during post-treatment
High-quality whispering-gallery-mode lasing from cesium lead halide perovskite nanoplatelets
Enhanced photovoltage for inverted planar heterojunction perovskite solar cells
The electronic properties of a 2D ruddlesden-popper perovskite and its energy level alignment with a 3d perovskite enable interfacial energy transfer
Deterministic fabrication of 3D/2D perovskite bilayer stacks for durable and efficient solar cells
Constructive molecular configurations for surface-defect passivation of perovskite photovoltaics
Constructing heterojunctions by surface sulfidation for efficient inverted perovskite solar cells
Defect engineering in wide-bandgap perovskites for efficient perovskite–silicon tandem solar cells
Evolution of defects during the degradation of metal halide perovskite solar cells under reverse bias and illumination
Reverse-bias resilience of monolithic perovskite/silicon tandem solar cells
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The authors acknowledge funding support from the National Key Research and Development Program of China (Grant No
the National Natural Science Foundation of China (Grant Nos
and China Postdoctoral Science Foundation (Grant No
The authors would like to thank BL14B1 in Shanghai Synchrotron Radiation Facility (SSRF) for providing the beam time
These authors contributed equally: Fengtao Pei
Experimental Centre for Advanced Materials
School of Materials Science and Engineering
Hunan Key Laboratory for Super-microstructure and Ultrafast Process
was involved in all experiments and drew the schematic diagram
helped with the fabricated of tandem devices
performed the in-situ PL and PLQY measurements
contributed to the XPS and AR-XPS measurements
assisted with the third-party testing of PCEs
processed and optimized the SHJ bottom cells
All authors contributed to the discussion and commented on the manuscript
Ning Yang take an internship at Auner Technology
Ye Duan (pursuing Eng.D at Peking University) are from Auner Technology
a startup company working on commercializing perovskite/silicon tandem solar cells
The remaining authors declare no competing interests
Nature Communications thanks the anonymous reviewer(s) for their contribution to the peer review of this work
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
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the University of Michigan (U-M) fired a director of one its Diversity
Equity and Inclusion (DEI) units for alleged “antisemitic” remarks
the director of the Office of Academic Multicultural Initiatives (OAMI)
was summarily sacked for comments she allegedly made to two professors in a private conversation at a diversity conference held last March in Philadelphia
Dawson was removed despite the admission by an investigating law firm
that there was no independent verification that she made the “antisemitic” remarks of which she was accused
Dawson has denied the allegations and declared her intention to sue the university
intervened when the university decided in October that Dawson would not be suspended or terminated
but would be required to undergo “training” on the issue of antisemitism
Bernstein objected and demanded that Dawson be fired
Trump and the Republican Party are spearheading a right-wing “America First” ideological offensive that falsely links identity politics and programs such as DEI
long the stock in trade of the Democratic Party
is bound up with a massive escalation of attacks on democratic rights and basic social programs
Trump and the Republicans are threatening to cut off federal funds to universities that continue DEI and similar programs
championed by middle-class radical academics and organizations
have been used across the country to elevate personal identity—race
sexual orientation—above class in order to sow divisions in the working class while covering up the real roots of inequality and discrimination in the capitalist profit system
they have facilitated the elevation of a thin layer of blacks and other minorities into lucrative positions in academia
while the social position of the broad masses of workers of all races has deteriorated and social inequality has reached unprecedented levels
The fascistic right is taking advantage of the discrediting of identity politics
which has nothing to do with genuine Marxism
to promote extreme national chauvinism and anti-communism
a December 16 statement sent to the Michigan Advance news site by the university’s director of public affairs
also cites her support for U-M students who faced police attack and arrest for protesting against the US-backed genocide in Gaza and the university’s ties to military aid to Israel
Jarvis writes that Dawson was “fired by the Provost because her behavior as a university representative at a conference and during an on-campus protest was inconsistent with her job responsibilities….”
along with universities and colleges across the US and around the world
is carrying out a vicious witch-hunt against opponents of the US/Israeli genocide
Dawson’s lawyer, Amanda Ghannam, told the Advance that Jarvis’ reference to an “on-campus protest” referred to her client’s presence at an August 28 anti-genocide protest on the Ann Arbor
at which four peaceful protesters were arrested
Dawson did there was advocate for student protesters not to be violently arrested,” she said
can be seen in Twitter/X videos of the protest trying to advise student protesters who are being brutally detained by police
According to an account in the New York Times
the alleged “antisemitic” incident took place at a diversity conference when Dawson was approached by two professors
Naomi Yavneh-Klos of Loyola University-New Orleans (LUNO) and another
who lists multiple academic collaborations in Israel on her university bio page
claiming to have “heard about the ‘negative experience’ of a University of Michigan Jewish student.” She “wanted to know
‘Does the DEI office work with these students?’”
It was really horrifying.” Yavneh-Klos also claims that Dawson said the “university is controlled by wealthy Jews” and that “Jewish people have no genetic DNA that would connect them to the land of Israel.”
Dawson said that “she unequivocally denies making the comments attributed to her.” She acknowledged that a discussion took place with the two professors
but said their allegations are deliberate mischaracterizations of what was discussed
Dawson says she told the professors that Jews and Palestinians shared an ancestral connection to the region
Yavneh-Klos contacted the Zionist Anti-Defamation League (ADL) and filed a report the day of the discussion
The ADL waited until August to send a letter to the University of Michigan about the allegations
In response to the August letter from the ADL
the University hired the outside law firm Covington & Burling to investigate the allegations
which itself is a highly unusual move for matters that are generally addressed internally
The New York Times reported that the ADL and Covington & Burling worked together previously on similar types of cases involving allegations of antisemitism
underscoring the biased and prejudicial character of the so-called “investigation.”
In an investigative report sent to the university on September 25
Covington & Burling wrote that it could find no independent verification that antisemitic remarks were made by Dawson
it concluded that the “weight of the available evidence supports ADL Michigan’s report.”
including the office of U-M President Santa Ono
initially determined that she would get a warning and undergo “training in antisemitism and leadership.”
When a university vice president informed the Board of Regents of this decision in late October
immediately responded to the president’s office that he was “disgusted” with the decision
Bernstein wrote that it made “a mockery of your/our commitment to address antisemitism and broaden our DEI efforts to include antisemitism and/or Jewish students,” and said the only acceptable response was that Dawson be “terminated immediately.”
has frequently denounced the anti-genocide protests as evidence of a “toxic presence of antisemitism” on campus.”
