Chronic diseases are a leading cause of adult mortality, accounting for 41 million deaths globally each year. Low levels of physical activity and sedentary behavior are major risk factors for adults to develop a chronic disease. Physical activity interventions can help support patients in clinical care to be more active. Commercial activity trackers that can measure daily steps, physical activity intensity, sedentary behavior, and distance moved are being more frequently used within health-related interventions. The RE-AIM  framework is a planning and evaluation approach to explore the reach, effectiveness, adoption, implementation, and maintenance of interventions.The objective of this study is to conduct an integrative systematic review and report the 5 main RE-AIM dimensions in interventions that used activity trackers in clinical care to improve physical activity or reduce sedentary behavior in adults diagnosed with chronic diseases.A search strategy and study protocol were developed and registered on the PROSPERO platform. Inclusion criteria included adults (18 years and older) diagnosed with a chronic disease and have used an activity tracker within their clinical care. Searches of 10 databases and gray literature were conducted, and qualitative, quantitative, and mixed methods studies were included. Screening was undertaken by more than 1 researcher to reduce the risk of bias. After screening, the final studies were analyzed using a RE-AIM framework data extraction evaluation tool. This tool assisted in identifying the 28 RE-AIM indicators within the studies and linked them to the 5 main RE-AIM dimensions.The initial search identified 4585 potential studies. After a title and abstract review followed by full-text screening, 15 studies were identified for data extraction. The analysis of the extracted data found that the RE-AIM dimensions of adoption  and maintenance  were underreported. The use of qualitative thematic analysis to understand the individual RE-AIM dimensions was also underreported and only used in 3 of the studies. Two studies used qualitative analysis to explore the effectiveness of the project, while 1 study used thematic analysis to understand the implementation of an intervention.Further research is required in the use of activity trackers to support patients to lead a more active lifestyle. Such studies should consider using the RE-AIM framework at the planning stage with a greater focus on the dimensions of adoption and maintenance and using qualitative methods to understand the main RE-AIM dimensions within their design. These results should form the basis for establishing long-term interventions in clinical care.PROSPERO CRD42022319635; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=319635 Noncommunicable diseases, also referred to as chronic diseases, are a major cause of premature death. They include cardiovascular disease, chronic respiratory disease, cancer, and diabetes mellitus. It is estimated that globally 41 million people die each year from chronic diseases, and this accounts for 71% of all deaths worldwide . It is ePhysical activity interventions have been developed in an effort to encourage individuals to be more active within both primary health care and community-based settings . ActivitDuring test and retest trials, activity trackers and pedometers were found to be valid and reliable methods of measuring steps  . Fitbit’Interventions involving changes in lifestyle such as increased physical activity, reduction in sedentary time, and weight loss can significantly reduce the risk of adults developing chronic diseases and related health complications. Weight loss programs involving dietary and physical activity education coupled with the use of an activity tracker have been shown to significantly reduce the weight of participants .While many studies involving public health interventions focus on effect and efficacy, these fail to fully evaluate the impact of such research when applied to real-world settings. The RE-AIM  framework was developed as both a planning and evaluation tool aimed at understanding the full impact of a public health intervention and how this could best be introduced into patient health care . The fraThe aim of this integrative systematic review was to comprehensively explore the reporting of the reach, effectiveness, adoption, implementation, and maintenance of using activity trackers in clinical care to support physical activity or reduce sedentary behavior in adults diagnosed with chronic diseases. The integrative methodology allows for the review of quantitative, qualitative, and mixed methods research while developing a comprehensive understanding of the RE-AIM elements reported and the particular health care problem under review .The protocol for this integrative systematic review was registered in the PROSPERO international prospective register of systematic reviews on March 23, 2022 (CRD42022319635). The review was undertaken in accordance with the PRISMA  2020 statement . All pubPICOS criteriaPopulation: Adults (18 years and older) diagnosed with a chronic diseaseIntervention type: Individual or combined use of an activity tracker within outpatient clinical careComparisons: All control or comparison groupsOutcomes of interest: RE-AIM  dimensions of using an activity tracker within outpatient clinical careStudy type: Intervention or experimental and observationalSPIDER criteriaSample: Adults (18 years and older) diagnosed with a chronic disease and adult (18 years and older) health care professionals working within a clinical capacityPhenomenon of interest: Experiences of using an activity tracker within outpatient clinical careStudy design: Qualitative and mixed methodsEvaluation: RE-AIM dimensions of using an activity tracker within outpatient clinical careResearch type: Qualitative and mixed methods A detailed search strategy was developed, with guidance from a qualified university librarian, around the core themes and RE-AIM dimensions. The key search words are displayed in The study searches were undertaken on the computer-based databases: Web of Science—Core Collection , MEDLINE , ACM , APA PsycINFO (EBSCO), Cochrane Library (Cochrane), MEDLINE , and gray literature , CORE (Core), OAIster and WorldCat.org (OCLC), and Open Access Thesis and Dissertations (OATD).Papers identified during the search phase were initially uploaded onto EndNote (Clarivate). Duplicates were identified and removed. Papers were subsequently uploaded onto the Rayyan (Rayyan Systems Inc) collaborative systematic review screening system. All remaining papers were screened on the Rayyan system by 4 authors  based on the topic, title, and abstract. Last, a full-text screening of the remaining papers was conducted by 2 authors (WH and ER). Conflicts were resolved at each stage through discussion between the screening authors without the need for an independent review.The final papers identified for review were uploaded onto a validated RE-AIM extraction Microsoft Excel spreadsheet  -14. The ReachMethod used to identify the target populationInclusion criteriaExclusion criteriaUse of qualitative methods to understand reach or recruitmentSample sizeParticipation rateSample representativesEffectivenessAssessment of the effect on outcomes at the shortest assessment pointImputation procedures reported (how missing data are processed)The presence of quality-of-life measureEffects at the longest follow-upUse of qualitative methods to understand outcomesPercent attrition or dropout rateAdoptionMethod of identifying target agentLevel of expertise of delivery agentsInclusion and exclusion criteria for target agentThe adoption rateComparison of settings or participants of adoption versus nonadoption settingsUse of qualitative methods to understand either adoption at the setting level or staff participationImplementationThe intervention type Intensity (components of intervention)The extent the protocol was delivered as intendedA measure of costUse of qualitative methods to understand the implementation of the studyMaintenanceWas an individual’s behavior assessed at least 6 months following completion of the interventionIs the program still in placeWas the program modifiedUse of qualitative methods to understand the long-term effectsEach identified journal paper was screened as previously described, and the reporting of each RE-AIM indicator was recorded on the RE-AIM data extraction sheet. The percentage of papers reporting the individual indicator was calculated.As the RE-AIM framework is an evaluation tool designed to identify and focus on the reporting of recommended dimensions and indicators within interventions, no additional risk of bias assessment was conducted .The total percentage of individual RE-AIM indicators reported from all journal papers was the main outcome measure.The search strategy identified 5619 potential studies for further analysis. After checking for duplicates, the number of eligible studies was reduced to 4585. After the topic, title, and abstract screening process, 63 studies were eligible. Full-text screening reduced this number to 15 studies for final analysis. The characteristics  of the 15 studies are reported in In total, 844 adult participants took part in the 15 studies. Of these, 412 (48.8%) were male, and 432 (51.2%) were female. The mean age of all participants was 58.3 (SD 8.6) years.The RE-AIM dimensions are supported by 28 indicators. The reach dimension is supported by 7 indicators, and the overall numbers and percentages reported are shown in The effectiveness dimension was supported by 6 indicators, and the overall numbers and percentages reported are shown in The adoption dimension was supported by 6 indicators, and the overall numbers and percentages reported are shown in The implementation dimension was supported by 5 indicators, and the overall numbers and percentages reported are shown in The maintenance dimension was supported by 4 indicators, and the overall numbers and percentages reported are shown in This integrative systematic review sets out to measure the level of reporting for each of the 28 RE-AIM indicators in studies identified during the search and screening phase. To the best of the lead author’s knowledge, no similar studies have been undertaken, and it is hoped these findings will be informative in the planning and evaluation of future public health interventions to support the management of chronic diseases. In summary, this review found that the RE-AIM dimensions of adoption and maintenance were underreported. The analysis of the indicators found that the use of qualitative methods to understand each dimension was underreported.The use of commercial activity trackers within physical activity interventions either on their own or when combined with behavior change strategies has been shown to increase activity levels and reduce sedentary behavior in people diagnosed with a chronic disease . In 2020Reach is set at an individual level and measures participation factors such as number, proportion, and representativeness of those taking part in an intervention . RE-AIM The effectiveness dimension aims to understand the impact of an intervention including outcomes, potential negative effects, wider issues such as quality of life, and variation outcomes between subgroups. These factors are vital when moving from a research environment into a real-world setting . In the The adoption dimension moves away from the individual participant level and focuses on the settings and intervention agents. In particular, this refers to where the intervention was delivered and by whom . StudiesThe implementation dimension is set at the settings level and measures how reliable and committed the delivery agent was in applying the intervention as intended along with reported monetary cost and staff time . ImplemeThe maintenance dimension is set at both the setting and individual levels. At the setting level, it refers to how well an intervention becomes part of routine health care. At an individual level, it is a measure of the long-term impact on the patient’s health. As most interventions are tested over a relatively short timescale, this is seldom reported in studies . The RE-After the initial search, all papers were double-screened at the initial title and abstract stage and full-text stage. The review was undertaken in accordance with the PRISMA 2020 statement .The initial study protocol sets out to identify specific adult age categories within each of the identified studies, for example, 18-20 and 21-30 years. As these were not reported, the protocol was amended with the focus being on adults aged 18 years and older. The lead author conducted all of the data extraction with 40% (n=6) of papers being quality-checked by 3 of the coauthors.This integrated systematic review sets out to comprehensively explore the reach, effectiveness, adoption, implementation, and maintenance of using activity trackers in clinical care to support physical activity or reduce sedentary behavior in adults diagnosed with chronic diseases. Applying the RE-AIM framework over the 5 main dimensions and 28 indicators identified a number of areas that were both well and poorly reported in studies. For this area of research, improved measurement and reporting of the dimensions adoption and maintenance are required with a focus on the settings element within studies. At an indicator level, the main area of underreporting and use was that of qualitative methods. Such methods would allow for detailed exploration of the experiences of both staff and patients at each stage of an intervention and over all RE-AIM dimensions. This would provide a better understanding of the use of activity trackers within clinical care for adults diagnosed with a chronic disease. Qualitative thematic hematic analysis involving one-to-one interviews or focus groups conducted at the prestudy, during the study, and poststudy stages with health care staff and participants would provide a greater understanding of the strengths and weaknesses of an intervention. The RE-AIM framework and findings from this systematic review also provide an insight into how such interventions could be applied in a clinical setting focusing on the dimensions of reach, effectiveness, adoption, implementation, and maintenance. The limited reporting of adoption and maintenance in studies makes it difficult to progress from a research study setting into the real-world health environment. Better reporting of these dimensions in studies would help clinicians in using activity trackers during patient care.


