The main determinants for classifying various stages of cognition are shrinkage of the hippocampus, growth of the brain's ventricles, and the change from gray matter to CSF  is proposed for describing texture qualities . A high Scale-invariant feature transform (SIFT) is another interesting local feature descriptor. The scale invariance and rotation invariance are the important characteristics of SIFT. Both the frequency domain and the spatial domain are utilized for extracting SIFT features. SIFT is effectively used for the early detection of AD –23. AccoThe Hessian matrix serves as the foundation for the Speeded Up Robust Features (SURF) which shares many characteristics with SIFT . SURF peAfter preprocessing, MRI images are sampled with nine volumes of interest in brain regions related to AD. Intensity and texture features are extracted from the interest of volume. The support vector machine classifier trains on the features. Non-linear registration systems can be made better even when the method offers tolerable accuracy . ClinicaThe orientation surrounding each voxel of eight local regions of MRI image including white matter and gray matter is calculated using a 3D local directional pattern. The algorithm is less susceptible to illumination and noise . The feaIn recent years, deep learning methods have been prominent in many medical sectors. For efficient and precise categorization, deep learning techniques will abstract important features from the images. The methods aid medical professionals in early disease diagnosis. These methods enhance researchers' abilities to engage in studies that examine medical image approaches for disease diagnosis. Shortly, deep learning may replace traditional medical diagnostic techniques because of its learning capabilities and cost-effectiveness. A sizable number of convolutional neural network (CNN) models are combined to successfully anticipate various stages of AD. The classification performance is good as a result of the integration of Bagging, Boosting, and Random Forest algorithms . The revThe algorithm  uses funTransfer learning and ensemble learning are typically expressed in computer vision by employing pre-trained models. The innovative approaches for dealing with the issue of training data and test data having different distributions include transfer learning and ensemble learning. Pre-trained models can be used as the foundation for new models for the early diagnosis of AD. Using a neural network model, transfer learning is utilized to improve the precision and computing efficiency of image categorization. In transfer learning models, pre-trained neural networks are used as feature extractors, and the output of the pre-trained network is given to a new classification layer that is trained on data particular to the task. By integrating many previously trained models with new classification layers, ensemble transfer learning models , 40 are A 3D multi-channel feature maps based on Voxception-Resnet is created for the classification of AD and CN . Data auAs discussed in the previous sections, AD develops gradually that takes years for symptoms to physically manifest in a patient, thus clinical approaches for an early diagnosis of the disease are insufficient. Physical symptoms of AD in its early stages will resemble those of a typical aged person in many ways. Clinical approaches are not very reliable for separating mild cognitive impairment into convertible and non-convertible stages in the context of early diagnosis.Early diagnosis is made using MRI scans using image processing techniques. The early diagnosis of AD utilizing MRI and Positron Emission Tomography (PET) image modalities is made possible by numerous algorithms , 47. AlgFor the early diagnosis of AD, deep learning algorithms play a significant role. Numerous algorithms are developed for deep learning-based early diagnosis. Reduced computational complexity, less calculation time, low dimension features and good differentiation capability between MCIc vs. MCInc should be the goal of the computer-based diagnostic system. The pre-trained models successfully adapt the MRI images to predict the early phase of AD . The higMany investigations tried to classify AD vs. CN, and AD vs. CN vs. MCI . But only less focus is given to the classification of MCI vs. MCInc. Even though early Alzheimer's disease detection has been the subject of countless research, it is still challenging to identify the specific traits that can detect the disease in its earliest stages . The mosAF, IP, and JA contributed to the study conception and design, literature review, interpretation, and manuscript preparation. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Automatic modulation classification (AMC) is an important method for monitoring and identifying any underwater communication interference. Since the underwater acoustic communication scenario is full of multi-path fading and ocean ambient noise (OAN), coupled with the application of modern communication technology, which is usually susceptible to environmental influences, automatic modulation classification (AMC) becomes particularly difficult when it comes to an underwater scenario. Motivated by the deep complex networks (DCN), which have an innate ability to process complex data, we explore DCN for AMC of underwater acoustic communication signals. To integrate the signal processing method with deep learning and overcome the influences of underwater acoustic channels, we propose two complex physical signal processing layers based on DCN. The proposed layers include a deep complex matched filter (DCMF) and deep complex channel equalizer (DCCE), which are designed to remove noise and reduce the influence of multi-path fading for the received signals, respectively. Hierarchical DCN is constructed using the proposed method to achieve better performance of AMC. The influence of the real-world underwater acoustic communication scenario is taken into account; two underwater acoustic multi-path fading channels are conducted using the real-world ocean observation dataset, white Gaussian noise, and real-world OAN are used as the additive noise, respectively. Contrastive experiments show that the AMC based on DCN can achieve better performance than the traditional deep neural network based on real value . The proposed method based on DCN can effectively reduce the influence of underwater acoustic channels and improve the AMC performance in different underwater acoustic channels. The performance of the proposed method was verified on the real-world dataset. In the underwater acoustic channels, the proposed method outperforms a series of advanced AMC method. Automatic modulation classification (AMC) plays an important role in underwater acoustic communication, especially in non-cooperative communication. AMC can be used in monitoring and identification of communication interference, such as spectrum surveillance and electronic countermeasure . Modern AMC is the intermediate process of signal detection and demodulation , occupyiCurrent AMC algorithms can be classified into two categories: the maximum likelihood ratio method based on hypothesis testing and the statistical pattern classification method, of which the latter is more commonly used. The pattern classification method relies on two processes. The first is feature extraction, which is widely used in many fields ,7. ThereIn recent years, deep learning  has emerSince deep learning was proposed, almost all architectures, techniques, and blocks of deep learning are based on real value because most computer vision, natural language, and speech datasets are real-valued. However, complex baseband representation is commonly used in communication systems. Most signal processing methods based on deep learning usually treat the real and imaginary parts of complex baseband signals as independent channels, which may result in the merging of in-phase and orthogonal components and loss of the basic polar representation properties . CompareWe adopted DCN to AMC of underwater acoustic communication signals to adequately learn features from the raw complex baseband signals.Two physical signal processing layers were constructed based on DCN to improve the AMC performance, including a deep complex matched filter (DCMF) and deep complex channel equalizer (DCCE). The DCMF can help to remove noise from the signals, and the DCCE can reduce the influence of multi-path fading effectively. DCMF and DCCE were embedded in DCN to improve the AMC performance.The influence of underwater acoustic channels on the signals was fully considered, and different underwater acoustic channels were simulated by using the real-world ocean observation dataset and ambient noise. The effectiveness of the proposed method was verified in different underwater acoustic channels and real-world dataset.In this paper, we proposed a new AMC method for AMC of underwater acoustic communication signals based on DCN. Our contributions are as follows:This paper is organized as follows. A is the amplitude of the signal, n is the symbol index, N is the total number of symbols, PSK and QAM have commonly used modulation types in the field of underwater acoustic communication. Both modulation processes of PSK and QAM involve phase keying. PSK and QAM can be formulated, respectively:In the real-world underwater acoustic communication scenario, the influence of underwater acoustic channels on communication signals mainly includes two aspects: multi-path fading and OAN, as is shown in (1) Multi-path fadingK is the total number of paths, k-th path.Multi-path propagation often exists in underwater acoustic communication. In a multi-path environment, the received signal can be represented as the superposition of a number of time-delayed and amplitude–attenuated versions of the transmitted signal. A typical underwater acoustic channel with multi-path fading can be seen as a filter whose impulse response function is k-th path.Since the source and receiver are usually not stationary and underwater acoustic reflection boundaries are unstable in most cases, multi-path fading is often accompanied by Doppler shift. We consider Doppler shift caused by relative motion in multi-path propagation. In a multi-path fading channel, each path has an independent Doppler shift factor Assume the transmitted signal is (2) Ocean ambient noiseOcean ambient noise (OAN) is an additive interference in underwater acoustic channels. The composition of the OAN is very complicated and full of impulsive interference due to numerous noise sources, such as ship-radiated noise, industrial noise, wind noise, biological noise, etc. The reasons mentioned above make the OAN cannot be simulated accurately using white Gaussian noise. AMC method based on Gaussianity assumptions will suffer degradation in their performance to a low level. We use real-world OAN as the additive noise of underwater acoustic channels to enhance the robustness of the proposed AMC method in real-world underwater acoustic communication scenarios.In this section, we presented the proposed AMC method for underwater acoustic communication signals based on DCN. DCMF and DCCE were proposed to improve the performance of DCN for AMC. We used the raw I/Q signals as the input of the DCN without any feature extraction, by which the DCN was forced to learn features from high-dimension complex time sequences. The framework of the proposed AMC method is illustrated in The matched filter is often used to improve the signal-to-noise ratio (SNR) of the received signal and optimize the quality of communication, which is an important module in communication. We proposed a deep complex matched filter (DCMF) to improve the SNR of the signals and optimize the classification performance. The DCMF in The proposed DCMF has three input channels and three output channels. The first input channel of DCMF accepts received signals  Experimental dataset under various conditions were built by simulations.(2) We analyzed the influence of underwater acoustic channels on AMC performance.(3) We compared the AMC performance between DCN and classical real-valued DNN.(4) We analyzed the performance of DCMF by visualizing the kernels, then the performance gain of the proposed AMC method was verified by a series of contrastive experiments, including verifying real-world underwater acoustic communication signals.(5) The AMC performance comparison between the proposed method and some other AMC methods were carried out.