Dawson was informed that the president’s office was reversing its decision
a constitutional law scholar from the University of Chicago
was quoted in the Times as saying the firing was likely unconstitutional
and even if she made the alleged comments “her speech should be protected by the First Amendment.”
Dawson’s firing is a brazen violation of democratic rights and due process
staff and faculty at U-M should demand that the decision be reversed and she be reinstated without any penalties or sanctions
A column of water reaching 10 meters high gushed out from beneath the asphalt in a residential area in Oami-Shirasato
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“The asphalt in front of my house is cracked and water is gushing out,” a resident said in a call to police at around 3:05 a.m
The cause is believed to be a broken underground pipe
The water pressure broke the windows of a nearby apartment and caused the roof to turn over
the road caved in and a hole more than 2 meters in diameter opened
The water was spurting out of that hole but subsided after about an hour and a half
as the water in the water pipe was turned off
The water pipe was restored at around 9:15 a.m.
and the road was open to traffic before noon
Our weekly ePaper presents the most noteworthy recent topics in an exciting
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A stilt-walker makes his way up the avenue
The Open Streets Boston pilot program came to Blue Hill Avenue last Saturday as the city closed off 1.2 miles of the roadway from Dudley Street west to Grove Hall
The morning and early-afternoon event brought out hundreds of residents who used the occasion to casually walk or bike up and down the Avenue
A focal point for the festivities came when city officials gathered around noon at Grove Hall to cut a ceremonial ribbon for Domingo Monteiro’s new Grove Hall Creamery ice cream shop
then made their way to the main stage near Brunswick Street for community awards
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the world’s leader in biometric authentication technology
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More than 2,100 Massachusetts residents died from an opiate-related overdose in 2023
“Every single overdose death is preventable
we think of every overdose death really as a policy failure
and we know that harm reduction works and saves lives
prevents overdose deaths and connects people to treatment," said Deputy Director of the Massachusetts Public Health Association Oami Amarasingham
one of the groups rallying at Beacon Hill to support the establishment of overdose prevention centers
“We are a nonprofit advocacy organization and we focus on public health writ large
really on community health and giving people increasing access to the fundamental building blocks of good health
the things that keep you healthy and safe where you live
Bills before Massachusetts legislators in the House and Senate would establish a 10-year pilot program for the centers
setting licensing standards for municipalities interested in opening their own across the commonwealth
“Someone who is going to use drugs can come into a safe space and consume those drugs under the supervision of a trained healthcare professional who can respond immediately if there are any signs of an overdose," Amarasingham explained
"And one really troubling thing that we're seeing right now with really high overdose death rates across the state is that overdoses happen really
and part of that is because what's in the drug supply these days
and there's just not enough time for someone who is experiencing overdose to be able to get medical care to save their life when that use is just happening out on the street.”
In 2023, Massachusetts recorded a 10% decrease in opiate-related overdose deaths, the largest drop in 13 years
Amarasingham warns that statistic masks a more complicated story
the disparities between communities of color – specifically Native American communities and Black communities – go up at shocking rates
while we see between 2022 and 2023 the rate of death for white people did go down," she told WAMC
"And this is really the legacy of the racist War on Drugs that began in the 1970s and really heavily criminalized drug use and baked stigma and fear into all of those policies and led directly to mass incarceration
undermines one's access to all of the social determinants of health
things like housing and medical treatment and employment
we are up against more than 50 years of those policies
and those policies disproportionately impacted Black and Brown communities
and we continue to see that play out In the overdose death rates.”
While Democratic Governor Maura Healey’s administration has endorsed overdose prevention centers
opposed them on the grounds that they violated federal law
Other opponents to the centers claim they promote drug use and would encourage crime
Democratic Berkshire State Representatives John Barrett and Tricia Farley-Bouvier have signed on as co-petitioners to the bill before the House
“I have chosen to co-sponsor this legislation because we know that in Massachusetts
the harm reduction approach to the addiction crisis that we have is the one that has been proven to work
and safe injection sites this legislation seeks to facilitate opening here in Massachusetts is another approach in harm reduction," said Farley-Bouvier
People are just- This is kind of nerve wracking to think that there would be a facility like this sited in a community
Important in the community is that you need local approval to get it
it's not a by-right entity that could be that could come into your
And I would say that with the session coming to a close
it would be difficult to get something like this through at this time
Amarasingham cautions that while overdose prevention centers are a vital tool in saving lives
“There's not going to be one single policy that reverses this trend," she told WAMC
"We need all of the public health and harm reduction tools
and we need comprehensive policies around housing
This is a housing crisis as much as anything else
and we need all of these tools on the table to make sure that people have what they need to be safe and healthy where they live.”
The first state-regulated overdose prevention center in the United States is expected to open in Providence, Rhode Island this year after city council approval in February
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While one might find common ground in issues Kennedy has raised regarding access to healthy food and reducing harmful chemicals and pollutants
his overall disdain for the role of public health experts and his penchant for conspiracy theories rather than science are cause for deep concern
The chaos and disinformation spread by the first Trump administration — from COVID-19 to climate change — threatened the health of our communities
Proponents of public health saw the power of working in alliance with community groups to insist on policies that were data-driven
It is a critical step for Massachusetts at a pivotal moment for our country
and sectors — is essential to meeting the public health challenges of today and tomorrow
The organization changed its name from the Massachusetts Public Health Association in September
When the president-elect announced his plan to nominate Robert F
to lead the Department of Health and Human Services
“I’m calling about your brother,” Dad said
I had just returned from my grandfather’s funeral
Dad also said that the doctor was worried about brain damage and that my Uncle George
It was touch and go for days before my brother and uncle recovered
Is this the world we want to return to? Have Americans forgotten how many died of COVID-19 before vaccines were available? It would be irresponsible and dangerous to put a vaccine denier such as Kennedy in charge of our country’s health.