Cervical myofascial pain is a very common clinical condition in the daily practice of musculoskeletal physicians. Physical examination is currently the cornerstone for evaluating the cervical muscles and identifying the eventual presence of myofascial trigger points. Herein, the role of ultrasound assessment in precisely localizing them is progressively mounting in the pertinent literature. Moreover, using ultrasound, not only the muscle tissue but also the fascial and neural elements can be accurately located/evaluated. Indeed, several potential pain generators, in addition to paraspinal muscles, can be involved in the clinical scenario of cervical myofascial pain syndrome. In this article, the authors extensively reviewed the sonographic approach for cervical myofascial pain in order to better diagnose or guide different procedures that can be performed in the clinical practice of musculoskeletal physicians. Chronic non-specific neck pain is one of the most frequent reasons for medical consultation with primary care physicians and pain clinics ,2. It isThe main purpose of this paper is to extensively review the scientific literature pertinent to both US assessment of cervical myofascial pain and US-guided procedures. The authors tried to propose an easy-to-use guide for the clinical practice of musculoskeletal physicians.In order to develop a practical, ready-to-use guide concerning the US-guided procedures used for cervical myofascial pain, the authors planned a three-step workflow as described below:1st Phase: An extensive review of the scientific literature related to the anatomical, histological, biochemical, and sonographic features of MTrPs was performed. Of note, correct identification of MTrPs using US requires a comprehensive knowledge of their histo-anatomical features.2nd Phase: Focusing on the cervical MPS, the review was expanded to (i) pain generators different from the MTrPs e.g., fascial/neural structures and, (ii) US-guided interventions commonly described in the literature. The complex interaction between several tissues (as pain generators) at the level of the cervical spine is a real challenge to tackle for musculoskeletal physicians.3rd Phase: Based on the aforementioned phases of the workflow, a “pain generator-based approach” for US-guided procedures in cervical MPS was proposed.MTrP complexSonographic assessment of the MTrPsFascial structures and neural elementsUS-guided proceduresConsidering the nature of the present review, the authors combined the results and discussion sections in order to provide a step-by-step approach to cervical MPS, as follows:For each and every pain generator potentially involved in cervical MPS, the corresponding interventional technique was described in order to optimize the practical management of patients in daily practice .The painful area in MPS is usually characterized by the presence of multiple elements anatomically and functionally connected to each other, i.e., collectively known as the MTrP complex ,2. The tStructural changes of the muscle fibers and endomysium are both considered the main histopathological features leading to macroscopic abnormalities of the muscle echotexture with the development of well-known hypoechoic nodules. Some authors have also demonstrated the use of magnetic resonance imaging whereby focal edematous changes  related to the local presence of abnormal fluids inside the micro-cracks of the intercellular scaffold of the skeletal muscle  can be detected ,15. InteThe clinical effects of massage could be partially related to the squeezing/drainage of extra water bound to the glycosaminoglycans within the intercellular matrix of the painful muscle area . The autThe typical pattern of MTrPs during US assessment is characterized by a focal hypoechoic area with heterogeneous internal texture ,8. Its mConsidering the complex anatomical architecture of the muscles and fasciae of the cervical spine, a step-by-step sonographic approach is suggested to optimize the evaluation of patients with myofascial pain. Herein, the authors suggest starting with a wide sonographic scan of the painful area. It is noteworthy to acquire a panoramic view of both the superficial and deep muscle layers. This pre-procedural phase can be very helpful, especially in patients in whom identification of MTrPs is otherwise difficult , either due to concomitant/diffuse cervical muscle spasm or their deep localization. Likewise, especially for beginners, a slow shift of the probe over the painful area is recommended to accurately depict minor changes in the muscle echotexture.In doubtful cases, the probe can be gently tilted to avoid fake hypoechogenicity of the muscle tissue related to the anisotropy artifact ,17. IndeSecond, B-mode evaluation should be coupled with power Doppler imaging for each and every patient in clinical practice. Not simply the intra/peri-nodular perfusion pattern, but also the eventual location of large neurovascular elements surrounding the MTrP, can be promptly assessed  11]. Th. Th11]. Lastly, the authors suggest always performing precise sono-palpation of the hypoechoic nodule to verify if the local or referred pain of the patient can be reproduced exactly. For sure, compression can be performed either directly with the (footprint of the) probe or with the fingertip  under real-time US guidance. Referred pain evoked by direct compression of the trigger point would be related to (i) the spatial orientation of the taut band harboring the nodule and (ii) the aforementioned biochemical milieu of the intercellular matrix activating/irritating the muscle nociceptors ,5.In the literature, Taheri et al. reported a sensitivity of 91% and specificity of 75% for US imaging to identify MTrPs within the upper fibers of the trapezius . LikewisAs previously mentioned, cervical MPS is a very complex clinical condition presenting with multiple pain generators cross-talking with each other. As such, not only the MTrPs but also the superficial and deep fasciae, peripheral nerves, and cutaneous branches of the dorsal rami (CBsDR) of spinal nerves can be involved in the clinical scenario .Superficial and deep fascia. The superficial fascia is a fibroelastic structure running within the subcutaneous tissue. It is connected to the overlying dermis and the underlying deep fascia through tiny skin ligaments known as the retinaculum cutis superficialis and profundus . Of. Of29]. Cutaneous branches of the dorsal rami of the spinal nerves. Anatomical studies have described four main segments of the CBsDR of spinal nerves at the level of the cervical spine  mechanical pressure over the MTrPs  and (ii) stretching of the affected muscle . ConsideA specific procedure or a combination of multiple interventions should be accurately selected in relation to both clinical and US findings . For insConsidering the above-quoted sonographic approach to MTrPs, it is crucial to accurately localize the hypoechoic nodule and its spatial relation with the surrounding neurovascular structures before performing the injection ,10. For A linear, high-frequency US transducer is commonly used for imaging the cervical spine to ensure a high spatial resolution while assessing superficial tissues. The authors suggest using an in-plane technique to clearly visualize the needle for its whole length during the entire procedure . SeveralAs regards technical aspects of the procedure, also considering the aforementioned histopathological features of MTrPs, the authors suggest combining multiple steps and not only injecting inside the hypoechoic nodule . HoweverIn the relevant literature, low-quality evidence suggests a superior effect of MTrP injections with local anesthetic for decreasing cervical muscle pain in the short term as compared with dry needling ,40. BaseIn patients with diffuse cervical muscle contraction and absence of clinically and/or sonographically detectable painful MTrPs, US-guided injections of the interfascial planes can be performed to selectively block specific peripheral nerves. Indeed, within the virtual space between different muscular layers of the cervical spine, many neural structures run, and they are surrounded by connective tissue rich in collagen fibers and loose connective tissue of the areolar type with a variable number of adipose cells . Among mThe SAN can be easily visualized and blocked within the anatomical interface between the trapezius and levator scapulae muscles  28]. Th. Th28]. The DSN can be promptly visualized and blocked within the anatomical plane between the rhomboid muscles and the thoracic wall  25]. An. An25]. Interestingly, some authors have described a multi-target technique to manage myofascial upper back pain: (i) blocking the SAN and DSN through interfascial hydro-dissection, and (ii) injecting the trapezius, levator scapulae, and rhomboid muscles simultaneously . Indeed,As previously mentioned, the deep fascia is a highly innervated and multi-layered fibrous structure that is extensively crossed by the CBsDR of spinal nerves ,32. NormMore superficial layers of the deep fascia are in continuity with the hyperechoic honeycombing fibrous scaffold of the subcutaneous tissue, and they generate a unique functional framework . In the US-guided hydro-dissection of the deep fascia can be considered an “advanced” interventional technique that simultaneously targets the intrafascial free nerve endings and the perforating cutaneous branches alike ,31. ThesCervical MPS is a very common but quite challenging clinical condition. In this review, the authors proposed a ready-to-use guide in the clinical practice of musculoskeletal physicians. It is a pain generator-based approach to describing the different US-guided interventions while targeting the neuromyofascial cervical tissues.