(6) Comparison experiments were carried out to analyze the limitations of the proposed method.The results in this section were the average values over multiple runs.We considered six commonly used modulation types, including BPSK, QPSK, 8PSK, 16QAM, 32QAM, and 64QAM. The parameters for simulation are presented in A real-world underwater acoustic communication scenario was considered in the following experiments. The ocean observation dataset of the chosen area came from the global gridded Argo dataset 2020 (BOA_Argo) . We chosT is the temperature, S is the salinity, and P are the static pressure, which is positively related to the depth. The depth of the chosen area is 460 m, and the sound velocity profile is shown in The dataset contains temperature, salinity, and static pressure for different months; we selected the data in January. The sound velocity profile can be calculated from temperature, salinity, and pressure byAs we can see that the sound gradient in this area presents positive and negative at different depths. We put one transmitter  and OAN influencing a QPSK signal is illustrated in The influence of underwater acoustic channels on the performance of AMC was analyzed through a series of contrastive experiments, in which multi-path fading effect and additive noise were considered individually. We trained an ordinary DCN without DCMF and DCCE in this section as a benchmark for subsequent experiments. (1) There is an obviously positive correlation between classification accuracy and SNR.(2) (3) Similar results can be observed when using OAN as the additive noise, in which Ch1 and Ch2 reduce the We also analyzed the performance of each modulation type individually in the underwater acoustic channel. We investigated the performance of DCN by comparing DCN with classical real-valued DNN. Two DNNs with different numbers of hidden units are built for contrastive experiments. Since DCMF and DCCE are unsuitable for real-valued DNN, an ordinary DCN without DCMF and DCCE is used for a fair comparison. The first DNN (DNN-1) is structurally similar to the DCN, and they have the same number of hidden units; the second DNN (DNN-2) is a scaled-up version of DNN-1 to keep the actual complexity and trainable parameters equal to that of the DCN. The contrastive experiments were carried out with the AWGN channel and the underwater acoustic channel (Ch1+OAN), respectively. We analyzed the performance of DCMF in this section. A contrastive experiment was carried out between two DCNs with and without DCMF in the Ch1+OAN channel. In the DCN without DCMF, an ordinary CConv layer was used to ensure the parameters of the two DCNs are equal. We tracked the kernels of DCMF during the training to monitor the filtering process of the DCMF. The variations of the first kernel at different training stages are visualized in The AMC performance comparison between DCN with and without DCMF is shown in Other contrastive experiments were carried out to evaluate the performance of DCCE. The DCCE was embedded in the DCN and followed the DCMF. Multi-path fading channels Ch1 and Ch2 were considered individually. The comparison of the AMC accuracies is illustrated in Another classification experiment was carried out on a real-world dataset, which was recorded in the South China Sea. The data were recorded using an omnidirectional hydrophone placed under the surface of about 10 m, the transmitter was about 3 km far away from the receiver, and the relative speed of the transmitter and receiver was less than 5 m/s. The modulation types of real-world signals include BPSK, QPSK, 16QAM, and 32QAM. The SNR of the received signals is about 3–5 dB. The received signals were down-converted and expressed as the sampled complex baseband, and all the signals were resampled and divided into 0.5 s to keep the same dimension as the simulated signals. The number of each modulation type is 100. The signals were classified by the proposed method; the classification results are shown in The AMC performance comparison between the proposed method and some others achieved AMC methods were carried out. There were three AMC methods based on deep neural networks (include VGGnet , ResNet We carried out one experiment to analyze the SNR limitation of the proposed method. We used the combination dataset in the channels Ch1+OAN and Ch2+OAN. In this paper, we adopted DCN into AMC of underwater acoustic communication signals, two physical signal processing layers based on DCN were proposed to improve the AMC performance. The two physical signal processing layers include DCMF and DCCE, DCMF can remove the noise from the received signals, and the DCCE can reduce the influence of multi-path fading. The proposed method can integrate the signal processing method with deep learning. Real-world underwater acoustic communication scenario was fully considered in this paper.The results of the experiments indicated that multi-path fading and OAN in the underwater acoustic channels have a great influence on underwater acoustic communication signal and the AMC performance, especially the multi-path fading effect. DCN showed a larger advantage than real-valued DNN in AMC of underwater acoustic communication signals. By tracking and visualizing the filters of DCMF, we can observe that DCMF can significantly remove the noise in the received signals. The proposed method yielded certain performance gains and achieved robustness to the underwater acoustic channel.


Recent in vitro and in vivo experiments demonstrate that astrocytes participate in the maintenance of cortical gamma oscillations and recognition memory. However, the mathematical understanding of the underlying dynamical mechanisms remains largely incomplete. Here we investigate how the interplay of slow modulatory astrocytic signaling with fast synaptic transmission controls coherent oscillations in the network of hippocampal interneurons that receive inputs from pyramidal cells. We show that the astrocytic regulation of signal transmission between neurons improves the firing synchrony and extends the region of coherent oscillations in the biologically relevant values of synaptic conductance. Astrocyte-mediated potentiation of inhibitory synaptic transmission markedly enhances the coherence of network oscillations over a broad range of model parameters. Astrocytic regulation of excitatory synaptic input improves the robustness of interneuron network gamma oscillations induced by physiologically relevant excitatory model drive. These findings suggest a mechanism, by which the astrocytes become involved in cognitive function and information processing through modulating fast neural network dynamics. Particularly, fast gamma cortical oscillations . Existing models with slow, weak, and hyperpolarizing synapses generate synchronized gamma activity only when the heterogeneity of the input drive is low and the amplitude is high11, which is physiologically inconsistent21. It was shown that sensitivity to heterogeneity can be significantly reduced by incorporating realistic synaptic properties in the models22. Search for the biologically plausible mechanisms to improve the robustness of coherent oscillation formation in the interneuron network models against heterogeneity remains a highly relevant task.Following the experimental findings, which show that interneurons, in particular fast-spiking basket cells (BCs), can generate 25. In particular, it was revealed that astrocytic vesicular release is necessary to maintain functional gamma oscillations, and it is essential for novel object recognition behavior both in vitro and in awake-behaving animals23. However, the cellular and network mechanisms underlying astrocytic involvement in the formation of synchronized neural network Recently, it was shown that glial cells substantially influence the formation of gamma oscillatory rhythms, which were previously thought to be a product of neuronal activity26. Due to the fact that astrocytic calcium dynamics has a significantly slower timescale than the fast synaptic transmission of neurons, it has been assumed for decades that astrocytes do not play a major role in modulating neural network activity, neural information processing, and cognition. Nevertheless, recent studies have shown that astrocytes can regulate neuronal excitability, synaptic transmission, and plasticity28 through the release of chemical transmitters (termed “gliotransmitters”) induced by intracellular Ca30. Numerous studies reveal the unexpected role of astrocytes in the coordination of the fast dynamics of neural circuits that underlie normal cognitive behaviors33. Several computational studies discuss the role of astrocytes in the spatio-temporal coordination of neural network signaling39, the emergence of coherent oscillations41, information processing46, and memory formation51. Savtchenko and Rusakov showed that the astroglia-like, volume-limited synaptic regulation of excitatory input appears to be better at preserving interneuron network synchronization while inducing the network clustering to neuron subgroups with distinct firing patterns41.Astrocytes sense and integrate neuronal activity by responding with intracellular Ca17. To do that we complemented it with an astrocytic network and explored how Nonetheless, the way the interplay of slow modulatory astrocytic signaling with fast synaptic transmission is involved in the formation of coherent oscillations in the interneuron network remains an open question. To address this issue, we studied the role of astrocyte-mediated regulation of synaptic transmission in the generation of 36. We showed that astrocytes can induce the intermittent synchronization of a pair of synaptically coupled fast spiking neurons on the slow timescale of calcium oscillations. Here, we employ a similar approach to study the dynamics of an extended version of the model .In our previous work, we investigated the dynamics of the bidirectional neuron-astrocyte interaction in a minimal network model15, which mimicked the organization of the BC network in hippocampal area CA1. Each neuron was randomly connected to its 100 nearest neighbors by inhibitory chemical synapses with a probability of 0.5. This connectivity reflects anatomical analyses of functional links among interneurons in area CA152. Interneurons receive excitatory inputs from pyramidal neurons whose stochastic firing is triggered by the random Poisson spike trains with a given rate. Astrocytes are organized in a ring-shaped network repeating the topology of the interneuron network. It was shown that the number of astrocytes and neurons is approximately the same in the mammalian brain and that the individual astrocytes occupy separate, non-overlapping tissue domains53. The astrocytic network in the proposed model consists of 200 diffusely coupled astrocytes. Each astrocyte is connected to the two nearest neighboring astrocytes through gap junctions54. Astrocytes generate the elevations of intracellular Ca27. It was shown that locations of dendritic trees of the BCs in the hippocampus do not significantly overlap with each other55. Therefore, an individual astrocyte can influence only one or a small proportion of BCs from the entire network41. The architecture of the simulated neuron-astrocyte network is shown in Fig. We studied the interneuron network model of 200 neurons arranged on a virtual ring56. Here we use the Mainen modification of the Hodgkin-Huxley neuron model for the mammalian brain58, as the most biologically plausible. Membrane potential neuronal dynamics was modeled asiV is given in mV, and time t in ms. 58:Various models describe the neuronal spiking dynamics at different levels of bio-fidelity, from simplified leaky integrate-and-fire model to biophysical Hodgkin-Huxley equations60. We chose the rest mode of a neuron with an equilibrium state of steady focus with a shift current value 36.Throughout this paper, we use the following parameter values: 41. The pulse has a rectangular shape with a constant duration of Each pyramidal neuron receives an external input i from N presynaptic neurons is defined as59:j denotes a presynaptic neuronal index, the reversal potential is 44. We assume that upon reaching the intracellular calcium concentration, [CaThe total synaptic current i generates an action potential, it causes the release of glutamate from the synapse. The glutamate concentration is described by the following equation61:62:44Each astrocyte tracks the activity of pyramidal neurons and can generate the elevation of the intracellular concentration