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Metrics details
Current research regarding the association between body mass index (BMI) and altered clinical outcomes of sepsis in Asian populations is insufficient
We investigated the association between BMI and clinical outcomes using two Japanese cohorts of severe sepsis (derivation cohort
Participants were categorized into the underweight (BMI < 18.5) and non-underweight (BMI ≥ 18.5) groups
Univariate analysis of the derivation cohort indicated increased 28-day mortality trend in the underweight group compared to the non-underweight group (underweight 24.4% [20/82 cases] vs
non-underweight 16.0% [85/532 cases]; p = 0.060)
multivariate analysis adjusted for baseline imbalance revealed that patients in the underweight group had a significantly increased 28-day mortality compared to those in the non-underweight group (p = 0.031
In a repeated analysis using a multicenter validation cohort (underweight n = 343
patients in the underweight group had a significantly increased 28-day mortality compared to those in the non-underweight group (p = 0.045
patients with a BMI < 18.5 had a significantly increased 28-day mortality compared to those with a BMI ≥ 18.5 in Japanese cohorts with severe sepsis
we tested the hypothesis that patients with a lower BMI have worse clinical outcomes through an altered inflammatory response using large Japanese cohorts of severe sepsis
and blood IL-6 levels were measured in the derivation cohort
This observational study deployed the following severe sepsis cohorts
The methods were conducted in accordance with the Declaration of Helsinki and relevant guidelines
Patients who had missing data regarding BMI and mortality were excluded
The validation cohort consisted of Japanese Association for Acute Medicine Sepsis Registry (JAAMSR) and Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome
observational studies conducted by the Japanese Association for Acute Medicine (JAAM) without an overlapping duration for patient enrollment
JAAMSR recruited patients with severe sepsis from 15 ICUs in Japan between June 2010 and May 2011
which followed JAAMSR and was conducted by the JAAM
enrolled study participants with severe sepsis from 59 ICUs in Japan between January 2016 and March 2017
We made the decision to combine the two cohorts with the aim of strengthening the robustness
Because our institution had participated in FORECAST
the population that overlapped with the derivation cohort was removed from the validation cohort
We chose our normal BMI range in accordance with the World Health Organization (WHO) classification (18.5 ≤ BMI < 25.0)
The WHO classification has two high BMI categories (25.0 ≤ BMI < 30.0 and BMI ≥ 30.0)
due to the small sample size of the highest BMI category (BMI ≥ 30.0
We first screened for differences in mortality between the abnormal BMI (underweight
BMI ≥ 25.0) and normal (18.5 ≤ BMI < 25.0) groups in the derivation cohort
Significant discovery results were tested for replication and generalizability in a multicenter validation cohort
Raw data were converted into a logarithmic scale for analysis
Categorical data were analyzed using the Pearson’s chi-square test
The Mann–Whitney U test or Kruskal–Wallis test was used for unpaired comparisons depending on the number of groups
Multivariate logistic regression was used to analyze 28-day mortality by the BMI category
We selected this approach to adjust for potential baseline imbalances
the Sequential Organ Failure Assessment (SOFA) score
We compared blood IL-6 levels measured on days 1
2 and 3 between the BMI categories using a generalized estimating equation
Statistical significance was determined by a two-tailed p value < 0.05
Data were analyzed using SPSS software version 24.0 (IBM Corporation
USA) and GraphPad Prism 6 (GraphPad Software
The institutional review board at Chiba University Graduate School of Medicine approved this study and waived the need for written informed consent from subjects or their legal surrogates
The 28-day mortality rate was 24.4%, 15.7%, and 16.5% in the underweight, normal, and overweight groups, respectively. According to the screening analysis, we chose the potential threshold of BMI 18.5 and further analyzed between the underweight (BMI < 18.5) and non-underweight (BMI ≥ 18.5) groups (Table 1)
Univariate analysis revealed a non-significant trend of increased 28-day mortality in the underweight group (24.4%) compared to the non-underweight group (16.0%) (p = 0.060)
To rule out the bias due to the comorbidities
we performed another logistic regression model using Charlson co-morbidities index with the data set of FORECAST study
the underweight group showed consistent worse outcome after correction with comorbidities
Comparison of blood IL-6 levels between the underweight (BMI < 18.5) and non-underweight (BMI ≥ 18.5) group at days 1
There was a non-significant trend of increased blood IL-6 levels in the underweight group compared to the non-underweight group in a generalized estimating equation using log-converted serum IL-6 concentration at days 1
found that patients with a BMI < 18.5 had an increased 28-day mortality
There was a trend of increased blood IL-6 levels in patients with a BMI < 18.5 during the initial 3 days
our study is potentially more robust with regard to the conclusions derived from the data
This study has limitations that need to be addressed
we used BMI as a surrogate value to assess the percentage of body fat
but this might not be accurate for the evaluation of metabolic status without more detailed information
would be greatly beneficial to further understand the effect of metabolism on clinical outcomes following sepsis
patients with a BMI < 18.5 had a significantly increased 28-day mortality compared to those with a BMI ≥ 18.5
The datasets used and analyzed during our study are available from the corresponding author upon reasonable request
Singer, M. et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315, 801–810. https://doi.org/10.1001/jama.2016.0287 (2016)
Vincent, J. L., Opal, S. M., Marshall, J. C. & Tracey, K. J. Sepsis definitions: time for change. Lancet 381, 774–775. https://doi.org/10.1016/S0140-6736(12)61815-7 (2013)
Wacharasint, P., Boyd, J. H., Russell, J. A. & Walley, K. R. One size does not fit all in severe infection: obesity alters outcome, susceptibility, treatment, and inflammatory response. Crit. Care 17, R122. https://doi.org/10.1186/cc12794 (2013)
Ng, P. Y. & Eikermann, M. The obesity conundrum in sepsis. BMC Anesthesiol. 17, 147. https://doi.org/10.1186/s12871-017-0434-z (2017)
Wang, S. et al. The role of increased body mass index in outcomes of sepsis: a systematic review and meta-analysis. BMC Anesthesiol. 17, 118. https://doi.org/10.1186/s12871-017-0405-4 (2017)
Schetz, M. et al. Obesity in the critically ill: a narrative review. Intensive Care Med. 45, 757–769. https://doi.org/10.1007/s00134-019-05594-1 (2019)
Zhou, Q. et al. Impact of body mass index on survival of medical patients with sepsis: a prospective cohort study in a university hospital in China. BMJ Open 8, e021979. https://doi.org/10.1136/bmjopen-2018-021979 (2018)