Severe traumatic brain injury (sTBI) is an important cause of disability and mortality and affects people of all ages. Current scientific evidence indicates that motor dysfunction and cognitive impairment are the main limiting factors in patients with sTBI. Transcranial direct current stimulation (tDCS) seems to be a good therapeutic option, but when it comes to patients with sTBI, the results are inconclusive, and some protocols have not yet been tested. In addition, there is still a lack of information on tDCS-related physiological mechanisms, especially during the acute phase. In the present study, based on current evidence on tDCS mechanisms of action, we hypothesized that performing tDCS sessions in individuals with sTBI, especially in the acute and subacute phases, together with conventional therapy sessions, could improve cognition and motor function in this population. This hypothesis presents a new possibility for treating sTBI, seeking to elucidate the extent to which early tDCS may affect long-term clinical outcomes. Severe traumatic brain injury (sTBI) is a major cause of death and disability affecting all ages worldwide with nearly 70 million new cases each year . Brain iPhysical disability after sTBI  is considerably higher in comparison with able-bodied individuals , leadingNon-invasive brain stimulation (NBIS) has been recommended for treating cognitive impairments and functional limitations in people with neurological and psychiatric disorders . A widelThus, depending on the size and location of the electrodes applied, tDCS may focally suppress or to modulate neuronal firing after sTBI, which may offer a promising method to minimize damage and promote functional recovery. In addition, cathodal and anodal tDCS can be used to suppress and increase, respectively, the excitability of neurotransmitters such as glutamate and GABA (gamma-aminobutyric acid) that are part of the cascade of neurochemical responses that occurs after brain trauma. Cathodal tDCS can be used to suppress acute glutamatergic hyperexcitability after sTBI. In the subacute phase, high levels of GABA can cause excessive inhibition, making recovery difficult. Therefore, modulation of GABAergic inhibition may be beneficial to minimize the functional impact at this stage. Finally, in the chronic phase of TBI, brain stimulation combined with rehabilitation can improve behavioral recovery, learning of new skills, and cortical plasticity .Previous research have demonstrated positive results after stroke , such asStudies showing positive results of tDCS after sTBI were performed in individuals in the chronic phases of trauma , revealiThe searches were performed in the Medline database and the reference lists of included studies were screened to identify further relevant studies. Seven randomized controlled trials that analyzed the potential effects of tDCS on brain activity in individuals with a disorder of consciousness after sTBI were included. Detailed information was provided in The first study examined the effects of a single session of tDCS over left DLPFC cortex in 55 participants. The experimental group received 20 min of stimulation at 2 mA. The control group received a sham-stimulation. There was a significant difference in favor of the experimental group on consciousness, in people with severe brain damage .The second study examined the effects of 10 consecutive sessions of tDCS over left DLPFC cortex in 36 participants. The experimental group received 20 min of continuous direct current stimulation at 1 mA. The control group received a sham-stimulation. There was a significant difference in favor of the experimental group in the regulation of cortical excitability .The third study examined the effects of 10 sessions of tDCS over the left DLPFC cortex (their specific location depended on participants’ damaged area) combined with computer-assisted training, 2 times per day, in 22 participants. The experimental group received 20 min of tDCS stimulation followed by 30 min of attention training. The control group received a sham-stimulation followed by 30 min of attention training. There was a significant difference in favor of the experimental group on neural reorganization and cognitive effort .The fourth study examined the effects of 5 consecutive sessions of tDCS over left DLPFC cortex in 16 participants. The experimental group received 20 min of stimulation at 2 mA. The control group received a sham-stimulation. There was a significant improvement on the recovery of consciousness in some chronic patients of the experimental group .The fifth study examined the effects of 5 consecutive sessions of tDCS over left DLPFC cortex in 13 participants. The experimental group received 20 min of stimulation at 2 mA. The control group received a sham-stimulation. There was no difference between-groups on short-term clinical and EEG in patients with prolonged disorders of consciousness .The sixth study examined the effects of 20 sessions of tDCS over left DLPFC cortex, 5 times per/week, during 4 weeks in 27 participants. The experimental group received 20 min of stimulation at 2 mA. The control group received a sham-stimulation. There was a significant difference in favor of the experimental group on signs of consciousness in chronic minimally conscious state patients .The last study examined the effects of a single session of tDCS over left parietal cortex in 30 participants. The experimental group received 20 min of stimulation at 2 mA. The control group received a sham-stimulation. There was no difference between-groups on working memory .Overall, the experimental groups always received stimulation during 20 min at 2 mA; however, the session frequency and program duration varied across trials. The control group always received a sham-stimulation. Most trials reported positive results in favor of the experimental group, which suggests that brain stimulation has a significant effect in outcomes in individuals with disorder of consciousness after TBI. On the other hand, most studies similar methodological limitations: small sample size, heterogeneity regarding participants’ baseline conditions  and medical support, lack of follow-up measurements.Studies have shown that tDCS has the potential to regulate brain function by activating the cerebral cortex using electrical current and may, therefore, induce an increase or decrease in motor cortical excitability, depending upon the polarity of tDCS . In addiOur hypothesis is that tDCS applied during the acute phase in individuals with sTBI may facilitate brain plasticity. The anode may promote depolarization of the neuronal membrane and long-term potentiation, which may stimulate hypoactive brain areas. Otherwise, the cathode, which has an inhibitory function, would hyperpolarize the neuronal membrane and promote long-term depression, which may inhibit overactive brain areas . BecauseThe integrity of white matter–mainly of the stimulated network–in TBI patients may be a factor that positively influences tDCS efficacy in such patients. A study performed by Li and colleagues that anodal stimulation improved response inhibition in control participants, an effect that was not observed in the patient group. The extent of traumatic axonal injury within the salience network strongly influenced the behavioral response to stimulation. Increasing damage to the tract connecting the stimulated right inferior frontal gyrus/anterior insula to the rest of the salience network was associated with reduced beneficial effects of stimulation. In addition, anodal stimulation normalized default mode network activation in patients with poor response inhibition, suggesting that stimulation modulates communication between the networks involved in supporting cognitive control. This is important because can show how patients with TBI can to have positive response to the tDCS approach.One recommendation is that the severity of encephalopathy following sTBI can be objectified through neurophysiological examinations, such as electroencephalogram. To better characterize the effect of tDCS, a combination of clinical evaluations with electroencephalogram, transcranial magnetic stimulation, and/or other neurophysiological assessments may help in the development of higher quality tDCS studies in sTBI. TMS may be particularly helpful for monitoring motor responses . In addiUnfortunately, there is a lack of evidence to support or refute the hypothesis of the beneficial effects of tDCS on cognition and motor function in patients with sTBI in the acute/subacute phases , AlthougBesides, previous studies have suggested benefits of TMS at chronic stages after TBI , the effRehabilitation of individuals after sTBI has major therapeutic challenges influenced by lesion severities, phases, or symptoms. The tDCS applied to individuals with sTBI in the acute phase of the injury may have a facilitating effect on the mechanism of brain plasticity, since the anode electrode promotes depolarization of the neuronal membrane and LTP, and the cathode electrode hyperpolarizes the neuronal membrane and promotes LDP . In addiA previous systematic review revealed that new studies are needed to establish tDCS parameters such as electrode positioning, current density, duration, and stimulation intervals, as well as their effects in combination with concomitant therapies. Based on the risks of polypharmacy after sTBI, tDCS may be useful for reducing the need for drugs, or at least counteracting their cognitive side effects. In addition, improved biomarkers of neural damage due to sTBI can help understanding the mechanisms underlying the neurophysiological effects of tDCS and estimating its clinical effects and monitoring therapy. sTBI is a heterogeneous disorder and aids therapists in adapting therapy or identifying those who will most benefit. This becomes particularly challenging as sTBI is typically associated with multiple comorbidities and interventions .Until now, most studies after sTBI were carried out during the chronic phase . There aOn the other hand, despite the growing interest in developing effective and innovative treatment approaches to improve outcomes after sTBI, the application of tDCS in the acute and subacute phases is challenging due to the high probability of epilepsy, unstable clinical conditions and other procedures such as craniectomy decompression and craniotomy that may limit the application of this technique . It is wThe effects of tDCS isolated or in combination with other therapies, as well as the most appropriate doses and intensities for improving motor and cognitive outcomes early after sTBI need to be elucidated. Although preliminary studies have suggested potential effects of tDCS, the current evidence is insufficient to precisely estimate the size effects of applying tDCS in individuals with sTBI. It would be interesting to show the effects of tDCS or an estimate of its effect sizes only in the treatment of patients with TBI by performing a systematic review with meta-analysis in which a qualitative and quantitative analysis of the RCTS data is performed, we have this gap in the literature. The hypothesis raised in this manuscript by the authors and its applicability in the next studies should be carried out to investigate the effects of tDCS in the rehabilitation of TBI patients in the acute/subacute phase.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors contributed to the development of the manuscript and read and approved the final version of the manuscript.