of IP62:z is the fraction of IP63. They evolve according to the following equations62:Glutamate released from presynaptic neurons is integrated over a larger timescale by the IP64. For our purposes, we fix Biophysical meaning of all parameters in Eqs. –8 and thSimulations were done using a finite difference integration scheme based on the fourth-order Runge-Kutta algorithm with time step 12:i and j denote the two interneurons, X(l) and Y(l) are the binary action potential patterns, and L is the number of time bins. In the case of full synchrony, k, during the CaFrequency and coherence of interneuron network activity were determined in 500-ms epochs. Average firing frequency, Ω, was determined as the inverse of the mean interspike interval. Neuronal membrane potentials were binarized . The network coherence was calculated as the mean of the coherence in all pairs of interneurons in the time window 27. Involved in the same neuronal circuit astrocytes can release various types of gliotransmitters that can modulate synaptic transmission in different ways. For instance, in the hippocampus, the astroglial release of glutamate can potentiate inhibitory transmission by triggering presynaptic kainate receptors65 and support neuronal synchrony by triggering postsynaptic NMDARs66. In the hippocampal CA1 region, the gliotransmitter ATP can also depress or enhance excitatory synaptic transmission by triggering either A1 or A2 receptors, respectively68. To mimic multiple forms of astrocytic physiological actions on synaptic transmission in the modeled network, we explored two scenarios of neuron-astrocyte interaction with variable gliotransmitter-induced changes in synaptic transmission. We explored how synchrony in an interneuron network can be regulated by the astrocytic influence (i) on inhibitory transmission in the interneuron network  of network oscillations. Two cases were considered: astrocyte-induced depression and potentiation of inhibitory transmission. Spiking activity of pyramidal neurons leads to the emergence of the calcium oscillations in astrocytes, which originally remained in the steady state  and high heterogeneity levels  in contrast with timescales of neuronal firing and excitatory or inhibitory synaptic transmission (milliseconds), the results of this study demonstrated that astrocytes can strongly regulate the fast dynamics of neural circuits that underlie normal cognitive behavior.31). Notably, both inhibitory and stimulatory effects of astrocytic modulation on the gamma oscillations are reported in the hippocampus, which is in line with the previously discussed simulation results. The optogenetic activation of ChR2-expressing astrocytes reduces the power of kainate-induced hippocampal ex vivo gamma oscillations via regulation of pyramidal cell and interneuron excitability by astrocyte-released ATP and/or adenosine25. The positive astrocytic influence on the gamma rhythm formation was observed in mice with genetically induced suppression of astrocytic exocytosis, which showed reduced electroencephalographic (EEG) power spectrum in the gamma frequency range in vivo and impairment of carbachol-induced gamma oscillations in vitro23. The activation of the astrocytic GABA24. Several studies provided direct evidence of the involvement of astrocyte signaling in cognitive functions and behavior71. However, in many of the cases, the understanding of astrocytic involvement is still incomplete. Now that we better understand the molecular components of astrocyte-neuron interactions, the new challenge is to investigate how they integrate at the network and physiological levels. To address this question, novel, bio-inspired, and detailed computational models should be developed to simulate the information processing through the coordinated activity of both astrocytes and neurons. Astrocytes provide an extradimensional influence over neuronal networks by a multiscale spatiotemporal integration of neural activity and can produce higher-order organization of the information coding45. The astrocytic Ca26.Recent experimental studies provided the lines of evidence that support multifunctional astrocytic contribution to local synaptic plasticity and coordination of neural network oscillatory activity, which in turn influence the information processing (for review see72). For example, Kanakov and colleagues42 and later Abrego et al.44 investigated the role of astrocyte-induced modulation of synaptic transmission in information processing in small neuron-astrocyte ensembles. These studies showed that the astrocytes can induce formation of the spatiotemporal activity patterns in neural network due to astrocyte-mediated facilitation of the synaptic connectivity at the timescale of astrocytic dynamics. Lenk and colleagues35 studied the astrocytic contribution to the maintenance of the average neuronal activity level. This study showed that astrocytes could promote homeostatic regulation of the firing rate in the neuronal network similar to the influence of the extracellular matrix73; astrocyte-mediated modulation of synapses induces the stabilization of the neuronal activity, preventing neuronal hyperactivation. Additionally, Makovkin et al.34 presented a two-layer oscillatory network mimics the interconnected astrocytic and neuronal networks. The astrocytic layer consists of low frequency phase oscillators coupled locally. The neuronal layer employs high frequency oscillators interconnected non-locally with regular or random topology. The analysis of the mixed coupling role in the collective dynamics and synchronization formation in such a multiplex neuron-astrocyte ensemble demonstrated that the inhibitory connections in the neural subnetwork decreases the level of phase synchronization, but sufficiently strong coupling to the astrocytes recovers synchrony in the entire network.Various computational models of the neuron-astrocyte interaction on the network level have been successfully applied to study the specific effects of neuronal activity regulation by astrocytes (for a review, see77. Understanding the emerging role of astrocytes in regulating neural network oscillations underlying cognitive function and dysfunction opens a way for the development of novel pharmacological treatments for brain disorders.Integration of astrocytic signaling in cognitive processing has implications for understanding the basis of cognitive alterations in pathological conditions. The abnormal astrocytic signaling can induce synaptic and network dysregulations leading to cognitive impairmentSupplementary Information 1.


One-way ANOVA tests with post-hoc analysis of variance were used to compare foot posture groups and effects of different types of customized foot orthoses. Results: When comparing the effects of CFOs with the respective balance basal level during the pistol squat exercise, we observed a significant (p = 0.0001) decrease in the sway area, antero-posterior displacement (APD) and medio-lateral displacement (MLD) compared to the basal using both types of CFOs. Conclusion: No significant positive effects of CFOs were observed in some static tests. On the contrary, positive effects of CFOs and, in particular, postural insoles, are relevant to dynamic balance.Background: Dynamic balance plays a key role in high-impact sports, such as CrossFit, where athletes are required to maintain balance in various weightlifting exercises. The loss of balance in these sport-specific movements may not only affect athlete performance, but also increase the risk of injuries. Objectives: The aim of the study is to achieve greater insight into the balance and athlete position during the CrossFit training by means of inertial sensors, with a particular focus on the role of different custom foot orthoses (CFOs) in order to detect correlations with the role of the cavus foot. Methods: A total of 42 CrossFit Workouts are made up of different exercises, including metabolic conditioning (running or skip rope), gymnastics , Olympic weightlifting (snatch and clean and jerk) and powerlifting movements .During the last few years, CrossFit has gained popularity in recreational and competitive forms, with a large percentage of musculoskeletal injuries; however, the biomechanical analysis of athlete sport-specific movement has not yet been studied . Given tRecent technological developments ensure to health figures and sports scientists new tools to validate rehabilitation treatment in a more objective way. In the last few years, there is a growing interest for developing technologies and methods for enabling human motion analysis that allows an understanding of the locomotor demands of various sport-specific movements. Sport scientists are focusing more than ever on products that deliver cheap, faster and more efficient clinical and biomechanical evaluation. Postural balance is evaluated by several methods and tools. In terms of computerized testing force, platforms are the most used methods for quantitative analysis of balance; however, they are expensive instruments and with several methodological limitations, which restrict their widespread sport and clinical application .Inertial sensors provide a cheap and accessible means to efficiently collect and process large amounts of athlete balance data in an unconstrained environment (outside of the laboratory environment) on the field and during dynamic tasks (such as sport-specific movements). The role of wearable sensors in postural analysis is becoming more important in sports and clinical applications ,5,6,7,8.Participants were randomized to receive a biomechanical insole or a postural insole and following a 4-week washout period, the participants crossed over to the other treatment. Even though many studies have investigated the effect of insoles on balance, with benefits on postural balance and control, as far as we know, no studies have yet investigated the effect of insoles on balance using wearable inertial sensors during sport-specific movements ,15.Forty-two CrossFit athletes was recruited between October 2021 and July 2022. In accordance with the requirements established by the declaration of Helsinki, written consent was obtained from each person, after having been informed in a clear and simple way about the purpose of the study and the procedures involved. The study protocol was approved by the Human Research Ethics Committee (reference: n° 659/2021/Sper/IOR). Inclusion criteria were subjects of both sexes who fulfilled the following criteria: (1) age of 18 years or older; (2) cavus feet with an arch index < 21% and Clarke’s angle > 45° bilaterally ; (3) CrossFit athletes for at least 3 years. The criteria for qualifying for the study included being aged from 18 to 43 years, in good health with a valid and up-to-date medical certificate, at least 3 years of regular CrossFit training experience and a minimum of 4 workout sessions (CrossFit) per week. We included both males and females. Exclusion criteria were: (1) history or presence of musculoskeletal conditions that may alter balance and/or gait; (2) lower limb injuries in the previous 6 months; (3) history of orthopedic surgery; (4) recent (<3 months) hospitalization due to the diagnosis of COVID-19. All the athletes provided demographic information, medical history and previous treatments for foot diseases. The characteristics of the participants are showed in Data are collected with an inertial sensor measurement system (IMUs) consisting of one sensor unit positioned at L5 level . We usedThe study selects athletes with a pes cavus (high arch), based on previous studies that suggest a functional correlation between a higher arch height and the probability of injuries ,18,19,20Postural/balance assessment was analyzed by measuring the motion of sway of the body, the antero-posterior displacement (APD) and medio-lateral displacement (MLD), as shown in p < 0.05.Data were presented as mean and standard deviation (SD); the quantitative variables were subjected to a descriptive analysis using central tendency and dispersion measures (mean and standard deviation). Interquartile range (IQR), coefficient of variation, standard deviation index (σ) and the ANOVA test are used to estimate the distribution of quantitative variables. The differences between the means of the two CFOs are also analyzed using graphic distributions (boxplot). Tests are considered significative if The analysis of the dynamic tests shows a more significant effect of CFOs (pr < 0.0001). In the pistol squat (sport-specific