Cardiovascular stent restenosis remains a major challenge in interventional treatment of cardiovascular occlusive disease. Although the changes in arterial mechanical environment due to stent implantation are the main causes of the initiation of restenosis and thrombosis, the mechanisms that cause this initiation are still not fully understood. In this article, we reviewed the studies on the issue of stent-induced alterations in arterial mechanical environment and discussed their roles in stent restenosis and late thrombosis from three aspects: (i) the interaction of the stent with host blood vessel, involve the response of vascular wall, the mechanism of mechanical signal transmission, the process of re-endothelialization and late thrombosis; (ii) the changes of hemodynamics in the lumen of the vascular segment and (iii) the changes of mechanical microenvironment within the vascular segment wall due to stent implantation. This review has summarized and analyzed current work in order to better solve the two main problems after stent implantation, namely in stent restenosis and late thrombosis, meanwhile propose the deficiencies of current work for future reference. Cardiovascular occlusive disease such as arteriosclerosis leads to poor blood circulation, angina pectoris, lack of oxygen and myocardial infarction. It has become one of the most threatening killers of human beings , 2. PercIt has been well documented that vascular cells can adapt to mechanical stimuli, resulting in vascular remodeling . Stent iThe goal of this review paper is to analyze the hemodynamics in the lumen after stent implantation, the mechanical microenvironment within the host artery, and to discuss their effects on re-endothelialization, restenosis, thrombosis formation and inflammation.In this section, we will review the response of vascular wall and the mechanism of mechanical signal transmission, and then discuss the process of re-endothelialization and late thrombosis.From inside to outside, there are three layers of the vascular wall: endothelial cells (ECs), SMCs and collagen fibers. ISR arises from multifactorial influences, including vascular intimal injury, thrombosis, vascular remodeling, inflammation and healing .After stent implantation, the adventitia and medium will respond to the stent-induced alterations in the host artery mechanical environment, hence leading to the remodeling of the vessel wall and resulting in significant changes of its mechanical properties, such as the elastic modulus , 15. In While atherosclerosis (AS) in native coronary arteries develops over decades, in-stent neoatherosclerosis seems to occur much faster, i.e. in months to years following stent placement . It is sIndeed, activated VSMCs could efficiently proliferate and migrate to contribute to vessel wall repair. However, the latest evidence  suggestsStent implantation inevitably injures the ECs. Moreover, the stent-induced mechanical environmental changes can also lead to a series of changes in the ECs. ECs respond to shear stress via various mechanical sensitivity receptors, such as vascular endothelial growth factor receptor 2, VE-cadherin, platelet EC adhesion molecule-1, integrin, glycoprotein complex, primary cilium and glycocalyx . MechaniIn addition to shear stress, because stent implantation alters the compliance of the host blood vessel, it will also affect the movement of the vascular wall under pulsatile blood pressure, hence the stretches of ECs. ECs have been confirmed to receive strain signal through the substantial cell membrane surface mechanical sensors, including cell adhesion sites , integriAfter stent implantation, thrombosis formed after 1 month to 1 year is defined as late thrombosis. Thrombosis formed after more than 1 year is defined as very late thrombosis . The incIn the early stage after stent implantation, endothelial ablation, platelet aggregation and activation, coagulation cascade and strong inflammation locally happen in vascular. Endothelial layer is destroyed, and the stent surface is coated with a thin thrombotic layer. The main cellular component of the neointima is α-actin positive SMCs, which begin to migrate into the intima from the tunica elastica within several days after implantation. A healthy endothelial layer has tight junctions that can strictly regulate lipid and inflammatory molecule infiltration, and has balanced secretion of anticoagulant molecules that can provide good resistance to thrombosis formation . Normal In the middle stage, ECs repair gradually completes, the coagulation cascade reaction decreases gradually, and SMCs migrate from the media membrane to the inner membrane . IntimalIn the late stage, the re-endothelialization is completed but lacks entire function, because of the insufficient secretion of the anticoagulation factor. Therefore, late thrombosis may occur . The re-Two recognized types of coronary artery calcification are atherosclerotic and medial artery calcification . VasculaAfter stent implantation, the