Pleiotrophin (PTN) is a cytokine which has been for long studied at the level of the central nervous system, however few studies focus on its role in the peripheral organs. The main aim of this review is to summarize the state of the art of what is known up to date about pleiotrophin and its implications in the main metabolic organs. In summary, pleiotrophin promotes the proliferation of preadipocytes, pancreatic β cells, as well as cells during the mammary gland development. Moreover, this cytokine is important for the structural integrity of the liver and the neuromuscular junction in the skeletal muscle. From a metabolic point of view, pleiotrophin plays a key role in the maintenance of glucose and lipid as well as whole-body insulin homeostasis and favors oxidative metabolism in the skeletal muscle. All in all, this review proposes pleiotrophin as a druggable target to prevent from the development of insulin-resistance-related pathologies. Ptn gene encodes a basic protein of 168 amino acids, that after post-transcriptional modifications, renders the active protein composed of 136 amino acids and a 32 amino acid signal peptide (Pleiotrophin (PTN) is an 18-kDa neurotrophic heparin-binding factor that was simultaneously described by several groups around 1990 . Ptn gen peptide , 6. In a peptide .Ptn expression is highly upregulated during embryonic development and during early cell differentiation  in controlling peripheral metabolism has been extensively described in the literature . The conPtn deletion protects against neuroinflammation, mitochondrial dysfunction, and aberrant protein aggregation in a high fat diet (HFD) induced obesity model (PTN is a potent modulator of neuroinflammation in the CNS  and partty model .In this review we summarize the main roles of pleiotrophin in the development and metabolism of key metabolic organs (Ptn expression and secretion is induced in the hepatic stellate cells (HSCs) and once secreted, PTN exerts its mitogenic effects on hepatocytes (3K/Akt/mTORC1 pathway what increases the levels of sterol regulatory element‐binding protein 1c (SREBP‐1c) and the expression of lipogenic genes, inducing fatty acid synthesis  and NUR77 activation that impairs lipid and carbohydrate metabolism. As a consequence, in the absence of pleiotrophin, a marked reduction in fatty acid, triacylglyceride and cholesterol synthesis is observed in the liver. Additionally, hepatic secretion of triacylglycerides and hepatic lipid accumulation are reduced in the pregnant Ptn knock out mice  which are important cell types implicated in the NMJ  and it is distributed in the basement membranes and epithelial cell surfaces –73. Firsmyotubes . Moreovemyotubes . PTN hasmyotubes . Moreove the NMJ . PTN als the NMJ .milieu, platelets and myogenic precursor cells start secreting various growth factors, to counteract the deleterious effects of a muscle lesion , under the control of the human bone specific osteocalcin promoter, exhibit higher oxidative metabolism in soleus muscle. This increment in oxidative metabolism may be the consequence of the enrichment in the number of the highly oxidative type 1 fibers, and higher mRNA levels of ATP-sensitive K+ channel (Abcc8), cytochrome c oxidase subunit IV (Cox4i1), and citrate synthase (Cs), and increased vascularization  via the Wnt/β-catenin pathway, the activation of ADAMTS1 could also play a role in preadipocyte differentiation , two adipocyte genes involved in the pathophysiology of obesity and insulin resistance, was found in the adipose tissue of obese mice fed with HFD (Some micro-RNAs that regulate adipogenesis have been involved in the development of metabolic disorders such as obesity and diabetes . miR-143pression . An up-rwith HFD .Ptn knock out mice model (Ptn-/-) reveal that Ptn deletion is associated with decreased body weight and adiposity, altered fat distribution, impaired periovarian white adipose tissue expandability, increased catecholamine-induced lipolysis and reduced inhibitory response to insulin of lipolysis  and increased fatty acid thermogenesis in brown adipose tissue .Pleiotrophin has been widely studied in the field of cancer and much work has been also carried out to analyze its implications in the CNS. In this review, we summarize the main actions of PTN at the main metabolic peripheral organs obtained from the experiments in which pleiotrophin levels are increased (by recombinant pleiotrophin administration and transgenic overexpression) or reduced (by miRNA, siRNA, neutralizing antibodies or Ptn in the muscle enhances vascularization and oxidative muscle metabolism through an increment in the activity of citric acid cycle and electron transport system. No evidence is available yet regarding the effects of Ptn deletion on muscle oxidative metabolism. However, the actions of PTN on oxidative metabolism and whole-body energy expenditure are also derived from the effects of PTN on adipose tissue and liver. Ptn expression increases in preadipocytes during confluence and quickly decreases once differentiation starts. In fact, when adipocyte differentiation starts miR-143 levels start to increase what may repress Ptn expression and treatment with rPTN inhibits preadipocyte differentiation. Nevertheless, pleiotrophin deletion impairs fat accumulation and the expansibility of adipose tissue and favors lipolysis of triacylglycerides in the adipose tissue and free fatty acid release. Moreover, pleiotrophin deletion induces browning in white adipose tissue and increases the thermogenic activity of the brown adipose tissue increasing the use of fatty acids instead of carbohydrates for energy production. The role of PTN on hepatic lipid metabolism and development has also been clearly evidenced. PTN expression increases during liver regeneration and development. Additionally, the overexpression of pleiotrophin has also shown to increase fatty acid synthesis and the expression of lipogenic genes. However, Ptn deletion decreases both the liver size and the gene expression of proteins involved in lipogenesis, both during late pregnancy and in a HFD-induced obesity mice model, and thus may protect against steatosis.In the mammary gland, this cytokine favors tumor growth and progression and delays the full development of the tissue. In this line of evidence, blocking PTN with anti-PTN antibody enhanced ductal development in the mammary glands. Pleiotrophin is expressed in the young endocrine pancreas and in the adult pancreas and it is overexpressed during β cell regeneration after streptozotocin treatment. Moreover, the administration of recombinant pleiotrophin in an insulinoma cell line induces β cell expansion and enhances the expression of insulin-related genes. In the muscle, pleiotrophin is overexpressed during tissue regeneration. Transgenic overexpression of Ptn knock out and transgenic animal models to fully elucidate the implications of this cytokine in pancreas functionality and muscle metabolism.These findings suggest a role for pleiotrophin in the development of pathologies related to insulin resistance such as aging or diabetes, however, much effort is still needed to fully understand and deepen the knowledge of the field. We believe in the importance of a more profound and further characterization of All authors contributed to the writing and review of the manuscript. All authors have read and agreed to the published version of the manuscript. The article is an original work, that hasn’t received prior publication and isn’t under consideration for publication elsewhere.