movement), both orthotic therapies were significantly lower than the average of the oscillations from the first use with a stable improvement. ANOVA was used to determine statistical differences in the balance oscillations between the different tests and CFO . The disAs illustrated on the study flow diagram in The dynamics of the human body during sport-specific movements has generated considerable recent research interest among scientists dedicated to reducing the number of injuries and for performance improvement. The main objectives of this paper were to provide new insights about the postural sport assessment through a wearable inertial sensor with a particular focus on the role of different custom foot orthoses (CFOs) on balance performance. CrossFit sport-specific movements, such as the pistol squat  and the overhead squat , were analyzed using wearable sensors that could constitute an interesting set up for in-field CrossFit movement analysis, being able to detect the role of the insole more accurately.Thanks to an inertial sensor, it is possible to better understand the physiological and balance changes induced by exercises to provide the basis for designing better therapies, such as custom foot orthoses or balance training programs, tailored to individual athletes with the goal of reducing injuries. The application of inertial sensor technology in the assessment of balance is a new and evolving domain useful to establish a new field of dynamic balance assessments in sports medicine. Regarding the inertial sensor set up, one of the main advantages was that it was not necessary to perform a calibration before conducting the data collection during the training. In fact, thanks to the algorithm, during the postprocessing, the raw data of the inertial sensors were reconstructed based on the design of the different CrossFit exercises . The reaStudies with larger samples, which include in their methods different training sessions with different exercise intensities and duration, are still needed to better investigate the benefits of foot orthoses on postural stability and draw more reliable conclusions.This study is not without limitations: one limitation of the present study concerns the evaluation of effects of foot orthoses on postural balance; the long-term effects were evaluated at 3 weeks. For these reasons, further studies should evaluate the effects at one year in order to better understand the balance improvement over time and the long-term clinical impact of this rehabilitative approach.Balance is one of the limiting factors of performance in many sports and there is a clear need of studies that analyze the effects of sport-specific exercises on postural balance control in CrossFit athletes. To our knowledge, the present research may be considered as the first study applying wearable inertial sensor in order to investigate the CrossFit movement during training and furthermore, the possible correlations with the use of CFOs, being important therapy for injury prevention and balance improvement. Both the insoles  produced a significant decrease of sway area, APD and MLD during the pistol-squat exercise and postural insole, even on the overhead squat. These changes may lead to an overall improvement in balance pattern and stability, suggesting that the use of these types of insoles may be a useful treatment strategy for improving dynamic balance in CrossFit athletes. Movement of the foot and ankle influences balance and it is important to understand the complex foot rotatory forces that occur during sports exercises in order to detect impaired lower limb biomechanics among people who participate in power/Olympic weightlifting sports such as CrossFit. CFOs should help to control foot and ankle joint moments; in addition, we demonstrated that customized foot orthoses may be a useful treatment strategy for improving foot alignment, controlling subtalar joint movement and excessive supination and reducing postural sway. Healthcare professionals and sport scientists should consider CFOs a key part of a treatment plan for sports injury prevention and the wearable sensor as a beneficial tool useful to assess the balance and performance improvements during the sport-specific movements.Based on the results, one could possibly assume that foot orthotics represent one key factor that may help to reduce the risk of lower limb injury due to a balance improvement during the sport-specific exercises; however, the degree of benefit and which disease states respond to this treatment require further investigation.


Nowadays, ultrasound has become an important diagnostic tool, and its applications are proving more robust and tremendously beneficial in different aspects of veterinary practices. The advent of ultrasonography enables researchers and veterinarians to assess and monitor tremendous physiological and pathological events in the farm, companion, and wild animals . BecauseZhang et al. explored the usefulness of ultrasonography and Computer-assisted pixel assessment of the echotextural features of the mammary gland parenchyma in buffaloes during lactation at different somatic cell levels for diagnosing subclinical mastitis. In addition, this study found that examining the structures of the mammary gland parenchyma with vertical positioning showed better results than the horizontal direction. Similarly, in cows  and abdominal ultrasonography for detecting the site of bile leakage in a dog with biloma [an encapsulated collection of bile outside or inside the biliary tract within the abdominal cavity;  exerted a significant improvement in testicular blood perfusion because of reductions of Doppler indices (resistive index: RI and pulsatility index: PI), which explain the elevation of arterial blood perfusion and decrease of the vessel resistance to blood flow  in buffalos from Day 5 till Day 40 after ovulation in pregnant and non-pregnant buffaloes. This study showed a significant elevation in CL area from Day 20 to Day 40 in pregnant buffalos compared to the non-pregnant ones with a marked elevation of plasma progesterone levels in the same group, which could indicate the importance of adequate CL area and diameter to establish the pregnancy. Concomitantly, CL blood flow increased, as evidenced by lowering Doppler indices values . SEP is defined as a chronic inflammatory condition in which the small intestines are encased in a dense fibro collagenous membrane  for differential diagnosis and monitoring the treatment of a rare case of colonic intramural hematoma in cats. Abdominal ultrasonography revealed the existence of a local heteroechogenic intramural mass located between the submucosal and muscular layers of the descending colon, causing severe compression and closure of the lumen of the colon. Cranial to the intramural colonic mass, colonic lymph nodes were enlarged. For efficient differential diagnosis , ultrasonography maybe not be a suitable tool. Scanning by CT and cytological examinations was performed to provide more information and reach the final definitive diagnosis. The patient responded well to the surgical approach without recurrence.Gomes et al. published an important case report of a golden retriever dog suffering from Helicobacter spp. gastritis with chronic vomiting. Abdominal ultrasonography revealed the presence of a cluster of multiple, round, and well-defined, hypoechoic foci of different sizes (~0.7–1.8 cm) surrounded by gas within the lumen of the stomach. The histopathology of fundic cup biopsies showed large lymphocytic aggregates with mild multifocal inflammation of lymphocytes and eosinophils with few Helicobacter-like organisms on the surface of the epithelium. After appropriate treatment, the vomiting and fundic lesions were resolved on ultrasonographic examination. This case represented novel gross morphologic findings for Helicobacter spp. gastritis in dogs that responded well to the appropriate therapy and also highlighted how early intervention with advanced imaging can aid in diagnosis and treatment.Hepworth-Warren et al. reported moderate sensitivity (66.7%) and high specificity (92.3%) of thoracic ultrasonography (TUS) for the identification of bacterial pneumonia in adult horses utilizing a TUS score system. In this study, ultrasonography was scored utilizing a novel scoring system evaluating several comet tails lesions, the presence or absence of pleural effusion, and/or pulmonary consolidation in each intercostal space. Ultrasonographic scores were significantly (P = 0.01) higher in the diseased group (median = 126) than in the control group (median = 20). Hence, TUS appears to be an acceptable stand-alone imaging tool for the diagnosis of bacterial pneumonia in horses when radiography is not practical.In equine, Toom et al. aimed to compare liver stiffness values between dogs with the closed extrahepatic portosystemic shunt (EHPSS) and those with multiple acquired portosystemic shunts (MAPSS) after gradual surgical attenuation and to evaluate whether SWV could be used to determine EHPSS closure. The mean 2D SWV between dogs with closed EHPSS and those with MAPSS did not differ significantly in this study. However, these results could serve as a baseline and reference for future studies.Two-dimensional shear wave elastography (2D SWE) is an ultrasound technique that uses the technique of acoustic radiation force impulse to provide a quantitative assessment of tissue stiffness. In recent years, increased interest in this technique has developed in veterinary medicine due to its non-invasive nature, wide availability, and low cost . InteresMandour et al. explored the feasibility and repeatability of the color M-mode echocardiography (CMME) approach to measure different variables of the intraventricular pressure difference (IVPD) and intraventricular pressure gradients (IVPG) in goats and to explore the effect of sedation on the measured variables. This is the first study of the quantitative measurement of the IVPD and IVPG in goats using a novel CMME technique. The findings of the study, in conjunction with conventional echocardiographic methods, might deepen understanding of the hemodynamic changes of the left ventricle in goats as well as other farm animals for further experimental and clinical studies.In veterinary cardiology, 5 papers were published in this e-collection. Ma et al. aimed to assess the changes in cardiac function in experimental induced uremic cardiomyopathy  rats and to assess the therapeutic efficacy of salvianolic acid B  using IVPG and two-dimensional speckle tracking echocardiography (2DSTE) techniques. This study confirmed increased ventricular stiffness and fibrosis in UC rats which was potentially treated by Sal B through decreasing edema, inflammation, and fibrosis. However, Further studies may be needed to clarify the molecular mechanisms of Sal B for the treatment of UC.Hirose et al. reported the usefulness of novel non-invasive assessment of the IVPD and IVPG by color M-mode echocardiography (CMME), a promising method in diagnosing diastolic function, before and after surgical occlusion of patent ductus arteriosus  in dogs. The findings of this interesting study revealed matched response of IVPD and IVPG to the reduced preload rather than left ventricular relaxation. This result is an initial step in the clinical utility of CMME-derived IVPD and IVPG measurements in the diastolic function evaluation in dogs with PDA that warrants upcoming clinical investigations.Yoshida et al. reported the pivotal roles of diagnostic imaging in the assessment and follow-up of the therapy of a case report of pulmonary thromboembolism (PTE) secondary to immune-mediated hemolytic anemia (IMHA) in cats. The echocardiographic assessment indicated an enlargement in the right ventricle and atrium, mild tricuspid regurgitation, and a recognized thrombus in the main pulmonary artery. Regenerative anemia and auto-agglutination tests were suggested on blood examination. Appropriate interventions using antithrombotic therapy and immunosuppressive therapy improved the case.Enokizono et al. evaluated the cardiovascular effects of a single dose of intramuscular (IM) and intravenous (IV) administrations of pimobendane (Pim) in healthy dogs by monitoring the echocardiographic hemodynamic parameters for up to 120 min. This study indicated that IM injection of Pim enhanced left ventricular relaxation and contractility, causing vasodilation within a short time approximately in the same way as the IV route. However, further clinical