Consultation, W. H. O. E. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363, 157–163. https://doi.org/10.1016/S0140-6736(03)15268-3 (2004)
Metabolically obese but normal weight (MONW) and metabolically healthy but obese (MHO) phenotypes in Koreans: characteristics and health behaviors
Zheng, W. et al. Association between body-mass index and risk of death in more than 1 million Asians. N. Engl. J. Med. 364, 719–729. https://doi.org/10.1056/NEJMoa1010679 (2011)
Levy, M. M. et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Crit. Care Med. 31, 1250–1256. https://doi.org/10.1097/01.CCM.0000050454.01978.3B (2003)
Shimazui, T. et al. Association between serum levels of interleukin-6 on ICU admission and subsequent outcomes in critically ill patients with acute kidney injury. BMC Nephrol. 20, 74. https://doi.org/10.1186/s12882-019-1265-6 (2019)
Dellinger, R. P. et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit. Care Med. 41, 580–637. https://doi.org/10.1097/CCM.0b013e31827e83af (2013)
Rhodes, A. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 43, 304–377. https://doi.org/10.1007/s00134-017-4683-6 (2017)
Pepper, D. J. et al. Increased body mass index and adjusted mortality in ICU patients with sepsis or septic shock: a systematic review and meta-analysis. Crit. Care 20, 181. https://doi.org/10.1186/s13054-016-1360-z (2016)
Pepper, D. J. et al. Does obesity protect against death in sepsis? A retrospective cohort study of 55,038 adult patients. Crit. Care Med. 47, 643–650. https://doi.org/10.1097/CCM.0000000000003692 (2019)
Li, S. et al. Increased body mass index linked to greater short- and long-term survival in sepsis patients: a retrospective analysis of a large clinical database. Int. J. Infect. Dis. 87, 109–116. https://doi.org/10.1016/j.ijid.2019.07.018 (2019)
Gaulton, T. G. et al. A retrospective cohort study examining the association between body mass index and mortality in severe sepsis. Intern. Emerg. Med. 10, 471–479. https://doi.org/10.1007/s11739-015-1200-1 (2015)
Sakr, Y. et al. Obesity is associated with increased morbidity but not mortality in critically ill patients. Intensive Care Med. 34, 1999–2009. https://doi.org/10.1007/s00134-008-1243-0 (2008)
Yatabe, T., Yamashita, K. & Yokoyama, M. Lower body mass index is associated with hospital mortality in critically ill Japanese patients. Asia Pac. J. Clin. Nutr. 25, 534–537. https://doi.org/10.6133/apjcn.092015.21 (2016)
Walley, K. R. et al. PCSK9 is a critical regulator of the innate immune response and septic shock outcome. Sci. Transl. Med. 6, 258ra143. https://doi.org/10.1126/scitranslmed.3008782 (2014)
Shimada, T. et al. Very low density lipoprotein receptor sequesters lipopolysaccharide into adipose tissue during sepsis. Crit. Care Med. 48, 41–48. https://doi.org/10.1097/CCM.0000000000004064 (2020)
Shimazui, T., Matsumura, Y., Nakada, T. A. & Oda, S. Serum levels of interleukin-6 may predict organ dysfunction earlier than SOFA score. Acute Med. Surg. 4, 255–261. https://doi.org/10.1002/ams2.263 (2017)
Takahashi, W., Nakada, T. A., Yazaki, M. & Oda, S. Interleukin-6 levels act as a diagnostic marker for infection and a prognostic marker in patients with organ dysfunction in intensive care units. Shock 46, 254–260. https://doi.org/10.1097/SHK.0000000000000616 (2016)
Oda, S. et al. Sequential measurement of IL-6 blood levels in patients with systemic inflammatory response syndrome (SIRS)/sepsis. Cytokine 29, 169–175. https://doi.org/10.1016/j.cyto.2004.10.010 (2005)
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We thank all contributors of the JAAM FORECAST group
A comprehensive list of consortium members appears at the end of the paper
Department of Emergency and Critical Care Medicine
Chiba University Graduate School of Medicine
Health Services Research and Development Center
Department of Traumatology and Acute Critical Medicine
Osaka University Graduate School of Medicine
Division of Emergency and Critical Care Medicine
Tohoku University Graduate School of Medicine
University of Occupational and Environmental Health
Department of Trauma and Critical Care Medicine
Center for Gastroenterology and Liver Disease
Division of Disaster and Emergency Medicine
Kobe University Graduate School of Medicine
Advanced Medical Emergency and Critical Care Center
Division of Trauma and Surgical Critical Care
Japan Community Healthcare Organization Chukyo Hospital
Division of Acute and Critical Care Medicine
Hokkaido University Graduate School of Medicine
Department of Acute and Critical Care Medicine
National Hospital Organization Sendai Medical Center
National Hospital Organization Disaster Medical Center
National Hospital Organization Hokkaido Medical Center
Japanese Red Cross Society Kyoto Daini Hospital
Subaru Health Insurance Society Ota Memorial Hospital
National Hospital Organization Kumamoto Medical Center
National Hospital Organization Higashi-Ohmi General Medical Center
National Hospital Organization Mito Medical Center
statistical analysis and interpretation of data
and critical revision of the manuscript for important intellectual content
acquisition of data and interpretation of data
and revising the article critically for important intellectual content
All authors read and approved the final manuscript
This work was supported by the Japanese Association for Acute Medicine (JAAM)
Tadanaga Shimada is currently receiving a grant (FDN 20K09301) from “Japan Society for the Promotion of Science”
The remaining authors have disclosed that they do not have any conflicts of interest
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
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DOI: https://doi.org/10.1038/s41598-020-80284-3
Metrics details
Early therapeutic interventions are crucial for reducing the mortality of acute coronary syndrome (ACS)1
A substantial number of patients have initial symptoms of ACS outside hospitals; emergency medical service (EMS) personnel play a role as the first responders to patients
EMS personnel estimate the possibility of ACS based on the symptoms of patients and transport them to the appropriate hospital for immediate treatment
Precise prediction of ACS in the prehospital setting may contribute to improving the quality of ACS care and clinical outcomes
there are few studies using machine learning to predict the onset of ACS in a prehospital setting
the aim of this study was to evaluate a predictive power of the machine learning algorithms predicting ACS based on vital signs
and symptoms using a large cohort of patients with suspected ACS
and higher frequency of ST elevation or ST change than non-ACS patients
ACS patients had greater pain severity and higher proportion of cold hands
higher frequency of ST elevation or ST change than non-ACS patients
which was consistent with the internal cohort
Receiver operating characteristic curve of prehospital diagnostic algorithms for acute coronary syndrome with 17 features
ROC curves of the top six machine learning algorithms for the prehospital prediction of ACS using 17 features are shown
The ROC curves are depicted at 1-specificity on the x-axis and sensitivity on the y-axis using (a) the training score