Coal gangue image recognition is a critical technology for achieving automatic separation in coal processing, characterized by its rapid, environmentally friendly, and energy-saving nature. However, the response characteristics of coal and gangue vary greatly under different illuminance conditions, which poses challenges to the stability of feature extraction and recognition, especially when strict illuminance requirements are necessary. This leads to fluctuating coal gangue recognition accuracy in industrial environments. To address these issues and improve the accuracy and stability of image recognition under variable illuminance conditions, we propose a novel coal gangue recognition method based on laser speckle images. Firstly, we studied the inter-class separability and intra-class compactness of the collected laser speckle images of coal and gangue by extracting gray and texture features from the laser speckle images, and analyzed the performance of laser speckle images in representing the differences between coal and gangue minerals. Subsequently, coal gangue recognition was achieved using an SVM classifier based on the extracted features from the laser speckle images. The fusion feature approach achieved a recognition accuracy of 94.4%, providing further evidence of the feasibility of this method. Lastly, we conducted a comparative experiment between natural images and laser speckle images for coal gangue recognition using the same features. The average accuracy of coal gangue laser speckle image recognition under various lighting conditions is 96.7%, with a standard deviation of the recognition accuracy of 1.7%. This significantly surpasses the recognition accuracy obtained from natural coal and gangue images. The results showed that the proposed laser speckle image features can facilitate more stable coal gangue recognition with illumination factors, providing a new, reliable method for achieving accurate classification of coal and gangue in the industrial environment of mines. Coal is an important primary energy that plays a significant role in supporting the steady and rapid development of the global economy and society. During the process of coal mining, separation coal from gangue  represents a critical processing step, promoting the efficient and comprehensive utilization of coal. Traditional methods for coal and gangue separation involve manual sorting, where operators rely on their subjective judgment based on the appearance, density, and other characteristics of coal and gangue for identification and separation. This method heavily relies on the subjective judgment of operators, which introduces a level of variability and potential errors in the separation process. Moreover, manual sorting is labor-intensive and time-consuming, resulting in increased costs and reduced efficiency. Mechanical separation techniques, such as the jigging process and heavy medium separation, are also used in industrial production ,2. TheseWith the rapid development of sensing and computer technologies, exploring more intelligent and automated technical solutions for coal gangue separation has become a hot topic in the field of coal mining ,5. In reTo improve the reliability of feature extraction while accounting for illumination, an increasing number of advanced sorting methods using different light sources have been proposed and tested by some scholars for automatic or intelligent recognition of coal and gangue, including infrared detection ,21, X-raSince the advent of the laser technique, speckle generated by coherent lasers has received great attention. Many scholars have studied the statistical characteristics of speckle patterns and proposed techniques for measuring surface roughness ,30,31,32This article proposes a novel method for coal gangue recognition based on laser speckle imaging and explores its feasibility and stability for distinguishing coal from gangue. Firstly, the principle of laser speckle was analyzed, and specific techniques for feature extraction, including grayscale and texture analysis, were introduced. The inter-class separableness and the intra-class compactness of collected laser speckle images of coal and gangue were evaluated using boxplots of the extracted features. The feasibility of this approach was confirmed by utilizing an SVM classifier based on the extracted features from coal gangue laser speckle images to recognize coal and gangue. Furthermore, to assess the stability of the proposed method in coal gangue recognition under varying illuminance levels, comparative experiments were conducted with a natural image-based feature recognition method. These experiments aimed to simulate the weak and unstable lighting conditions typically encountered in production site scenarios. Six sets of coal gangue natural images and coal gangue laser speckle images were collected at illuminance levels of 100, 288, 442, 672, 770, and 912 lux. The coal gangue recognition accuracy of these two types of images was compared under different illuminance levels to evaluate the stability of this new approach with respect to lighting conditions during image acquisition.The molecular orientation, density fluctuation and interaction with matter in the surface medium cause light to deviate from the original propagation direction as the surface of coal and gangue is irradiated by single-wavelength light, which is light scattering. When coherent light is incident on the surface of a scattering medium, the scattering direction and intensity of light are influenced by factors such as particle size, shape, composition, and surface roughness, resulting in random scattering patterns. The mutual interference of these scattered light waves gives rise to a random distribution of speckles, known as laser speckle . The obsP on the ε plane, its complex amplitude is U0(P), and s is a diffraction surface element. The microscopic surface of coal and gangue is composed of a large number of mutually unrelated scattering points, and each point area is a diffraction surface element. When the laser beam is irradiated to the diffraction surface element point, a complex amplitude superposition is formed on the observation plane. According to the Fresnel principle , the comx0y0 plane and the observation point is in the xy plane, Equation (1) can be expressed as follows:If the aperture plane is in the With Fresnel approximation, the impulse response can be approximately expressed as:z is the distance from the diffraction surface element to the observation plane. The imaging system from the diffraction plane element to the observation plane is regarded as a linear space-invariant system. The light intensity at a point on the observation plane is expressed as:z from the diffraction surface element to the observation plane, and the distance z is affected by the surface roughness. The speckle distributions of laser speckle images formed by different surface roughness of samples are also different.It can be seen from the above that the speckle intensity distribution at each point of the observation plane is related to the distance Coal and gangue have different surface morphology characteristics, and the surface microscopic diagram is shown in The laser speckle image of coal gangue is formed by irradiating the surface of coal and gangue with coherent light, as shown in The gray histogram  of the ib is a gray level in a coal gangue laser speckle image, ranging from 0 to 255; n(b) represents the number of pixels of gray level b; M × N is the pixel area in the coal gangue laser speckle image.m), gray standard deviation (σ), skewness (s), and kurtosis (k). The calculation formulas are as follows:Four statistical characteristics are extracted based on the distribution of the gray histogram, namely gray mean (ASM), entropy (ENT), contrast (CON), and inverse difference moment (IDM).The gray level co-occurrence matrix (GLCM) is defined by the joint probability density of pixels in two positions, which not only reflects the brightness distribution, but also the position distribution between pixels with the same brightness in the reaction space. In this paper, four independent texture features based on GLCM are extracted, including angular second moment :ENT, reflecting the randomness of image information, is defined as Equation (12) when all values in the co-occurrence matrix are equal or pixel values exhibit maximum randomness. By comparing the entropy of coal and gangue images, their textural complexity can be differentiated.CON, reflecting the clarity of the image and the depth of the texture, is defined as Equation (13). In coal gangue identification, CON can reflect the clarity of mineral textures.IDM, reflecting the degree of local change of image texture, is defined as Equation (14).j, k) with adjacent intervals in the α is 45°, d is 1.A coal gangue laser speckle observation instrument was set up, as depicted in During the acquisition of mineral laser speckle images, the industrial camera was fixed on the carrier platform perpendicular to the surface of the coal gangue samples at 460 mm. To ensure a high contrast in the scattered speckle images of coal gangue, the exposure time of the industrial camera was set at 3000 μs. The laser source was positioned at an angle of 15° relative to the direction of the industrial camera, with the collimating and beam expanding system placed directly behind it. The coal gangue samples were placed on the carrier platform, and the coherent beam was irradiated onto the surface of the samples through the beam system. The industrial camera captured the laser speckle patterns with varying intensity distributions on the surface of the coal gangue samples. To control the illuminance environment, an adjustable LED light source was used to collect images under different lighting conditions.The background areas of the original coal gangue laser speckle images collected by the experiment are large. The speckle regions of interest were extracted from the laser speckle images in order to improve the speed and accuracy of the feature extraction of the coal gangue laser speckle images.The propagation of coherent beams in the air is affected by suspended air particles, which introduce shot noise. In this study, Gaussian filtering was used to remove such noise from the laser speckle images during the acquisition process. The Gaussian filter convolves the image with a Gaussian kernel, which assigns weights to neighboring pixels based on their distance from the center pixel. These weights were determined using a Gaussian distribution with a specified standard deviation. By adjusting the standard deviation, we can fine-tune the denoising effect to match the specific noise characteristics and desired image quality. The Gaussian filtering method effectively balanced noise reduction and preservation of important image details, resulting in improved quality of the collected laser speckle images. After graying and Gaussian filtering, the maximum between-class variance (Otsu)  adaptiveIn the experiment, 120 laser speckle images of coal and gangue under natural illuminance were collected, and their gray and texture features were extracted according to The boxplots of the four gray feature parameters of the coal gangue laser speckle images are shown in The box diagram of the four texture feature parameters of the coal gangue laser speckle images is shown in The median lines of coal laser speckle image features (except for gray mean) are observed to lie outside the box of corresponding gangue features. This observation suggests a significant difference in the central tendencies of these features between coal and gangue samples. Such findings provide evidence for the strong inter-class separability of the two categories based on the analyzed features. Furthermore, the texture features outperformed the gray features, as evidenced by the more pronounced spacing between the feature boxes of the two minerals. Moreover, the box lengths representing the interquartile ranges can indicate the degree to which a feature distribution is stretched or compressed. Since the image features vary significantly in magnitude, we conducted scale standardization on the interquartile ranges to facilitate the comparative analysis of all features in capturing the intra-class compactness of minerals. The standardized outcomes are depicted in Using the aforementioned features of coal gangue laser speckle images as input, coal gangue recognition was realized based on the SVM recognition model. SVM ,45, whicThe identification feasibility of coal gangue laser speckle images was explored in this study. However, only one kind of illuminance was studied, whereas the illuminance environment of the actual coal caving site is weak and unstable, which seriously affects the feature extraction and coal gangue recognition accuracy. Therefore, in order to verify the role of the research method in this paper to solve this problem, in the future, it is necessary to collect more kinds of illuminance from different minerals to assess whether the proposed research method is universal. In order to further discuss and verify the stability of coal gangue laser speckle image recognition to illuminance, an image acquisition system with controllable illuminance was established to collect the coal gangue natural images and coal gangue laser speckle images, and each group was illuminated with an illuminance of 100, 288, 442, 672, 770, and 912 lx. The gray and texture features of the coal gangue natural images and coal gangue laser speckle images under different illuminances were abstracted, and the training set and test set were divided according to 7:3; the recognition accuracy of two different images with different illuminances is shown in It can be observed from This paper presents a novel method for identifying coal and gangue under different lighting conditions using laser speckle imaging technology. The analysis of four gray features and four texture features confirms that laser speckle images effectively demonstrate the differences in the distribution of these minerals. The extracted texture features show better inter-class separability and intra-class compactness compared to the gray features. Using a single texture feature, the SVM model achieves an average recognition accuracy of 86.1% for coal and gangue, outperforming the accuracy of 71.3% achieved by a single gray feature. By fusing all the extracted features, the model’s recognition capability is positively optimized, resulting in an increased accuracy of 94.4%. Furthermore, the proposed method achieves an average recognition accuracy of 96.7% under different lighting conditions, with a maximum accuracy of 98.7%. These results significantly surpass the recognition accuracy obtained from natural coal and gangue images using the same features. The method also exhibits good stability in coal and gangue recognition with a smaller standard deviation of recognition accuracy. Based on the above aspects, the proposed method shows great promise for coal and gangue identification in practical production applications, particularly under challenging lighting conditions. It can also be extended to address other image-related tasks in coal mining processes conducted in low-light and unstable environments. For instance, it can be employed for identifying equipment failures in underground mines and detecting and measuring deformations in roadway structures. Furthermore, this paper only focuses on training models using the eight typical coal and gangue image features. Future research can explore feature design methods to enhance the performance of the proposed method. For example, researchers can incorporate morphological features to further explore the performance of local texture information in laser speckle for reflecting mineral categories. Additionally, considering the impact of model parameters and structure on recognition accuracy, research on model optimization methods is necessary to improve their recognition accuracy and stability.