studies should be performed to explore the effectiveness of IM injections of Pim in case of emergency.HS conceptualized the idea and wrote the manuscript. AS and MK reviewed the manuscript with the first author. All authors reviewed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Clostridioides difficile infections. The differences, sometimes subtle, between these guideline recommendations have caused some debate among clinicians. This paper delves into select key recommendations from each respective CPG and analyzes the differences and evidence associated with each. One primary difference between the CPGs is the preference given to fidaxomicin over vancomycin for initial treatment in non-severe and severe disease endorsed by IDSA/SHEA and ESCMID guidelines, while the ACG-sponsored CPGs do not offer a preference. The emphasis on cost effective data was also a noticeable difference between the CPGs and thus interpretation of the available evidence. When using guidelines to help support local practice or institutional treatment pathways, clinicians should carefully balance CPG recommendations with local patient populations and feasibility of implementation, especially when multiple guidelines for the same disease state exist.In 2021, the American College of Gastroenterology (ACG), the Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America (IDSA/SHEA), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published updated clinical practice guidelines (CPGs) for the management of  Clostridioides difficile infections (CDIs) pose a burden on healthcare systems with significant morbidity, mortality, and healthcare-associated costs. In the United States in 2011, CDIs led to nearly 29,000 deaths, with an estimated incidence of 453,000 cases [00 cases .Multiple clinical practice guidelines (CPGs) for the management of CDI were updated in 2021, including guidelines from the American College of Gastroenterology (ACG), the Infectious Diseases Society of America (IDSA) in collaboration with the Society for Healthcare Epidemiology of America (SHEA), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). These CPGs were previously published in 2013 , 2017 88, and 20The 2017 IDSA/SHEA CPGs were a comprehensive document that included recommendations for the management and prevention of CDIs in both pediatric and adult patient populations. Likewise, the 2013 ACG and ESCMID CPGs also addressed all aspects of care for CDIs. The 2017 IDSA/SHEA, 2013 ACG, and 2014 ESCMID CPGs were concordant in most of their major recommendations, with the primary exception being the use of metronidazole to treat mild or moderate CDI, which was recommended only in the ACG and ESCMID CPGs. The recent updates for each of the CPGs are similar; however, the 2021 IDSA/SHEA CPGs recommend fidaxomicin as the preferred agent throughout, the 2021 ACG CPGs list both vancomycin and fidaxomicin as acceptable first line options, and the 2021 ESCMID CPGs list fidaxomicin as the preferred agent in the initial occurrence but differ from both ACG and IDSA/SHEA in its recommendations for the management of recurrent CDI.The 2021 ACG CPGs are a comprehensive set of recommendations that address both primary and secondary prevention, diagnosis, treatment, and special populations. The 2021 IDSA/SHEA CPGs are a focused update; therefore, the 2017 CPGs still house the majority of their recommendations, with the exception of the three major changes: the use of vancomycin versus fidaxomicin during an initial CDI occurrence, the use of vancomycin versus fidaxomicin during recurrent CDIs, and the role of BEZ in conjunction with standard of care antibiotics. The 2021 ESCMID CPGs are an update of the 2014 CPGs and aim to answer nine specific CDI-related questions, which encompasses the majority of CDI management issues.The recommendations included in each of the CPGs were assigned strength and quality measures according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)  approachThe ACG CPG author panel included seven individuals, some of whom currently provide patient care and are leading scholars in fecal microbiota transplant (FMT), with only one having a formal background in infectious diseases. The IDSA/SHEA CPG author panel also included seven individuals, with the majority having a background in infectious diseases. The ESCMID CPG author panel comprised of 20 individuals across 11 countries in Europe, the majority of which have a background in microbiology and/or infectious diseases, and only one having a background in gastroenterology; however, these authors also incorporated the expertise of external consultants, which included multiple gastroenterologists. Unsurprisingly, only one author of the ACG CPG has an infectious diseases background and only one author of the IDSA/SHEA CPG has a gastroenterology background. The authors of each CPG are represented by both physicians and pharmacists, which provides a value-added expert level review ,16.There is a stark contrast between how each of the CPGs address the financial components of each therapeutic option, which may have impacted each organization’s recommendations. The 2021 ESCMID CPGs did not make their recommendations based on economic considerations; however, they acknowledged that access may be limited and offered alternative recommendations in the instance where first line therapies are not accessible. The ESCMID CPGs stated that recommendations were based on clinical cure, recurrence, and sustained cure .Research surrounding fidaxomicin included multiple cost-effectiveness models between 2016 and 2020 that were referenced in the ACG and IDSA/SHEA CPGs. Notably, each of these CPGs reference different cost-effectiveness analyses, which may be a factor in the differing recommendations. Previous CPGs from the ACG in 2013 did offer cost comparison among the recommended agents (detailed below). The 2021 ACG CPGs, which referenced four cost-effectiveness analyses, mention that although fidaxomicin is the more expensive option upfront, the associated decrease in 30-day recurrence will offset the initial cost, giving each regimen a similar overall cost-effectiveness ,17,18. TThe 2021 IDSA/SHEA CPGs offer recommendations for three major components of CDI management: treatment of index CDI, treatment of recurrent CDI, and the use of BEZ to prevent future recurrence. Authors formed PICO questions to address each of these sections, and used six randomized controlled trials (RCTs) to support their recommendations ,23,24. NEach of the 2021 CPGs address similar clinical questions but do not always agree on their recommendations. The main differences between these CPGs are summarized in C. difficile isolates, which may influence future application of these guideline recommendations if clinical outcome correlations are verified [Previous 2017 IDSA/SHEA CPGs recommended either vancomycin or fidaxomicin for the management of non-severe CDIs, and each of these agents were favored over metronidazole . This chverified .Previous ACG CPGs published in 2013 recommended metronidazole to treat mild to moderate CDIs, while vancomycin was reserved for severe infections. Those CPGs mentioned the newly FDA approved fidaxomicin; however, withheld it from formal recommendations due to lack of evidence and cost. The 2013 CPGs compared the cost of each treatment, pricing for a full ten-day course was as follows: metronidazole $22, vancomycin capsules $680, vancomycin oral solution compounded from intravenous (IV) solution components ranged $100–400, and fidaxomicin $2800 . The 202Previous 2014 ESCMID CPGs recommended the use of metronidazole for the treatment of an initial non-severe CDI episode, with vancomycin and fidaxomicin being equally reserved for the treatment of severe infections. This recommendation was led by the absence of statistical significance between metronidazole and vancomycin . The 202The preference for fidaxomicin is guided by a decrease in recurrence. The ESCMID CPG differs from other CPGs by including a recommendation for the use of BEZ during the initial episode if patients are unable to receive fidaxomicin as the standard of care antibiotic and are at high risk for recurrence. The authors exclude fidaxomicin from the BEZ combination because of lack of data; only 4% of patients in the MODIFY trials received fidaxomicin/BEZ, compared to the 48% which received vancomycin/BEZ ,22. In sBecause a previous episode of CDI is a well-established risk factor for recurrence, the CPG recommendations are separated by the number of recurrences the patient has experienced.For the initial recurrence episode, the 2017 IDSA/SHEA CPG recommendations were dependent upon the therapy used to manage the initial infection. If metronidazole was used, IDSA/SHEA CPGs recommended treatment with vancomycin. However, if vancomycin was used, prolonged taper and pulse dosed vancomycin or fidaxomicin was recommended . The 202The 2013 ACG CPGs recommended repeating the same regimen for the first recurrence that was used during the initial infection, unless recurrence was severe, then vancomycin was preferred. The 2021 ACG CPGs update this recommendation to prefer vancomycin regardless of the agent used during the initial infection , or fidaxomicin as long as it was not used previously .The 2014 ESCMID CPGs recommended vancomycin and fidaxomicin as equally preferred agents for the first recurrence of CDI. The 2021 CPGs offer recommendations based on the previous regimen. If vancomycin was used to treat the initial CDI, then a standard fidaxomicin regimen is recommended for the first recurrence . If fidaxomicin was used to treat the initial CDI, then BEZ should be added to either vancomycin  or fidaxomicin (good practice statement). If neither BEZ nor fidaxomicin are available to the patient, a vancomycin taper and pulse regimen may be used .For patients experiencing multiple recurrences, the 2017 IDSA/SHEA CPGs recommended tapered and pulsed vancomycin, vancomycin followed by rifaximin, or fidaxomicin as antibiotic therapies with no preference given among the options. If patients continued to experience CDI recurrence despite appropriate antibiotic regimens, these CPGs recommended FMT as the next step . The 202The 2013 ACG CPGs recommended management of the second recurrence with pulsed vancomycin, then an FMT beginning with the third recurrence . The 202The 2014 ESCMID CPGs recommend tapered and pulsed regimen of vancomycin and standard regimen of fidaxomicin equally for the treatment of recurrent CDI, or an FMT following four days of vancomycin therapy . The 202None of the prior CPGs mention BEZ as a treatment option as literature review was completed prior to the FDA and EMA approvals. BEZ is administered as a single-dose IV infusion and is only indicated to prevent recurrence of CDI, therefore it should only be used in conjunction with standard of care antibiotics . The MODThe 2021 IDSA/SHEA CPGs encourage the use of BEZ in addition to standard of care antibiotics if the patient experiences a recurrent CDI within six months of the previous infection . However, this recommendation is backed by limited evidence for the use of BEZ combination therapy with fidaxomicin .The 2021 ACG CPGs state that BEZ showed no significant benefit over placebo in low-risk patients and, therefore, should be reserved for the prevention of CDI recurrence in patients who are considered high risk . High riEach of the 2021 CPGs mention the increased incidence of heart failure in the BEZ arm of the MODIFY trials  but diffEscherichia coli [The process of FMT introduces donor fecal material into a recipient’s intestinal tract to change the composition of the gut microbiome and make it healthier. The 2021 ACG CPGs note that FMT can result in reduced rates of sepsis and CDI-related colectomy-associated problems . Patienthia coli ,39,40.The 2017 IDSA/SHEA CPGs recommended FMT after the second and subsequent recurrences of CDI  and stated that, although FMT may be used for patients with irritable bowel disease (IBD), there is less benefit when compared to patients without IBD . The 202The 2013 ACG CPGs stated that FMT may be considered during a third CDI occurrence (second recurrence) after an appropriate regimen of pulsed vancomycin was trialed  . LikewisThe 2014 ESCMID CPGs strongly recommended the use of FMT following a four day course of vancomycin after multiple CDI recurrences . The 202Saccharomyces boulardii demonstrated the potential to be effective in decreasing the recurrence of CDI when supplemented alongside