ECs are peeled off, and the subcutaneous tissue is exposed to the flowing blood. Although vascular mechanical damage caused by stent appears to be a prerequisite for the expression of the inflammatory response such as white blood cells and platelets, the inflammatory response and persistence may be related to individual factors. In particular, the increased expression of interleukin-antagonists (anti-inflammatory molecules) results in risk reduction of restenosis especially in young patients . The reaAs early as 10–15 min after stent implantation, recruitment and aggregation of white blood cells can be detected in the stent area of the coronary artery , 64. InfRecently, it has been shown that the main pathological basis of ISR is the activation, migration and proliferation of VSMCs with intimal hyperplasia . FindingIn normal coronary arteries, blood flow takes a form of laminar flow, resulting in relatively high WSS on VECs. In the narrow section of the coronary artery with AS plaques, magnetic resonance imaging has been used to detect rapid increase in blood flow speed with significantly enhanced WSS . Distal Stent implantation restores the stenotic lumen of the blood vessel to the normal state of dredging , 64–77, Finite element analysis shows that the stress distribution of a stent after deployment is not uniform . The majCurrently, commercially available stents are manufactured using mesh-wired tube with certain thickness. As mentioned previously, the thickness of the strut leads to the formation of vortices or disturbed flow. On one hand, disturbed flow with vortices may facilitate deposition of substances. On the other hand, due to the intrusion of the stent into the vascular lumen, different stress distribution of the proximal and distal end of the stent leads to changes in hemodynamics. As shown in Different strut spaces lead to different stress distribution both at the proximal and distal end of the strut . In a stCompared with ‘rhombus’ stent, the ‘S’ type stent has lower radial stiffness, which results in less stress magnitude and radial displacement of the arterial wall  84]. In. In84]. Stent implantation changes the compliance of the blood vessel, which also affects the hemodynamics in the blood vessel . Stiff mAdverse hemodynamic alteration by stent implantation is only one of the major factors leading to ISR. Since other forces can also affect the surrounding mechanical environment of vascular cells, the mechanism of the cellular response to its surrounding mechanical environment alterations needs further studies. Furthermore, the alteration of mechanical environment after stent implantation may postpone re-endothelialization that further leads to late thrombosis formation. However, the vascular cells may not directly respond to the force from external environment, perhaps in an indirect way or other signals. Therefore, how to optimize the stent design to reduce the degree of changes in vascular internal mechanical environment is a problem for us to consider, such as trying different kinds of flower patterns and softer scaffold materials.In this section, we will review the changes in the mechanical microenvironment of the host artery due to stent implantation and the effects of these changes on vascular cells in an attempt to better understand the mechanism of ISR and late thrombosis formation.τ0) [The data show a clear impact of the vascular mechanical microenvironment on vessel cells. τ0) . The numτ0) . Both anτ0) .Numerical simulation analysis of the thrombus-induced spatial WSS gradient with time suggests that stents cause a transient HSS gradient after implantation and that the shear stress gradually returns to normal 14 days after implantation  73]..73].Although it has been recognized that ISR and late thrombosis are mainly attributed to stent-induced mechanical microenvironment alterations, the regularity of the stent-induced mechanical changes in the host artery is still far from clarified because most of the existing studies regarding this aspect are based on very simplified models, which cannot reflect the real dynamic scenarios of the host artery with stent implantation. The future work can be based on the changes in the mechanical microenvironment after the stent implantation, which can affect the mediator and thus cause the ISR. Improving evaluation means of mechanical microenvironmental changes caused by the design of stent is conducted to better serve the stent design and optimize the mechanical environment of vascular stent.It has been widely documented that ISR is mostly attributed to the changes in mechanical microenvironment due to stent implantation , 12. WitISR is a repair process of the arterial wall after mechanical injury, consisting of elastic retraction, intimal hyperplasia and vascular remodeling . In thisThe delayed healing of EC layer after stent implantation is considered to be the key pathological event leading to late stent thrombosis. It is believed that the proliferation and migration of