Aspergillus niger, which was discovered to produce large amounts of citrate, a primary metabolite mainly used today as a food additive  and yeasts  are commonly utilized as production hosts. However, when the genomes of the first filamentous fungi were sequenced two decades ago, researchers realized that they contained more genes involved in degradation of plant polymers  and production of secondary metabolites than had been previously realized. Nevertheless, the challenges of realizing this potential are substantial: filamentous fungi are difficult to grow at high density in liquid cultures due to pellet formation; genetic manipulation methods are complicated, as compared to the cases of bacteria and yeasts; and strain development via recombination is time-prohibitive. Therefore, the implementation of existing strategies in new ways and the development of new metabolic and genetic engineering techniques is essential for the production of high-value enzymes and primary and secondary metabolites from fungi for scientific and commercial use.In the wider field of microbial production of valuable compounds, bacteria . With the significant reduction in production of extraneous chemicals, the efficiency and quantity of directed metabolite synthesis via heterologous expression by this host was greatly increased.Yamaguchi et al. characterized a biosynthetic gene cluster (BGC) involved in synthesis of the novel cyclic peptide compound KK-1 in the filamentous fungus Curvularia clavata. They identified candidate BGCs using two methods. The first method was to sequence the genome of the fungus and mine genes with non-ribosomal peptide synthetase (NRPS) motifs. The second method was to identify BGCs whose expression was induced after growth in target-compound-producing culture conditions. Both methods led to the same candidate: a 10-gene BGC spanning 71 kb. Deletion mutants of cluster biosynthetic genes eliminated KK-1 production, while overexpression of the cluster transcription factor gene enhanced KK-1 production. The series of experiments described represents an excellent laboratory roadmap leading to the identification and characterization of a novel BGC.Tamano and Yoshimi summarized and commented on research reports relevant to valuable metabolite production in filamentous fungi. They described methods that can be used to improve the metabolism of filamentous fungal strains to make them more suitable for mass production of target metabolites. In addition, heterologous production was cited as an important method for mass production in cases where metabolic modification cannot be applied to the original producing strains, owing to fermentation difficulties or to intractable genetic methods.In their opinion article, Umemura and Tamano summarized efforts to improve the production of peptidyl secondary metabolites. Fungal peptidyl compounds are synthesized by either an NRPS or a ribosome. Proteins synthesized by ribosomes that undergo post-translational modifications are referred to as RiPPs . The authors described multiple approaches to improve the production of this important class of secondary metabolites, focusing primarily on directed strain enhancement techniques, and discussed published examples from the literature.A. oryzae by deletion of the SREBP regulatory system and by increasing the availability of the polyketide precursor acetyl-CoA by overexpressing snf1 (A. oryzae by disrupting the gene agsB, which is responsible for the biosynthesis of α-1,3-glucan, a major cell wall component, and the genes sphZ and ugeZ, which are responsible for the biosynthesis of galactosaminogalactan, an extracellular polysaccharide. A mutant strain with these genetic changes produced a significant increase in yields of recombinant protein per unit culture volume. The work described here helps with efforts to increase the production of valuable metabolites in filamentous fungi.The four papers published in this Research Topic describe an array of technologies and approaches directed at increasing the production of primary and secondary metabolites, including peptidyl compounds, through the improvement of host strains, BGC identification, and implementation of new productivity-enhancing strategies. However, neither efforts to enhance production of polyketide compounds nor the impact of hyphae morphology on production are mentioned. These two factors are important to consider with reference to the production of valuable metabolites. Here, we mention two recent papers that cover these topics. Along with peptidyl compounds, polyketides are a major class of secondary metabolites that are often produced at a low level or not at all in laboratory cultures. Production of the polyketide curcumin was recently increased more than sixfold in ing snf1 . RegardiKT drafted the text of the editorial. DB and AY reviewed and revised the draft. All authors contributed to the article and approved the submitted version.


INTEROCC is a seven-country cohort study of occupational exposures and brain cancer risk, including occupational exposure to electromagnetic fields (EMF). In the absence of data on individual exposures, a Job Exposure Matrix (JEM) may be used to construct likely exposure scenarios in occupational settings. This tool was constructed using statistical summaries of exposure to EMF for various occupational categories for a comparable group of workers.In this study, we use the Canadian data from INTEROCC to determine the best EMF exposure surrogate/estimate from three appropriately chosen surrogates from the JEM, along with a fourth surrogate based on Berkson error adjustments obtained via numerical approximation of the likelihood function. In this article, we examine the case in which exposures are gamma-distributed for each occupation in the JEM, as an alternative to the log-normal exposure distribution considered in a previous study conducted by our research team. We also study using those surrogates and the Berkson error adjustment in Poisson regression and conditional logistic regression.Simulations show that the introduced methods of Berkson error adjustment for non-stratified analyses provide accurate estimates of the risk of developing tumors in case of gamma exposure model. Alternatively, and under some technical assumptions, the arithmetic mean is the best surrogate when a gamma-distribution is used as an exposure model. Simulations also show that none of the present methods could provide an accurate estimate of the risk in case of stratified analyses.While our previous study found the geometric mean to be the best exposure surrogate, the present study suggests that the best surrogate is dependent on the exposure model; the arithmetic means in case of gamma-exposure model and the geometric means in case of log-normal exposure model. However, we could present a better method of Berkson error adjustment for each of the two exposure models. Our results provide useful guidance on the application of JEMs for occupational exposure assessments, with adjustment for Berkson error.The online version contains supplementary material available at 10.1186/s12874-023-02044-x. In a retrospective cohort study, it is a challenge to find accurate measures of exposure to hazardous substances and radiation. Group-based exposure surrogates, such as those provided by job exposure matrices (JEM) in occupational epidemiological studies, are usually used to establish past exposures . AnotherEpidemiologists frequently make use of both prospective and retrospective cohort studies to identify risk factors for adverse health outcomes. In both cases, the goal is to identify risk factors that can discriminate between cases experiencing the adverse health effect of interest and controls who do not demonstrate this adverse effect. Mantel and Haenszel 1959) demonstrated the importance of stratification on covariates related to the outcome of interest and gave an estimator of the odds ratio formed by combining estimators from individual strata . Truett,9 demonstThe notion of prospective studies in which exposed subjects would be followed to identify incident cases of the disease of interest was introduced by Prentice and Pyke (1979) in , extendiBerkson error happens when using group exposure measurement in place of the actual individual measurements. This differs from classical measurement error, which arises due to inaccuracies in the measurement process. Berkson error does not lead to biased estimates in linear regression but can cause biased estimates of parameters in nonlinear models. Classical measurement error, on the other hand, can occur in various studies and can lead to biased estimates of relationships between variables. Both types of errors require careful identification in studies and the application of relevant statistical procedures to mitigate their effect on the results; otherwise, they may lead to misled conclusions. See  for moreIn this article, we evaluate new approaches to adjusting JEM-based occupational exposure estimates for Berkson error in stratified and non-stratified analyses, using both logistic and Poisson regression. The main assumption is that variation in exposure about the true value follows a gamma distribution, a common choice in exposure modeling, e.g. , 16. In INTEROCC was a follow-up to the 13 country INTERPHONE  study ofThe INTEROCC study is a collaborative effort between 7 of these 13 countries . One of the specific aims of INTEROCC was to investigate a possible association between occupational exposure to EMF and brain tumors (glioma and meningioma). This study used a JEM comprised of full-shift measurements of the TWA magnitudes of the ELF magnetic field B, in micro-tesla (μT). Each job was coded to the ISCO 1968 and 1988 occupational classification and each industry to the ISIC 1971 classification  conSome epidemiological stratified analyses use the arithmetic mean and the geometric mean as surrogates in retrospective cohort studies. In those studies, researchers use conditional logistic regression as described in this paper. We have shown that in that case Berkson adjustment as well as using the arithmetic mean and the geometric mean as surrogates do not provide accurate estimates of the logarithms of the odds-ratios. That must shed some light on the challenge in finding models of exposures for stratified analyses in those cohort studies.We have shown that using Berkson error adjustment and surrogates when the statistical analyses are done using conditional logistic regression lead to inaccurate estimates. Hence, there remains a need to find accurate and precise exposure surrogates that can be reliably used in conditional logistic regression. Berkson error adjustment for other regression models, such as the Cox proportional hazard model, and other models of exposure, such as power law models, are also important open research topics.The results presented in this paper show that in case of gamma exposure models, using methods of Berkson error adjustment are far better than using surrogates. That conclusion along with our earlier results about the case of log-normal exposure model  support Additional file 1: Appendix I. Proofs of Propositions 1 and 3. Appendix II. Gradient and Hessian of the log-likelihood of the ordinary logistic regression. Appendix III. Gradient and Hessian of the log-likelihood of the conditional logistic regression.