AUC is presented with 95% confidence interval
AUC (area under the receiver operating characteristic curve)
SVM (R) (support vector machine radial basis function)
SHAP values of the prehospital diagnostic algorithm for acute coronary syndrome using 17 features
The impact of the features on the model output was expressed as the SHAP value calculated with the support vector machine (radial basis function)
The features are placed in descending order according to their importance
The association between the feature value and SHAP value indicates a positive or negative impact of the predictors
The extent of the value is depicted as red (high) or blue (low) plots
we found that the machine learning-based prehospital model showed a high predictive power for predicting the diagnosis of ACS and subcategories of ACS using 17 features including vital signs
This accurate diagnostic algorithm may contribute to early prediction of diagnosis in prehospital settings and reduce the transport time to a facility where therapeutic intervention is available
even without special equipment or technical training
our models had a higher predictive power even in the prehospital setting
which compared diagnostic accuracy for ACS between an assessment of general practitioners and clinical decision rule (CDR) based on medical history and physical examination
reported that the AUC was 0.66 for the physicians’ risk estimate and 0.75 for the CDR
This result implies that the diagnostic precision for ACS based on physical assessment reaches the ceiling when 12-lead ECG or cardiac enzymes are not available
our novel approach for predicting the onset of ACS with vital signs
and symptoms using machine learning would provide us with substantial advantages over traditional methods
With the high predictive accuracy of the algorithm for the diagnosis of ACS
the SHAP analysis presented significant features contributing to the diagnosis of ACS: ST change
While 12-lead ECG has been recognized as one of the most reliable tests for estimating the probability of diagnosis
or III demonstrated noteworthy findings for an assessment of the likelihood
Other features listed as contributing factors are potentially used as additional information to determine the possibility of ACS in a prehospital setting
Based on the extent of the contribution to the diagnosis
we successfully decreased the number of features for the prediction algorithm from 43 to 17 features
This can be explained by that the exclusion of the irrelevant and redundant features
and noises has improved the model performance
The advantages of the modified algorithm with a decreased number of features include reduction of workload and shorter duration of implementation
leading to potential feasibility of clinical application in the future
Such a diagnostic tool with a predicting algorithm is soon to be launched with validation in a prehospital setting
While 12-lead ECG may have a better predictive power
machine learning algorithms based on promptly available 3-lead ECG monitoring
and symptoms showed a high predictive power
we found that the prehospital prediction algorithm had a high predictive power for diagnosing the onset of ACS using machine learning from the data of vital signs
Further investigations are needed to validate the accuracy and feasibility of the algorithm in a prehospital setting
This study was a multicenter observational study that was prospectively conducted in an urban area of Japan (Chiba city
2022 were assigned to the internal cohort and the external cohort
Consecutive adult patients (≥ 20 years of age) identified by EMS personnel with suspected ACS who were transported to one of the twelve participating facilities were enrolled in the study
The symptoms indicating ACS to EMS personnel included pain
Patients with other symptoms that were strongly suspected of having an onset of ACS were also enrolled in the study
Patients with cardiac arrest were excluded from the study because they could not be interviewed in a manner consistent with the other patients
The study was approved by the Ethical Review Board of the Graduate School of Medicine
In accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects in Japan
the requirement for written informed consent was waived by the review board
ACS was defined as acute myocardial infarction (AMI) and unstable angina (UA)
Of the 663 screened patients in the internal cohort, 555 patients were included in the final analysis after excluding 108 patients because of missing diagnostic data, multiple entries, and cardiac arrest (Supplementary Fig. S4)
Of the 69 screened patients in the external cohort
61 patients were included in the final analysis after exclusion of 8 patients due to missing diagnostic data and multiple entries
As our data had missing values for some features
we performed imputations before building the machine learning models
We used the imputed values as input even to the gradient boosting model
which can deal with missing values by treating them the same way as categorical values
because we found that our imputation approach written below had improved its performance compared to the implementation without imputation
we mutually imputed the missing values in some features: symptoms 4 to 21
and a pair of systolic and diastolic blood pressure
the missing values were replaced with a new subcategory “Unknown”
The voting classifier was selected as an ensemble method of all the rest of classifiers above
we built binary classification models for AMI and STEMI prediction
Non-ST-segment elevation myocardial infarction (NSTEMI) was not included in the secondary analysis because of its small number
The parameters were optimized using the grid search method with nested cross-validation
We assessed the feature importance in the machine learning model based on the Shapley Additive exPlanation (SHAP) value30
which was calculated using the machine learning algorithms with the highest AUC in the test score
The voting classifier was excluded from the algorithms to calculate the SHAP values due to the lack of available code
The SHAP value is a solution concept used in game theory and is computed by the difference in model output resulting from the inclusion of a feature in the algorithm
providing information on the impact of each feature on the output
The SHAP value is a method for its interpretability in machine learning models and is also used as a feature selection tool
A higher absolute SHAP value indicates a more important feature
Feature selection was performed by the following steps: i.e.
(1) We built models using 42 features with dropping one feature from 43 features and evaluated the model through nested CV (5-outer fold and 5-outer fold)
(2) We replaced the feature to be removed with another feature and repeated this for 43 features
(3) The best combinations of the explainable feature were selected by ROC AUC of these 43 models
(4) The procedures (1)–(3) were repeated until the number of features became one
This process was repeated 10 times to avoid less important features appearing in the higher ranking by chance
we determined the most plausible number of features (i.e.