metronidazole or vancomycin; however, there was not enough evidence showing clinical benefit in decreasing recurrence alone [Probiotic products are marketed as supplements to promote healthy gut microbiota. ce alone . The 2017 IDSA/SHEA CPGs stated that there was insufficient evidence to make a formal recommendation regarding probiotics as primary prevention of CDI . The 202Lactobacillus rhamnoses GG and S. boulardii may reduce the occurrence of antibiotic-associated diarrheal symptoms. The 2021 ACG CPGs recommend against the use of probiotics for the prevention of CDI in patients, regardless of antibiotic choice or use [The 2013 ACG CPGs mention limited evidence for probiotics and their role in decreasing the recurrence of CDIs ; howevere or use .The 2014 ESCMID CPGs mentioned that there was not enough evidence to support the use of probiotics to prevent CDI, and the 2021 CPGs now recommend against their use ,14.The ACG, IDSA/SHEA, and ESCMID have all published updated CPGs for the management of CDIs in 2021. The 2021 CPGs have sparked some debate among clinicians because they do not offer the same recommendations. There are many factors that will influence the management of CDIs, a major one being access to resources. For inpatients transitioning at discharge, outpatient pharmacy “meds to bed” services can play a vital role in ensuring the patient receives the appropriate CDI therapy before being discharged from the hospital . AdditioClinicians should evaluate CPGs, including the evidence used to arrive at the panel recommendations, in the setting of their institution and patient population. Each hospital should certainly have protocols established for CDI management that include inpatient, outpatient, and transitions of care settings. Leveraging interdisciplinary teams is ideal to determine the most appropriate protocols for individual institutions and recommendations for patients who fall out of typical guideline pathways.


Visual images and music have long been known as a means to optimize emotions . Together  they may help students and professional cope with the negative side of intensive workloads .Our study attempts a multi-level assessment of the relaxation effect of a slide-film as part of student education.Sample - 46 psychology students. The 20 minute relaxation film was shown after lectures and discussion of a forthcoming examination. Measures: standard psychological and physiological functional state tests and a cognitive task before and after the film ; an original questionnaire revealing individual associations and experiences felt during the film.The results showed pronounced subjective discomfort and anxiety before the film. The relaxation film resulted in lowered blood pressure, increased subjective comfort, decreased fatigue and acute anxiety, and negative emotion scores, as well as higher productivity in performing the cognitive test . Concentration on the film subject, as well as the combination of the student’s thoughts and associations around the plot, showed a positive correlation with the amount of relaxation effect.Our research showed that using the relaxation slide-film (with imagery and music) can provide positive effects on students’ functional state. It also revealed the importance of the relevance of individual experience to the subject of the film to obtain optimal positive effects.No significant relationships.


P < 0.0001), and identified new pathogens not detected by cultures in 49% of the cases. However, three cases of pneumonia with targets not included in the molecular platform, were not detected. Implementation of the molecular syndromic facilitated treatment modification from broad to narrow spectrum antimicrobial therapy, resulting in significant reductions in antibiotic consumption in the study group compared to the control group, without a negative impact in patient outcome. The implementation of syndromic molecular diagnosis in critically ill patients with pneumonia is associated with timely and improved diagnosis and has significant impact on reduction of antibiotic consumption.The impact of syndromic molecular diagnosis in the management of nosocomial infections caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) pathogens has been incompletely characterized. We evaluated the performance of a molecular syndromic platform (BioFire FilmArray-Pneumonia plus Panel) in patients with pneumonia in the intensive care unit (ICU) of a University Hospital in Greece over a 2-year period. We evaluated 79 consecutive patients diagnosed with pneumonia in the ICU (2018–2020), including 55 patients with ventilator associated pneumonia (VAP). We included 40 control patients diagnosed with pneumonia in the ICU the year before the study (2017–2018). We identified 16 cases of VAP due to XDR bacterial pathogens. We found an excellent agreement (89.4% 76/85 reported results) between the results of syndromic platform and conventional cultures of tracheal aspirates. The molecular syndromic test significantly improved time to diagnosis versus conventional culture  in 79 patients with pneumonia in the intensive care unit (ICU) of a University Hospital in Greece over a 2-year period (2018–2020) compared to 40 control patients diagnosed with pneumonia in the ICU the year before the study (2017–2018). Importantly, implementation of syndromic pneumonia panel improved time to diagnosis, identified new pathogens not detected by cultures in 49% of the cases and resulted in a significant reduction in antibiotic consumption compared to the year before initiation of the study without a negative impact in mortality of patients. Collectively, our study demonstrates the positive value of PCR syndromic testing in the management of pneumonia in ICUs high rates of MDR/XDR nosocomial pathogens. Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) has become an epidemic in many European countries, including Greece  in the ICU and compared them with an historical control group of patients with pneumonia in the ICU during the year before initiation of the study. The demographics and clinical characteristics of both groups of patients are presented in Acinetobacter, Pseudomonas,andKlebsiella species were the main causes of bacterial pneumonia in the ICU. Of interest, there was a trend of increased rates of MDR/XDR causes of pneumonia in the historical control group. Next, we compared the yield of syndromic PCR versus conventional culture of tracheal aspirates in the study group of patients (n = 3) caused by Gram negative pathogens  and 6 co-infections with C. albicans (considered as co-pathogen by the primary physician) (The causative pathogens of pneumonia in the study (syndromic PCR) and control groups identified by conventional cultures are shown in patients . We founpatients  and resupatients . Additiopatients  and C. Npatients , the patysician) . ApproprS. aureus (n = 6), E. coli (n = 4), and Klebsiella spp. (n = 2), in agreement with the phenotype of susceptibility testing of the corresponding isolates  in the study group versus the historical control group . Of intePrevious studies demonstrated an excellent performance of syndromic PCR panel in diagnosis of the causative agent of pneumonia compared to conventional microbiological cultures , 15. Of Herein, we employed a study in ICU patients hospitalized with different types of severe pneumonia  with a need for mechanical ventilation. The majority of these patients (> 60%) had VAP due to MDR and XDR bacterial pathogens. In contrast to previous studies, we employed a historical control group of patients with pneumonia hospitalized in the ICU during the previous year of the study. Importantly, the control group had comparable clinical and microbiological features with the PCR syndromic group, which allowed to study the impact of the diagnostic platform on antibiotic consumption rates in a relatively unbiased approach. Furthermore, the choice of antimicrobial therapy guided by the PCR result was a decision made by the primary physician (intensivist) following discussion with the primary investigators, rather than by an expert committee , a practStenotrophomonas) in the molecular platform requires increased vigilance and the need for complementarity with other diagnostic procedures  to ensure optimal patient care. The clinical relevance of detection of microbial causes of VAP at relatively low copy numbers  exclusively by syndromic PCR requires validation in future studies. While early report of resistance mechanism in very useful for targeted antibiotic therapy , the PCR panel does not capture complex resistance mechanisms in certain nosocomial pathogens  leading to potential misguidance of therapy. Therefore, microbiological cultures remain the gold standard in diagnosis and guidance on targeted therapy in severe bacterial pneumonia. Nonetheless, molecular syndromic platforms should be regarded as important adjunct diagnostic tools for antibiotic stewardship and timely diagnosis of non-culturable pathogens . Collectively, our study illustrates that the PCR syndromic approach is a useful tool in the management of pneumonia in the ICU, especially in the nosocomial setting of high rates of MDR/XDR nosocomial pathogens.Limitations of the study include its retrospective nature, possible changes in infection control and antimicrobial therapy strategies which have not been captured by the investigators of the study , the single center nature of the study and the relatively limited numbers of patients enrolled. Furthermore, the lack of certain nosocomial pathogens  ICU patients with fever of another etiology, (ii) colonization of the lung or ventilator associated tracheobronchitis (VAT), (iii) patient already enrolled in the study, and (iv) patients on palliative care.2 atmosphere at 35°C for 48 h. Colonies were then counted and bacterial concentrations (CFU/mL) were calculated. Diagnostic thresholds of ≥ 104 CFU/mL and ≥ 105 CFU/mL were adopted for BAL cultures and EA, respectively; bacteria grown in numbers < 104 CFU/mL were not reported as a relevant cause of pneumonia  samples with <10 epithelial cells per low power field on Gram-stained smears were acceptable for culture . The resPseudomonas, Klebsiella spp.) in the year before the study was provided to all participating physicians. The primary physician decided on the most appropriate antimicrobial therapy for each pneumonia episode.Clinical and demographical characteristics were retrospectively obtained from the electronic medical records of each patient. Investigators collected demographic characteristics  and medical data including comorbidities, classification of pneumonia , severity scores, antibiotics prescribed, and outcome. For each episode, the result of the syndromic PCR was presented to the primary physician on call (intensivist) and the primary investigators of the study  in real time. The clinical microbiologist in charge of the study (D.S.) provided explanation on the results of the syndromic PCR test to the primary physician, including discussion on antibiotic choices based on detected pathogen and the results of the genetic markers of antimicrobial resistance. Detailed information on the susceptibility of the predominant causes of VAP in the ICU  bacterial pathogens. To address this endpoint, we performed comparative analysis of the rates of antimicrobial consumption in ICU patients with pneumonia the year before  and over the study period (2018–2020). Rates of antibiotic consumption were expressed as defined daily dose (DDD) per 100 bed days .Additionally, the following measures were assessed: The accuracy of multiplex PCR compared to routine microbiological diagnosis, the decrease in time to diagnosis associated with the use of multiplex PCR; the impact of molecular diagnosis on establishment of etiological diagnosis of severe pneumonia and VAP; the effect of rapid molecular diagnostic result on the outcome of patients, defined by days of ICU hospitalization and overall mortality.t test was used for statistical comparisons of continuous variables between the two groups. Fisher’s exact test was used for analysis of categorical variables. P < 0.05 was considered statistically significant. Analysis was performed using the GraphPad Prism software (version VII). The study was approved by the Ethics Committee of the University of Crete .All data were anonymously collected and stored on a secured database. Two-sided unpaired Student's The data sets used during the current study are available from the corresponding author on reasonable request.