The internal microenvironment of a living cell is heterogeneous and comprises a multitude of organelles with distinct biochemistry. Amongst them are biomolecular condensates, which are membrane-less, phase-separated compartments enriched in system-specific proteins and nucleic acids. The heterogeneity of the cell engenders the presence of multiple spatiotemporal gradients in chemistry, charge, concentration, temperature, and pressure. Such thermodynamic gradients can lead to non-equilibrium driving forces for the formation and transport of biomolecular condensates. Here, we report how ion gradients impact the transport processes of biomolecular condensates on the mesoscale and biomolecules on the microscale. Utilizing a microfluidic platform, we demonstrate that the presence of ion concentration gradients can accelerate the transport of biomolecules, including nucleic acids and proteins, via diffusiophoresis. This hydrodynamic transport process allows localized enrichment of biomolecules, thereby promoting the location-specific formation of biomolecular condensates via phase separation. The ion gradients further impart active motility of condensates, allowing them to exhibit enhanced diffusion along the gradient. Coupled with reentrant phase behavior, the gradient-induced active motility leads to a dynamical redistribution of condensates that ultimately extends their lifetime. Together, our results demonstrate diffusiophoresis as a non-equilibrium thermodynamic force that governs the formation and active transport of biomolecular condensates. Segregative transitions, such as phase separation, have been heavily cited as the most plausible mechanism for the formation of biomolecular condensates.4 Phase separation is a density transition that occurs through a hierarchy of attractive chain-chain and repulsive chain-solvent interactions leading to the formation of compositionally distinct macromolecular phases.5 The spatial location and active transport of biomolecular condensates within the cell are often tightly regulated. For example, P granules, which are RNA- and protein-rich condensates, form near the posterior of the cytoplasm during C. elegans zygote polarization.6 The asymmetric spatial patterning of P granules has been attributed to the intracellular concentration gradients of proteins and RNA.7 Similar observations were made for bacterial PopZ condensates that regulate cell division in bacteria.8 PopZ condensates locally form at the poles of bacterial cells. Although not fully understood, it has been hypothesized that PopZ condensates localize to the poles of the bacterial cells due to less crowded chromatin at the poles.9 Plant cells provide further examples of the spatially controlled formation of condensates.10 These examples and many others11 suggest that the site-specific localization of condensates within the cell is a prerequisite to their function. For these reasons, a deeper understanding of the biophysical mechanisms that dictate condensate spatial localization and transport is a topic of significant importance.Biomolecular condensates are a group of non-membraneous organelles that carry out a myriad of intracellular functions including stress response,13 The presence of gradients often lead to nonequilibrium processes such as the asymmetric diffusion of molecules and particles up and down the gradients.14 Thermophoretic particles migrate to regions of higher (thermophilic) or lower (thermophobic) temperature when a temperature gradient is established.15 Charged particles exhibit active transport in the presence of electrical potential gradients, a phenomenon that is known as electrophoresis and used in many technological applications.17 The migration of particles induced by solute gradients is referred to as diffusiophoresis.19 In a metabolically active cell, diffusiophoresis can facilitate the transport of macromolecular assemblies across the cell cytoplasm.20 However, it is unknown whether thermodynamic gradients within the cell can cause nonequilibrium forces to drive the motility of biomolecular condensates in space and time through diffusiophoresis. Importantly, the diffusiophoretic response of biomolecular condensate to a gradient would depend on the interfacial properties of the condensate and the type of gradients present. Therefore, understanding how biomolecular condensates behave in the presence of gradients is critical for elucidating their spatial patterning and active motion within the cell.The biological cell is intrinsically heterogeneous in space and time, exhibiting several types of thermodynamic gradients such as temperature, pressure, ions, and biological macromolecules.in vitro model system comprised of Arg/Gly-rich multivalent peptide 22 These positively charged multivalent domains undergo phase separation with nucleic acids through a combination of their attractive electrostatic forces with the negatively charged backbone of nucleic acids and cation 25 Several recent studies have characterized the phase behavior and material properties of RGG domains with ssDNA and RNA.28 Importantly, RGG-nucleic acid (NA) phase separation is reentrant, meaning that phase separation is only favored within a finite window of mixing ratios that are usually centered around the stoichiometric charge-balanced mixture composition.29 The stoichiometry of RGG-NA mixtures also dictates the interfacial charge of these condensates via a charge inversion mechanism.31 The tunable phase behavior and interfacial properties of RGG-NA condensates make them suitable systems for studying the effect of ion gradients on condensate motility.In this work, we study the effect of salt concentration gradients on the formation and transport of biomolecular condensates formed by associative phase separation of multivalent disordered proteins and nucleic acids. We postulate two types of effects that a gradient may impart on a biomolecular condensate system: (a) the gradient dictates the regions where the formation of biomolecular condensates via phase separation is favorable, and (b) the gradient leads to active motility of a biomolecular condensate by biasing the condensate diffusion towards a certain direction with respect to the gradient axis. Both of these effects are plausible and may occur concurrently. To understand these two effects and their interplay with the biophysical properties of condensates, we employ an Using a controlled microfluidic setup alongside fluorescence microscopy, we find that concentration gradients of the peptide and the ssDNA promote spatially patterned condensate formation in specific regions along the salt gradient. We show that the formation of condensates is more robust in the presence of salt gradients due to the local enrichment of the oppositely charged biomolecules via diffusiophoresis. After their formation, the presence of the salt gradient enhances the motility of condensates along the gradient and establishes their active transport that is dependent on the condensate surface charge. Microfluidics studies on peptide and ssDNA solutions reveal that spatial patterning of condensates is dictated by the location-specific concentration and stoichiometry of peptide and ssDNA mixtures. These results are extended to other biomolecular systems where phase separation is driven by obligate heterotypic electrostatic interactions, such as in the mixtures of cationic nucleic acid binding protein protamine and homopolymeric RNA, poly(rU). Overall, our results show that the controlled spatial localization of biomolecular condensates can be spontaneously achieved with macromolecular and ionic concentration gradients. Furthermore, the active motility of condensates in the presence of salt gradients can add additional control over their localization. Together, these findings shed light on the role of ion and chemical gradients in controlling the localization and transport of biomolecular condensates and highlight diffusiophoresis as a plausible mechanism of localization control of biomolecular condensates within cells.Supplementary Fig. S1). Then, along the left reservoir channel, we supply an oppositely charged ssDNA 33 This ensures that only salt gradients are established while keeping the buffer conditions identical throughout the channel. The PEGDA membrane also suppresses 34To investigate the associative phase separation of ssDNAs and cationic polypeptides in the presence of salt gradients, we employ a controlled microfluidic platform . In an HSupplementary Movie S1) and their corresponding fluorescence intensity profiles in 28 Similar to complex coacervates, RGG-NA phase separation is suppressed with an increasing salt concentration in the buffer since electrostatic interactions are one of the major drivers of phase separation of the mixture.31 Consistent with this, we observe that with less NaCl in the background We monitor the phase separation and transport of radients . These r35 The particle velocity 36 Indeed, the electrophoretic light scattering measurements of the condensates at the mixture ratio of Supplementary Fig. S2). Based on the experimental conditions in our microfluidic setup, the mobility 39We further observe that peptide-ssDNA condensates are not only formed locally inside the channel but also display wave-like patterns that move along the channel. Notably, the wave speed is faster and moves further down the channel when the NaCl gradient is present, as shown in ribution . We posiSupplementary Movie S2). We plot a kymograph showing the spatiotemporal dynamics of the wave and the condensates. In the absence of NaCl gradient, we find that individual condensate trajectories are stochastic and do not have a directional bias, appearing as flat tracks as a function of time . Also, their distinct mobility signs confirm once again that the transport of oppositely charged biomolecules is accelerated toward each other by diffusiophoresis, providing a non-equilibrium driving force to phase separate. These results collectively highlight the importance of non-equilibrium interactions of ionic species with biomolecules and their condensates. The equilibrium electrostatics of the monovalent cations We further confirm the diffusiophoretic transport of 29 From the intensity distributions for the individual biomolecules presented in 23 Plotting turbidity as a function of mixture composition Supplementary Fig. S4). The wider reentrant window may be attributed to the difference in the measurement methods where the smaller spatial resolution of the turbidity measurements compared to optical microscopy will likely detect smaller clusters that form at stoichiometries far from the optimal conditions.54 Nonetheless, the agreement of the two methods suggests that the phase separation behavior under non-equilibrium is dictated by local equilibrium thermodynamics. This is consistent with a recent report that suggested that local thermodynamic equilibrium governs phase separation in living cell cytoplasm despite of their inherent non-equilibrium nature.55Regardless of the