ECs in uninjured artery segment might eventually repair the wounded EC layer , but thiThe immune cells in blood are regulated by flow shear stress . For insin vivo experimental verification. Theoretical models of the blood vessel and the stent after stent implantation can be predicted by numerical simulation, but the interaction between the stent and the blood vessel, blood vessel and blood cannot be directly reflected. In the future, more realistic numerical models are needed to elucidate the dynamic interaction between the stent and the host artery in terms of hemodynamic and vessel WSS distributions including the distributions of flow shear stress, the axial, radial and circumferential stress of vascular wall. Then, based on the detailed information of stent-induced mechanical environment changes obtained, systematic study should be designed to clarify the responses of the vascular and vascular immune cells to these mechanical stimuli, so as to build a more realistic model where we could get more hypotheses. The model can be improved when the new hypothesis is verified. Second, systematically study the effects of mechanical environment changes on the physiological characteristics of vascular cells , cells (mainly dendritic cells) that are involved in vascular immune system, and vascular EPCs that are involved in vascular injury repair. Finally, systematically clarify the interactive relationship between mechanic-cell biological behavior and its biological significance in ISR, and the relationship between mechanic-vascular biological behaviors, explore the molecular mechanism involved in the ISR and re-endothelialization. In this way, we may find targeted and effective ways to resolve the two problems of stenting.To sum up, finding out how the vascular stent implantation changes the biomechanical environment of blood vessels, thereby affecting the formation of restenosis and late thrombosis, and its molecular mechanism is a scientific problem of great concern. Based on this, future researches can be carried out from the following three aspects. Presently, most of the work on this issue is based on simplified theoretical models, lacking


Group B streptococcus, found in the vagina or lower gastrointestinal tract of about 10–40% of women of reproductive age, is a leading cause of early life invasive bacterial disease, potentially amenable to prevention through maternal immunization during pregnancy. Following a consultation process with global stakeholders, the World Health Organization is herein proposing priority research and development pathways and preferred product characteristics for GBS vaccines, with the aim to facilitate and accelerate vaccine licensure, policy recommendation for wide scale use and implementation. It is now over forty years ago that an association between transplacental transfer of maternal Group B streptococcus (GBS) antibodies and infant protection from invasive infection was shown, supporting the concept of a maternal immunization-based prevention strategy Past investments in GBS vaccine research have been limited, probably due to a (mis)perception that IAP based strategies are sufficient to deal with the disease in high-income countries, concerns about the complexity of developing vaccines for use in pregnancy, and an incomplete evidence base on the global disease burden. New data, a better understanding of the limitations of existing control strategies and progress in the definition of regulatory and policy pathways for immunization during pregnancy have renewed the interest in vaccine strategies against perinatal GBS disease As expressed in these documents, the strategic goal is to see the development and licensure of safe, effective and affordable GBS vaccines for maternal immunization during the second or third trimester of pregnancy to prevent GBS-related stillbirth and invasive GBS disease in neonates and young infants, appropriate for use in high-, middle- and low-income countries. A target of 80% protection against the combined risk of laboratory-confirmed GBS stillbirth and invasive disease in the offspring was set.Among the research priorities, more and better data are needed to quantify the precise potential public health impact of a GBS vaccine. Very little information is available from some of the poorest world regions. The vaccine composition will need to overcome the diversity of bacterial capsular types or target protein expression prevalence and polymorphism, targeting at least 90% of the current invasive disease isolates. Long-term strain composition monitoring should be planned and the potential for capsular switching, strain evolution and replacement of the bacterial population as a cause of invasive disease considered. In line with principles of safety precaution, there is a preference for an adjuvant-free formulation, although the inclusion of an aluminium salt or another adjuvant with an extensively demonstrated favourable safety profile in pregnancy would likely be acceptable.Detailed