To present the youngest age ever reported for acute corneal hydrops with total corneal edema in a child with advanced bilateral keratoconus.  Patient presentation in ophthalmic clinic. The patient underwent various clinical tests and examinations including anterior segment optical coherence tomography (AS-OCT) and Scheimpflug corneal tomography.  A 5-year-old girl presented with uncorrected distance visual acuity (UDVA) of 0.4 in the right eye and nonmeasurable UDVA associated with severe photophobia in her left eye of a 3-day duration. Intraocular pressure using the iCare tonometer was 14 and 5 mmHg in the right and left eyes, respectively. An old corneal hydrops scar and posterior subcapsular cataract (PSC) in the right eye and a total limbus to limbus corneal hydrops in the left eye were observed on slit-lamp examinations. Scheimpflug corneal tomography was possible in the right eye but, due to excessive irregularity and scaring, was not possible in the left eye. Corneal thinning and scarring were evident in the anterior segment optical coherence tomography in the right eye and very edematous cornea associated with stromal cleft and epithelial bullae in the left eye. A management plan consisting of topical hypertonic solution and ointment was started to reduce her symptoms.  Acute corneal hydrops may be the presenting sign of keratoconus; however, extensive hydrops involving the total cornea area at a very young age is very rare and has not been previously reported in the literature. Corneal hydrops as a complication of keratoconus (KCN) is characterized by significant bullous edema of the cornea secondary to breaks in the Descemet membrane and an influx of aqueous into the stroma and epithelium of the cornea . It has A 5-year-old girl presented to the ophthalmic clinic after her parents noticed whitish discoloration in her left eye and the child exhibiting severe light sensitivity for a three-day duration. Her clinical history was negative for any systemic, congenital/genetic disorders, atopy (recurrent rhinitis and dermatitis), and/or chronic rubbing of the eye. There was no history of topical or systemic medications, and the family history was negative for any ectatic disease. Uncorrected distance visual acuity (UDVA) recorded as decimal notation was 0.4 in the right eye and not measurable in the left eye. Intraocular pressure measured using iCare tonometer  was 14 and 5 mmHg in the right and left eyes, respectively.Slit-lamp biomicroscope examination showed an old corneal scar compatible with prior hydrops and a posterior subcapsular cataract (PSC) in the right eye and limbus to limbus corneal edema with hydrops in the left eye .Corneal topo/tomography was performed in the right eye, but due to excessive corneal irregularity secondary to the corneal scar, only a Scheimpflug image with an unacceptable quality specification (QS) was possible  after several attempts. A thin irregular cornea with a large posterior ectasia was noted on the corneal thickens and posterior elevation maps. The anterior elevation and anterior curvature showed milder changes with a maximum simulated keratometry of 60.7 diopters, possibly secondary to earlier scarring .AS-OCT of both eyes showed a thin and scarified cornea associated with an opacity under the posterior capsular surface in the right eye. The left eye had a very edematous cornea associated with multiple stromal clefts and epithelial bullae  .Dilated fundus examination was not possible but the attached retina was visible in both eyes on B-scan ultrasonography.Based on the examination of prior hydrops in the right eye, a diagnosis of acute corneal hydrops was made in the left eye. Both the slit lamp exam and AS-OCT revealed edema extending to the limbus.Her mother was informed about the nature and course of KCN and the possible future need for penetrating keratoplasty (PKP) in her left eye. Reliable autorefraction was not possible in the presence of corneal scar and PSC in the right eye. Due to severe photophobia, the patient did not cooperate enough to achieve accurate retinoscopic refraction in the right eye, and the decision was made to postpone for subsequent sessions after corneal hydrops reduction in the left eye. A management plan consisting of topical hypertonic solution and ointment was started, and it was emphasized that hydrops in most cases of KCN is a transient condition, and the patient will be followed for changes in her visual acuity, corneal transparency, and intraocular pressure.The classic view is that KCN begins as a progressive corneal disorder during puberty and progresses to midlife. KCN is less commonly seen in the very young, and this may be related to a delay in diagnosis or the inability of the very young to verbalize or note their visual complaints . It was The youngest child with KCN was reported in a 4-year-old girl secondary to vernal keratoconjunctivitis and sequentially eye rubbing without evidence of hydrops . A 5-yeaAlthough corneal hydrops can occur in various types of ectatic corneal disorders such as keratoconus, pellucid marginal degeneration (PMD), terrien marginal degeneration (TMD), and keratoglobus, it is often seen in association with keratoconus . It occuAlthough with the introduction of corneal cross-linking as a treatment option for KCN by improving the mechanical strength of the cornea, the incidence of corneal hydrops appears to have decreased.Several studies have reported corneal hydrops in children with KCN. A summary of the literature is provided in Gaskin and colleagues (2013) reported eye-rubbing, lower visual acuity at the first visit, and negative family history as risk factors for acute hydrops in KCN, while atopic disorders and a history of contact lens wear showed no association with hydrops. In their study, the average time to develop hydrops was 4 years following the detection of KCN . In agreOften, severe and chronic rubbing of the eye is considered one of the main risk factor for hydrops, sometimes very minor trauma, such as the insertion of the contact lens has been reported as causative .Multimodal imaging has improved the diagnosis of acute corneal hydrops associated with the assessment of corneal integrity. The AS-OCT of the present case showed structural changes in detail such as multiple stromal clefts and epithelial bullae as evident in the left eye delineated the location and extension of the Descemet's membrane break. Another application of AS-OCT is to determine the effectiveness of interventions such as intracameral gas injection in resolving acute edema. Basu et al.'s study showed that the measurement of break dimension (size and depth) in the DM correlates with the resolution of acute hydrops after intracameral injection of C3F8 . CompareIn conclusion, limbus to limbus involvement in corneal hydrops is in itself an uncommon presentation. To the authors' knowledge, this is the youngest reported case of corneal hydrops (5 years of age) associated with total corneal edema reported in the literature documented with AS-OCT.