the most important features to be included) from the model that showed the best performance in the mean CV scores
we built a classification model for ACS prediction using nine machine leaning algorithms with the 17 selected features
Systematic review of clinical decision support systems for prehospital acute coronary syndrome identification
Part 5: Acute coronary syndromes: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
JCS 2018 guideline on diagnosis and treatment of acute coronary syndrome
The impact of pre-hospital 12-lead electrocardiogram and first contact by cardiologist in patients with ST-elevation myocardial infarction in Kanagawa
Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study
Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta-analysis
Optimising prehospital pathways to improve acute stroke reperfusion therapy delivery: Systems-based approaches
Emergent large vessel occlusion screen is an ideal prehospital scale to avoid missing endovascular therapy in acute stroke
Prehospital triage of acute aortic syndrome using a machine learning algorithm
Machine learning-based prediction of acute coronary syndrome using only the pre-hospital 12-lead electrocardiogram
The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making
Chest pain in the emergency room: Value of the HEART score
Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: Prospective multinational observational study (GRACE)
Cincinnati prehospital stroke scale: Reproducibility and validity
Diagnosing acute coronary syndrome in primary care: Comparison of the physicians’ risk estimation and a clinical decision rule
Japanese nationwide PCI (J-PCI) registry annual report 2019: Patient demographics and in-hospital outcomes
management and outcome of japanese patients with acute myocardial infarction in the troponin era - Japanese registry of acute myocardial infarction diagnosed by universal definition (J-MINUET)
2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American college of cardiology/American heart association task force on practice guidelines
Best leads in the standard electrocardiogram for the emergency detection of acute coronary syndrome
Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes
TIMI risk score for ST-elevation myocardial infarction: A convenient
clinical score for risk assessment at presentation: An intravenous nPA for treatment of infarcting myocardium early II trial substudy
Fourth universal definition of myocardial infarction (2018)
Cross-validation pitfalls when selecting and assessing regression and classification models
Bias in error estimation when using cross-validation for model selection
Machine learning algorithm validation with a limited sample size
Applications of machine learning to undifferentiated chest pain in the emergency department: A systematic review
From local explanations to global understanding with explainable AI for trees
Predicting 30-days mortality for MIMIC-III patients with sepsis-3: A machine learning approach using XGboost
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especially the following investigators: Chiba Emergency Medical Center (Iwao Ishibashi)
Chiba Chuo Medical Center (Kazumasa Fukuda)
National Hospital Organization Chiba Medical Center (Yukio Saito)
Chiba Aoba Municipal Hospital (Kyohei Yamamoto)
Chiba Kaihin Municipal Hospital (Masaru Terai)
Mitsuwadai General Hospital (Yasuhiko Nakata)
Japan Community Health Care Organization Chiba Hospital (Noriyoshi Murotani)
and Chiba City Fire Department (Hideki Shinhama)
This research was supported by the Japan Agency for Medical Research and Development under Grant Number #JPhe1502001
The funder had no role in the study design
Critical revision of the manuscript for important intellectual content: M.T.
All authors have read and approved the final manuscript
and RA declare that they have no potential conflicts of interest
TN and YY are inventors and have submitted patents related to this work
TN and YY serve as directors and receive executive compensation and hold shares in Smart119 Inc
REM serves as a chief scientist in Smart119 Inc
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DOI: https://doi.org/10.1038/s41598-022-18650-6
Metrics details
The role of autophagy in the maintenance of renal homeostasis during sepsis is not well understood
We therefore aimed to determine the influence of autophagy on kidney during sepsis using a murine sepsis model
the number of autolysosomes observed by electron microscopy increased over time
The number of autophagosomes in CLP animals decreased relative sham operated controls at 24 hrs after CLP
indicating that autophagy flux is already diminishing by that time
CLP induced an increase in LC3-II/LC3-I ratio at 6–8 hrs
as well as an increase in GFP-LC3 dots at 6–8 hrs and 24 hrs
using immunofluorescence and anti-LC3 and LAMP1 antibodies on tissue sections from GFP-LC3 transgenic mice
LC3-II/LC3-I ratio and the number of co-localized GFP-LC3 dots and LAMP1 signals (GFP LC3 + LAMP1 dots) in CLP mice at 24 hrs were significantly reduced compared with data obtained at 6–8 hrs
acceleration of autophagy by rapamycin resulted in improvement of renal function that was associated with improvement in the histologic severity of tubular epithelial injury in CLP treated animals
Autophagy in the kidney was significantly slowed in the kidney during the acute phase of sepsis; nonetheless
autophagy in kidney appears to play a protective role against sepsis
Autophagy (type II programmed cell death) is therefore speculated to play an active role in both kidney and liver in early sepsis
we focused on the role of autophagy in kidney epithelial injury and renal function during sepsis
We thus investigated the roles of autophagy
including a dynamic morphologic classification of autophagic structures and their relative changes over time
in the pathogenesis of septic AKI using the cecal ligation and puncture (CLP) mouse model of sepsis
Male C57BL/6 N (6- to 8-week-old) mice and green fluorescent protein (GFP)- microtubule-associated protein light chain 3 (LC3) transgenic mice (C57BL/6 background; 6- to 8-week-old) were acclimated to a 12-hr day/night cycle under specific pathogen-free conditions with food at least 1 week before experiments
All experimental procedures were approved by the Institutional Animal Care and Use Committees of Chiba University (ref.# 29–287) and were in compliance with the National Institute of Health guidelines
Mice were sacrificed at indicated time points after treatment and tissue samples were taken for analysis
Mice were sacrificed when they were moribund
Total proteins were prepared from mouse kidneys
Each tissue was lysed in 2 × SDS sampling buffer (1.245 M Tris-HCl at pH 6.8 containing 10% glycerol
Extracts were homogenized on ice and boiled for 5 minutes; these were then centrifuged at 10,000 × g for 10 minutes at room temperature
and the supernatants were obtained as total protein
Equal amounts of protein were separated by SDS polyacrylamide gel electrophoresis and transferred to polyvinylidene difluoride membrane
The membranes were subsequently incubated with 5% nonfat dry milk in Tris-buffered saline (TBS) containing 0.1% Tween-20 (TBS-T) for 1 hr at room temperature
Antibodies were added and incubated overnight at 4 °C in TBS-T
The following primary antibodies were used: rabbit polyclonal GAPDH (Abcam
rabbit polyclonal anti-LC3B (Sigma-Aldrich
rabbit polyclonal anti-p62 (DakoCytomation
rabbit monoclonal Rubicon (Cell Signaling Technology
Membranes were washed 3 times in TBS-T and subsequently incubated with peroxidase conjugated secondary antibodies (goat anti-rabbit IgG: Jackson Immuno Research
1:2000; goat anti-mouse IgG: Jackson Immuno Research
Blots were washed 3 times with TBS-T and once with TBS
and the signal was then detected using enhanced chemiluminescence (ECL-Plus) reagent (GE Healthcare
Band images were scanned and densitometric analysis was performed using NIH Image software (Bethesda
evaluated by band-intensity of LC3-I and -II
Mice were transcardially perfused with 4% paraformaldehyde (PFA) in phosphate buffer
Kidneys were removed and were further fixed with 4% PFA at 4 °C overnight
The kidneys were then placed in 15% sucrose in PBS at 4 °C for 4 hrs; this was then exchanged for 30% sucrose in PBS
and incubation continued at 4 °C overnight
The kidneys were frozen in optimum cutting temperature (OCT) compound and sectioned serially into 7-μm-thick sections using a cryostat
Samples were kept frozen at −80 °C until used
sections were stained using rabbit polyclonal anti-lysosome-associated membrane protein type 1 (LAMP1) (Abcam
Cy3-conjugated goat anti-rabbit immunoglobulin G (IgG) (H + L) was used as a secondary antibody (Jackson Immuno Research; 1:1000 dilution)
All fluorescence images were digitally acquired at 400× magnification with KEYENCE Fluorescence Microscope BZ-X700 (KEYENCE Co.