presence of NaCl gradients, the biomolecular condensates are distributed in a wave-like fashion where the condensates are formed only within a narrow region in the channel , as shown in the intensity profiles in both cases –g. Thesersus x/L ,d. As we/nP plot  with the/nP plot ,b, we inling end , thus crling end  where th23 In our system, In the case of NaCl gradients ,d, we obd region .36 To confirm this, we performed electrophoretic mobility measurements of condensates at varying mixture compositions , which showed that the zeta potential of the condensates changes from −17.2 mV when The spatial variation within the given stoichiometry window suggests that the condensates’ surface charge may also vary spatially since the surface charge, and thus the diffusiophoretic mobility, of the condensates is governed by the mixture stoichiometry.57 These gradients may further segregate biomolecular condensates by convective transport processes such as Marangoni or gravity-driven flows, having implications in prebiotic compartmentalization and localization.57 Self-generated chemical gradients via enzymatic reactions can lead to a dynamical response of the condensates. Testa et al. showed that pH gradients established by the enzymatic reactions of urease-containing condensates could induce hydrodynamic flow within and around the condensates via Marangoni flow.58 Similar enzymatic-driven gradients may also enable freely suspended condensates to self-propel.59 It was also recently predicted that the activity gradients in the nucleus expedite nucleolar coalescence, which helps in the positioning of nucleolus towards the nuclear periphery, a key factor in the localized organization of the nucleus.60 Other types of gradients, such as protein gradients, have been proposed to drive the localization of biomolecular condensates, such as the asymmetric patterning of P granules in germline polarized cells due to an underlying MEG3 protein gradient.7 Chromatin density gradients have also been suggested to drive the local enrichment of PopZ condensates on the poles of bacterial cells.8 Therefore, thermodynamic gradients are expected to play a ubiquitous role in regulating the formation and localization of biomolecular condensates in space and time.A number of recent studies have identified that a variety of dynamical processes of biomolecular condensates are associated with thermodynamic activity gradients. For instance, concentration and temperature gradients established by evaporation at liquid-vapor interfaces are shown to promote phase separation in various biomolecular systems.In this work, we provided an elaborate study on the effect of salt gradients on biomolecular condensates formed by RGG repeat polypeptides and ssDNA. Using a controlled microfluidic platform, we showed that heterotypic condensates form non-monotonic patterning along salt and biomolecular gradients due to the reentrant nature of their phase separation. We further delineated two effects of salt gradients on RGG-ssDNA condensates that are both driven by diffusiophoresis on different length scales . The first is that salt gradients enhance the formation of condensates due to their non-linear effect on the diffusiophoresis of the individual protein and ssDNA molecules. The second effect is that salt gradients can impart active migration of the charged condensates, which is controlled by the stoichiometry of peptide-ssDNA mixtures. Both of these effects can have important implications in living cells and can provide multiple levels of localization control over biomolecular condensates by either dictating the spatial location where the condensate formation is favored or by enhancing the diffusion of preformed condensates towards a particular location with respect to the underlying gradient.Supplementary Fig. S5). Recent studies on diffusiophoresis with a variety of other biomolecules and biocolloids such as membrane proteins,61 exosomes,45 bacteria,62 and blood cells63 suggest the ubiquity of diffusiophoresis in biological systems where chemical gradients are ever-present, providing suitable conditions for diffusiophoresis to arise.64 The presence of a concentrated, active, and nonuniform mixture of proteins, nucleic acids, metabolites, and ions such as More generally, diffusiophoresis, a non-equilibrium driving force generated by (electro)chemical potential gradients, can arise in a wide range of biomolecular condensates. Regardless of whether the biomolecules are negatively or positively charged, natural or synthetic, the individual constituents and the associated condensates can experience diffusiophoresis. We further observe that diffusiophoresis can promote the formation and transport of


Lactobacilliso as to allow the implantation of the fertilised egg. New therapies should beholistic and address both the dysbiosis as well as immune abnormalities. Routineimmune monitoring of the immune cells derived from the endometrium and/ormicrobial profiling should recommended to better predict assisted reproductionoutcomes in these couples.Endometriosis is a chronic inflammatory condition affecting up to 10% of women ofreproductive age and this, depending on its severity, very often leads toinfertility. New research has shed light on the role of underlying endometritisdue to the presence of inflammatory, non-oestrogen metabolising microbiome atthe mucosal interface and this in turn leads to the activation of aggressive,non-tolerant immune cells in the endometrium. These immune cells require thepresence of tolerance-inducing commensals such as  Chronic endometriosis is a devastating condition affecting up to 10% of women ofreproductive ages  and it is characterised byextensive growth of endometrial tissue and stoma outside of the uterus. Thepresenting symptoms include unexplained infertility, pelvic pain, excessive bleedingand pain upon urination or intercourse or even bowel movements. The current medicalmanagement of such cases include repeated surgery to remove the ectopic endometrialtissue and/or hormonal therapy but these approaches seem ineffective in preventingrecurrences.The current knowledge of the aetiology of endometriosis is limited but the principaltheory is that endometrial tissue implants at ectopic sites far from the uterus butnormally the immune cells at such sites are responsible for the clearance of suchlesions. In 10% of women, it appears that such immune clearance is ineffectiveleading to the establishment and proliferation of the tissue leading to the lesions.Chronic inflammation in the peritoneal cavity causes the spread of the lesions.What then is the link between hormone metabolism, the local microbiome and thepro-inflammatory profile displayed by most women suffering from this condition?Lactobacillusdominance and the overgrowth of inflammatory species such asFirmicutes, elevated Gardnerella, Streptococcus,Escherichia, Shigella, and Ureoplasma in their cervixand elevated Shigella/Escherichia in their stool  and theobvious microbiome dysregulation can be applied directly to the microbiologicalprofile seen in endometriosis and chronic endometritis. The role of the microbiotain possibly driving local and systemic inflammation and the relationship to thepathophysiology of multiple gynaecologic conditions remains under investigation the predominantoestrogen in humans, with glucuronic acid (glucuronide) and secretes the glucuronideinto bile salts, where the glucuronides are later released into the intestinal tractfor excretion of the unused conjugated toxins and hormones  and by production of anti-inflammatory cytokines andantimicrobial peptides from epithelial cells, which fortifies the epithelial cellbarrier  cells that belong to the innate immunity compartment. Macrophages anddendritic cells are also detected, together with adaptive immune T cells, such as Tregulatory cells (Tregs) . Over tiIn endometriosis, the peritoneal environment is in a chronic state of localinflammation and contains immune cells with altered functions. This immunedysregulation in endometriosis creates an ideal environment for disease progression, proangiogenicfactors (VEGF), growth factors and adhesion molecules  cells, T cells, dendritic cells, and macrophages make up halfof the total number of endometrial cells. In order for a pregnancy to proceed, therole of the CD4+ CD25+ FOXP3+ regulatory T cells (T-regs) are important in mediatingmaternal immune tolerance to the allogeneic foetus during embryo implantation andearly pregnancy. In general, pregnancy is associated with Th2 dominance, and Th1immune response is associated with pregnancy losses. T helper 17 (Th17) cellsdifferentiate from naive T-cells and produce the cytokine IL-17 that has animportant role in the feto-maternal interface. During implantation, the Th17 cellsare present in decidua and their numbers increase in the peripheral blood in thefirst trimester. However, it is proposed that lack of the T-regs  present in the endometrium leads to a subtle but constantinflammatory scenario which is not conductive to a successful implantation and livebirth outcome. These immunosuppressive T cells work in conjunction with the uNKswhich happen to be tolerance-inducing cells . In the endometrium, the uNKs arephenotypically CD3-CD56+, secreting cytokines such as TGF-β or IL10, therebycreating an immune supressed environment to allow implantation. It is an interestingbut important fact that T-regs require the presence of commensals to becomeactivated and when the microbiome is disturbed, the T-regs do not carry out theirimmune suppressive functions and control local inflammation.Gardnerella, Ureoplasma, Enterococcus, Staphylococcus, E.coli, and other mixed cultures), these bacteria induce an uncontrolledinflammatory response with all its consequences. To add to the injury, thepredominant estrogenic milieu (due to lack of oestrogen-metabolizing bacteria) feedsthe inflammatory cells and overtakes the tolerogenic cells (T-regs and uNKs) whichare progesterone sensitive!The immediate answer is a resounding YES! There is abundant literature from IBS caseswhich clearly suggest that a state of dysbiosis with overgrowth by inflammatorybacteria leads to an immune profile conductive to chronic inflammation. It isbelieved that when the gut microbiome is disrupted and replaced by non-physiologicalcommensals, the immune cells are typical of that of a dysregulated immune responsewith little to no tolerance to ingested foods, especially foreign proteins. The sameapplies to the endometrial surface: when the microbiome is replaced by endometrialpathogens  and hormonal balancing to control the raised oestrogenlevels seen in these affected women. It is imperative to determine the immuneprofile of the cells in the endometrium  in order tomonitor the beneficial changes induced by the therapy of choice and predict apossible positive outcome on the in vitro reproductiveprocesses.It is logical to hypothesize that decreasing the numbers of bacterial pathogens inthe reproductive tract and increasing the proportion of beneficial