Maximal safe resection is the goal of insular glioma surgery. The combination of intraoperative augmented reality (AR) diffusion tensor imaging (DTI) fiber tracking with fluorescein dye (F) helps achieve this goal throughout a microscope-based visualization of the tumor and white matter fiber tracts.The aim of the present video article was to show the technical key aspects of DTI-F microscope-based AR-assisted surgery during the gross-total resection of an insular Berger-Sanai type I+IV high-grade glioma in a 63-year-old patient, performed through a pterional transsylvian approach.https://stream.cadmore.media/r10.3171/2021.10.FOCVID2157The video can be found here:  This video article aims to show the technical key aspects of the microscope-based augmented reality (AR) with diffusion tensor imaging (DTI) and fluorescein in insular glioma resection.A 63-year-old female patient suffered from a progressive decline in learning and memory, and new-onset epilepsy. The neurological exam revealed a neurocognitive and visuospatial impairment. Past medical history was unremarkable.MRI revealed a right insular Berger-Sanai type I+IV high-grade glioma.The tumor arose at the level of the extreme capsule, and it involved the short and long gyri.The claustrum and the lentiform nucleus were pushed medially, and the medial part of the lesion was in contact with the putamen.1–9In their progressive growth, insular gliomas tend to encase the lenticulostriate arteries, this aspect being the major cause of morbidity of insular glioma surgery.3D-rendered MRI showed in more detail the anatomical relationships between the tumor, circular sulcus of the insula, and putamen.Preoperative DTI fiber tracking showed the spatial distribution of the corticospinal tract, occipitofrontal fasciculus, posterior thalamic peduncle, and optic radiation compared to the tumor. It also allowed for the selection of the surgical approach.A pterional transsylvian approach was selected.Noteworthy, transsylvian route allows for multiple working corridors.The different vascular supply of the basal ganglia and insular cortex from the lenticulostriate arteries and MCA, respectively, is to be taken into account during the planning of surgery.Total intravenous anesthesia target-controlled infusion was used to allow the neuromonitoring. Cortical subcortical mapping was performed with transcranial electric stimulation motor evoked potentials, while subcortical mapping was carried out with the high-frequency bipolar stimulation technique.Asleep craniotomy was performed. A one-layer submuscular pterional approach was carried out with the full exposure of the lateral part of the sylvian fissure.Brain mapping is recommended since DTI provides only anatomical information but no data about the function.The first step of surgery consisted of the opening of the carotid cistern, Liliequist membrane, chiasmatic cistern, along with the fenestration of the lamina terminalis.Meticulous sharp dissection of the arachnoid membranes is of utmost importance in avoiding any damage to the neurovascular structures of the basal cisterns.It is also essential to keep clean the surgical field.A wide opening of the basal cisterns, Liliequist membrane included, allows for CSF withdrawal. This is the key point to avoid the use of fixed brain retraction in the transsylvian approach.The dynamic retraction by the surgical instruments is less traumatizing and more effective in allowing for the progressive recognition and exposure of the anatomical structures.The visualization of the lenticulostriate arteries is crucial since they mark the most medial limit of surgery.Microscope-based AR fiber tractography provided for virtual view of the anatomical relationships between the lateral lenticulostriate arteries and white matter fiber tracts.The splitting of the lateral and anterior insular compartment of the sylvian fissure and opening of the sylvian cistern allowed to expose the M1 segment of the middle cerebral artery (MCA), MCA bifurcation, superior and inferior limiting sulcus of the insula, limen insula, and entire insular cortex.In this case, the middle trunk of the MCA originated from the superior trunk.The insular cortex showed a fluorescein enhancement.The cortical branches of the MCA were coagulated and the tumor was resected in piecemeal fashion. The use of fluorescein filter aided the recognition of the tumor boundaries.Care must be taken during tumor removal in avoiding mechanical vasospasm of the MCA or its branches caused by an excessive retraction of the vessels.The use of the cavitron ultrasonic aspirator facilitated the tumor resection.DTI allowed for a constant awareness of the spatial location of the corticospinal tract, fronto-occipital fasciculus, and optic radiation.The accuracy of the AR fiber tractography was checked at a cortical and subcortical level, having the motor strip as a landmark. At the cortical level, the matching between the virtual corticospinal tract and the opercular part of the motor area was tested. At the subcortical level, the matching was verified through the subcortical mapping.DTI navigation was extremely useful during the resection of the deepest part of the lesion, close to the putamen.At this step, the lack of fluorescence confirmed the gross-total resection of the tumor.At the end of surgery, the check of the blood flow ruled out spasm of the MCA and its branches.ICG videoangiography showed the patency of the MCA.A gross-total resection of the glioma was achieved, as confirmed by the postoperative MRI. Postoperative DTI documented the preserved structural anatomical connectivity of the corticospinal tract, IFOF, and optic radiation. It was basically as an anatomical confirmation of a functional check which has been already obtained intraoperatively by means of the cortical-subcortical mapping of the motor pathway.The patient was discharged without deficits on the 7th postoperative day. The relatively longer perioperative follow-up was justified by the known risk of delayed ischemic complications. A urinary tract infection occurred at the 3rd postoperative day, required the administration of intravenous antibiotic therapy. Pathology revealed an anaplastic astrocytoma. Standard Stupp protocol was employed and no recurrence occurred at the 21st-month follow-up.In conclusion, DTI-fluorescein microscope-based AR resulted safe and effective in maximizing the extent of resection of the reported insular high-grade glioma. Its association with brain mapping is recommended. Further theoretical advantages may also come from its use during awake surgery.We thank Eng. Giorgia Di Giusto for the technical support.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.Primary surgeon: Luzzi. Assistant surgeon: Giotta Lucifero. Editing and drafting the video and abstract: both authors. Critically revising the work: Luzzi. Reviewed submitted version of the work: Luzzi. Approved the final version of the work on behalf of both authors: Luzzi. Supervision: Luzzi.


This study examines the accessibility to COVID-19 vaccination resources in two counties surrounding Newark, NJ in the New York Metropolitan Area, United States. The study area represents diverse population makeups. COVID-19 vaccines were made available by different types of vaccination sites including county mass vaccination sites, medical facilities and pharmacies, and a FEMA community vaccination center in spring 2021. We used the two-step floating catchment area method to measure accessibility and calculated the average accessibility scores of different population groups. We examined the patterns and tested the significance of the differences in accessibility across population groups. The results showed clear spatial heterogeneity in the accessibility to vaccine resources with the existing infrastructure . Accessibility patterns changed with the introduction of county mass sites and the FEMA community site. The county mass vaccination sites in one county greatly increased accessibilities for populations of minority and poverty. The FEMA community site in the other county accomplished the same. Both the local health department and the federal government played an important role in mitigating pre-existing inequalities during the vaccination campaign. Our study shows that social determinants of health need to be addressed and taken into explicit consideration when planning resource distribution during the pandemic. The COVID-19 pandemic not only caused profound damage to human health, livelihood of humans and economy worldwide . During The United States started its COVID-19 vaccination campaign in December 2020. By spring 2021, vaccine production and supply had increased for vaccination to open up to all adult populations. Counties established community vaccination sites in addition to medical facilities and pharmacies to push for mass vaccinations. The Federal Emergency and Management Agency (FEMA) also established community vaccination centers in dense urban areas . In partThe existence of disparities in COVID-19 infections and mortality between racial groups in the US has been widely documented –14. It cAccess to vaccination sites can be evaluated using proximity-based measures such as distance from census tract centroids to vaccination sites . AdditioDuring early stages of the COVID-19 pandemic, studies evaluated accessibilities to testing sites using rapid measures by taking into consideration of testing capacities, population demands, and travel distances ). We adoThe objectives are to (1) examine the spatial heterogeneity of accessibility in diversely populated communities, (2) investigate the relationship between accessibility and socioeconomic factors, and (3) compare the effect of different types of vaccination sites during the mass vaccination campaign. The goal is to provide insight into any mismatch of resources and population, inform public health planners to guide efforts in establishing sites, and allocate resources in an equitable manner. The method provides rapid assessments with readily available data and is applicable for prospective analysis by public health decision makers during an ongoing vaccination campaign to evaluate scenarios for resource distribution and adjust the setup of vaccination sites. Thus it adds to the toolset for future vaccination planning of other emerging/re-emerging infectious disease outbreaks or if COVID-19 co-exists with the human population for a long time and yearly re-vaccination becomes necessary.This study was performed in Essex County and Union County, New Jersey. New Jersey is one of the most affected US states in the COVID-19 pandemic  and the Vaccination site locations as of May 23rd 2021 were obtained through the NJ Department of Health's COVID-19 information hub  and geocj). Delineation of catchment areas is based on a threshold travel distance (d0) along road networks. A supply-to-demand ratio Rj is then computed for each site using Equation 1.We used the two-step floating catchment area (2SFCA) method  to calcuSj is the available vaccination appointments of site j, Pk is the population of census tract k, whose centroid falls within the catchment of site j. The travel distance dkj from k to j is no greater than a preset threshold driving distance d0. In our study, we tested different thresholds in the delineation of catchments from 1–5 miles. It was observed that with 5-mile catchments, almost all areas in the two counties are covered. As vaccines can be readily administered at many pharmacies, accessibility to vaccination sites should be evaluated differently from accessibility to primary care doctors, for which the commonly used threshold is a 30 min travel time  are all critical in mitigating the disparities. In the case of the two diversely populated New Jersey counties, there was clear spatial heterogeneity in the accessibility to vaccine resources with the existing infrastructure . Accessibility patterns changed with the introduction of county mass sites and the FEMA community site. In particular, county mass sites were set up in Union County targeting densely populated areas and minority populations, so was the FEMA community site in Essex County. These resulted in notable changes in the accessibility landscape. It shows how both the local health department and the federal government play an important role in mitigating pre-existing inequalities.Second, social determinants of health need to be addressed  and takeThird, utilizing appropriate tools and technology can help improve public health response and decision making. The quick accessibility measure and geospatial analysis used in this study could be applied prospectively during an ongoing mass vaccination campaign to provide essential and timely evaluation of resource accessibility to guide decision making. County health departments can repeatedly run such analyses with various scenarios to guide site selection. Continued analyses could be done to monitor the change of accessibility landscape as vaccine shipments and daily operations of vaccination sites change from time to time.The accessibility measure used in this study can be quickly calculated with readily available data. Improvements can be made to increase the accuracy of accessibility evaluation, such as considering distance decay  or usingThis pandemic has shown how marginalized and minority groups have and will suffer disproportionately due to the inequities in society perpetuated by systematic practices. This study is timely to investigate one aspect of health equity, raise consciousness, and use tools and resources to confront inequities. Vaccine distribution system design can greatly influence equity and accessibility at the community level . As publhttps://covid19.nj.gov/pages/covid-19-vaccine-locations.Publicly available datasets were analyzed in this study. This data can be found here: FQ conceived the study and wrote the manuscript. DB and MR implemented the analyses. JL assisted in the analyses and writing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.