a minimum of 8–10 random fields (to minimize unintended sampling bias) were examined at 2,500× magnification for evidence of autophagy or cell injury/death
and the number of autophagosomes and autolysosomes in each 2500× image was counted
The median ± interquartile per 50 images from each mouse was calculated and the data from different groups were compared (CLP (n = 3) versus Sham (n = 3)) at the time course of 6–8hrs and 24hrs after each surgery
Only the proximal tubular epithelial cells were evaluated
Blood samples were obtained from heart chamber of mice (n = 6)
Serum concentration of Cystatin C was measured using an enzyme immunoassay kit (R&D
Blood urea nitrogen (BUN) and serum creatinine were measured by SRL company
Renal tubules in 5 high power fields (HPFs)
All data were analyzed for statistical significance using the unpaired t test or Mann-Whitney test
All data were expressed as the median ± interquartile range using the statistical software program PRISM (GraphPad Software
Cecal ligation and puncture (CLP) induces autophagy in the kidney of CLP model mice
(A) Western blotting analysis of microtubule-associated protein light chain 3 (LC3) in the kidney
Kidney samples were prepared from sham-operated and CLP mice at each indicated time point after surgery
The left graph is the ratio between the levels of LC3-II and GAPDH
and the right graph is the ratio between the levels of LC3-II and LC3-I at each time point
All data are expressed as median ± interquartile range
Data were analyzed for statistical significance using the unpaired t test (*P < 0.05
Whole image of the blot is shown in supplementary information
(B) Co-localization of green fluorescent protein (GFP)-Microtubule-associated protein light chain 3 (LC3) dots with lysosome associated membrane protein type 1 (LAMP1) in the kidney after cecal ligation and puncture (CLP) or sham surgery
Confocal images of kidney samples obtained from GFP-LC3 transgenic mice
LAMP1 was stained using Cy3-conjugated IgG secondary antibodies
Merged images demonstrate co-localization of GFP-LC3 dots and LAMP1
The number of GFP-LC3 and GFP-LC3 + LAMP1 dots per cellular confocal image was quantified at 6–8 and 24 hrs after CLP
(C) We counted the number of dots within entire renal tubular cells and dots within glomerular cells were not counted
The ratio of GFP-LC3 and GFP-LC3 + LAMP1 dots was calculated
Data were analyzed for statistical significance using the Mann-Whitney test
**P < 0.01; n = 50 cells /animal; n = 4 animals)
This indicates that formation of autophagic structures accelerates early in CLP
Classification of Autophagosome/Autolysosome
(A) An autophagosome with clear double membrane structures
(B) An autophagosome being engulfed process or just recently engulfed by a sequestered membrane
(C) A lysosome with an enclosed organelle in the process of degradation
(D) An autolysosome clearly enclosing a damaged organelle (in this case
Electron microscopic analysis of the proximal tubules
(A) The number of autophagosomes and autolysosomes in CLP and sham animals are compared
All data were expressed as the median ± interquartile range
Data were analyzed for statistical significance using the Mann-Whitney test (*P < 0.05; n = 3 in each group)
(B) Images of electron microscopy of the proximal convoluted tubule of kidney at 24 hrs after operation; a–c: Kidney sample obtained from sham-operated mice
Organelles in the proximal convoluted tubule cells are generally intact; d–e: CLP-operated mice
Double arrow heads identify complex structures bounded by two membranes (autophagosomes); arrow heads identify single membrane-bound lysosomal complexes with degraded organellar content (autolysosomes)
Evaluation of autophagy flux change in the kidney of cecal ligation puncture (CLP)
Relative expression of p62 protein (A) and Rubicon (B) in the kidney at 6–8 and 24 hrs after sham or CLP operation in C57BL/6 N mice
The amount of p62 protein and Rubicon was normalized to that of GAPDH by evaluation of band intensity from western blotting
Data were analyzed for statistical significance using the Mann-Whitney test (*P < 0.05
Promotion of autophagy attenuates cecal ligation and puncture (CLP)-induced kidney injury
Nephropathy as defined by serum (A) cystatin C
(C) blood urea nitrogen and creatinine levels
Samples were obtained from either sham-operated or CLP mice with or without rapamycin treatment 6–8 and 24 hrs after surgery
Histological findings of mouse kidney by hematoxylin and eosin staining (100×)
Kidney tissue was obtained from CLP mice with rapamycin or DMSO treatment at 24 hrs after surgery
Black arrow heads show parts of cells shedding
and white double arrow heads show chromatin condensation
Renal tubules are surrounded by dotted circular lines
CLP mice kidneys (24 hrs after surgery) treated by rapamycin had significantly lower kidney injury scores than those of treated by DMSO
Data were analyzed for statistical significance using the unpaired t test (*P < 0.05; n = 4 animals)
we analyzed autophagic structures in renal proximal tubular epithelial cells in septic mice using electron microscopy
The number of autolysosomes in the kidney of CLP treated mice increased within 24 hrs after operation
biochemical analysis revealed that autophagy flux was suppressed with progression of sepsis after 6–8 hrs
Impaired renal function in the 24-hr CLP model was mitigated by enhancement of autophagy with rapamycin
These results raise the possibility that stimulation of autophagy might improve renal function in sepsis
and this mechanism could contribute to renal impairment through proximal tubular cell apoptosis during sepsis
The latter observation emphasizes that crosstalk between autophagy and apoptosis might play an important role in the pathophysiology of septic AKI
providing morphologic evidence of autophagy flux stagnation in CLP
It is possible that initial activation of the autophagy machinery is delayed in the kidney of the septic mice compared to sham mice
Renal tubular cells may sense environmental change
such as blood flow and pH caused by sepsis
and initially reserve activation of autophagy machinery
This might account for why the number of autophagosomes and autolysosomes in the sham mice was higher than those of CLP mice early in sepsis
Further study is required to elucidate the mechanism and factors that activate or inhibit the autophagic machinery in sepsis
mTORC1 is also associated with other vital phenomena (including cell growth
suggesting that rapamycin likely exerts its influence on pathways other than autophagy
While increased autophagy is a possible reason for the improved pathology and cystatin C values
further study is needed by using a models built on kidney specific transgenic animals
Further studies are needed to develop an effective treatment strategy for septic AKI (drugs and optimal timing of administration) with this in mind
It is also important to clarify the patient population that benefits most from autophagy stimulation
Autophagy flux diminishes in the kidney of septic mice over time
Acceleration of autophagy improves renal function
These results suggest that autophagy plays a protective role against sepsis-induced kidney injury and may mitigate other physiological abnormalities during sepsis as well
the appropriate timing of autophagy upregulation in the clinical setting has not yet been determined
since no method of in vivo monitoring of autophagy in humans has yet been established
because autophagy regulation is organ specific
additional analysis of the mechanisms underlying autophagy in different organs during sepsis is required
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Japan) for kindly gifted Green fluorescent protein (GFP) - microtubule-associated protein light chain 3 (LC3) transgenic mice
Haruko Watanabe-Takano for helpful discussion
Aya Goda for her excellent technical assistance
Yoshiko Ohashi for her excellent secretarial assistance
This work was supported by Grants-in-Aid for Scientific Research from the Ministry of Education
This work was also supported by Grant for Young Doctors of Abdominal Emergency Clinical Research from the Japanese Society for Abdominal Emergency Medicine
University of Washington School of Medicine
and participated in its design and grant finding
and gave a critical suggestion to the project
participated in analysis of electron micrographs and critical review of the manuscript
performed the animal experiments and protein analysis
performed histological analysis of the kidney
The authors declare that they have no competing interests
Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
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DOI: https://doi.org/10.1038/s41598-018-19350-w
Hill Harper attends the premiere of "Loving" at the Landmark Sunshine Cinema on Wednesday
(Photo by Evan Agostini/Invision/AP)(Evan Agostini)
.st1{fill-rule:evenodd;clip-rule:evenodd;fill:#2a2a2a}By Martin Slagter | mslagter@mlive.comANN ARBOR
MI - The University of Michigan is welcoming award-winning actor
best-selling author and philanthropist Hill Harper to deliver its annual Rev
Symposium keynote memorial lecture in January
The university announced Harper will take part in the symposium keynote address at 10 a.m
The keynote is co-sponsored by the Office of Academic Multicultural Initiatives under the Office of Diversity
Ross School of Business with support from the William K
"Every year our planning committee seeks to find a theme and speaker that reflects the legacy of Dr
to be critical of the inequities in the status quo
yet act and be inclusive in generating solutions," OAMI Associate Director Lumas J
Harper is noted for his acting roles in the Spike Lee films "Get on the Bus" and "He Got Game." He later appeared as crime scene investigator Sheldon Hawkes on the CBS crime drama "CSI: NY" for nine seasons until 2013
he was the winner of the NAACP Image Award for Outstanding Actor in a Drama Series for three consecutive years from 2008 to 2010
Harper appeared in the ABC's "The Good Doctor."
authoring several books including "Letters to a Young Brother: MANifest Your Destiny," "Letters to a Young Sister: DeFINE Your Destiny" and "Letters to an Incarcerated Brother: Encouragement
Hope and Healing for Inmates and Their Loved Ones."
Harper established the Manifest Your Destiny Foundation
which provides under-served youth with a path to empowerment and educational excellence through mentoring
academic enrichment programming and college access skills obtainment
A graduate of Brown University and Harvard Law School, Harper recently became the new owner of the iconic Charles T. Fisher mansion in Detroit's Historic Boston-Edison District, according to The Detroit News
For more information on this year's Dr. Martin Luther King Jr. Symposium, "The Fierce Urgency of Now," visit the UM website
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Tokyo
which opened just last Friday July 19.
The eight-storey shop specialises in all sorts of figurines
ranging from collectables like Be@rbrick to those from popular franchises such as Gundam
To give you an idea of what you can expect from Amiami Akihabara Figure Tower
here’s a breakdown of the store floor by floor
miniatures)Floor 2: Popular franchise scale figures (Evangelion
Shonen Manga)Floor 3: Action figures (Nendoroid
Figma)Floor 4: American comic movie characters
etc)Floor 5: General and Bishojo anime (including games popular with women)Floor 6: Bishojo games
Fate)Floor 7: Bishojo figurinesFloor 8: Event space
Amiami Akihabara Figure Tower is a short two minutes’ walk from JR Akihabara Station. It’s open daily from 10am-9pm. For more information, visit the website
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View the discussion thread.
It’s handsome styling has already won the hearts of Fiat fan-boys across the world
and as enthusiasts wait for a properly hotted up Abarth version
a sports styling pack has been reported in the meanwhile
These touched up patent images reveal the Tipo/Egea with a purported styling package
side skirts and an aggressive rear bumper with a diffuser and chromed
the fins on the front grille are painted in body color
while the side mirror caps and the roof receive a contrasting black finish
Other embellishments comprise of a subtle lip spoiler on the trunk
and a black “356 S” body decal that runs along the shoulder line
indicating that this new derivative will likely be called “Egea 356 S”
Production of the Egea/Tipo has already commenced at the TOFAŞ facilities in Bursa
from where it will be exported to more than 40 countries in the EMEA (Europe
The premium compact sedan will be powered by a choice of two diesel engines and two petrol engines; all 4-cylinder units
with the most powerful of them being a 120 HP
strapped to a 6-speed manual gearbox – the latter being the most probable candidate to host the “S” pack
For more on the Fiat Tipo/Egea: 2016 Fiat Tipo Sedan detailed in 40+ images; specifications and feature list inlcuded
Prices for the Tipo in Italy were announced earlier this year
Source: oami.europa.eu