determinants of immunogenicity in pregnant women and antibody transfer to offspring should be characterized. There is a clear preference for a one-dose regimen. The role of past natural GBS exposure, of a priming dose, of boosters during subsequent pregnancies will need to be defined. Immunogenicity upon co-administration with recommended vaccines for use in pregnancy, and impact on immune responses to relevant infant vaccines  need to be evaluated.The development of a quality-assured, regulatory-acceptable immune correlate of protection could accelerate and would reduce the cost of vaccine development. Further assay development, detailed immuno-epidemiological and vaccine studies are needed to confirm whether, in addition to favourable safety being established, large pre-licensure efficacy trials are needed, or whether it would be acceptable for licensure and policy decision to be based on indirect evidence of efficacy, with more comprehensive health impact evaluation ongoing after initial licensure, such as during pilot implementation projects.In the absence of evidence that supports licensure based on immune correlates of protection, a pivotal efficacy trial will be needed. Endpoint case definitions and ascertainment methodologies will need to be defined and standardized, including in the case of stillbirth or fatality. Priority endpoints are presented. Leading principles about appropriate standards of care for maternal and infant infectious risk management in the context of a GBS vaccine efficacy trial are proposed, in due consideration of local standards of care and WHO recommendations on infection risk management.The influence of important maternal comorbidities such as HIV infection and malaria in pregnancy on vaccine outcomes should be evaluated. Considering the high prevalence of HIV infection in certain regions with high GBS disease incidence, and the much increased risk of invasive GBS disease in HIV-exposed infants, HIV should not be a contra-indication to vaccination.Robust clinical development planning, data collection and delivery will require constitution of networks of investigators, including research centres in low- and middle-income countries with strong clinical trial research capacity, documented baseline rates of disease and of common adverse obstetric and neonatal outcomes, and appropriate regulatory and ethical oversight. Global recommendations and resources are available to support adequate assessment of the safety of vaccines for use in pregnancy. The maternal immunization delivery platform needs to be rationalized based on a long-term vision, considering the various disease targets and the need for integrated prenatal care.The cost of research, production, procurement and delivery must be manageable and ensure that when available, there are no access barriers for products that meet critical medical needs, and no time gap between low- and high-income countries. The residual disease burden in high-income countries should be re-assessed, with due consideration of adverse consequences of IAP-associated perinatal antibiotic use. Precise estimates of the global health economic value of resources and efforts spent on GBS vaccine development should guide responsible public and private investments. Funding partnerships may be required. In terms of approval and implementation, the WHO prequalification and SAGE policy recommendation pathway, complementary to national regulatory licensure, provide a way to ensure programmatic suitability and constitute a requirement for some financing and procurement agencies.Not applicable.The funding source had no role in the development of the present manuscript.


Eurosurveillance invites authors to submit papers in the categories Research, Surveillance, Outbreaks, Reviews and Perspectives for a special issue focusing on how point of care/point of impact testing (POCT/POIT) and self-testing impact surveillance and public health.Kits for testing close to the patient frequently by healthcare workers who may or may not have specific laboratory training, or self-testing are becoming increasingly available. Both POCT and POIT make testing easier and produce more rapid results, which enables timely treatment as well as the implementation of infection prevention and control measures. Self-testing approaches increase accessibility and confidentiality, which the individual may perceive as a benefit.However, the incorrect use of tests can affect their accuracy and the quality, sensitivity and specificity of different tests can vary. Limitations of rapid diagnostics could have important consequences for individual and public health and thus appropriateness of use should be ensured. Aside from appropriate standards and accreditation of tests, self-tested patients need to be linked to care, and policies should be in place to address these varying aspects.Capturing results from POCT/POIT and self-testing in a systematic and comprehensive manner may pose a challenge for traditional epidemiological surveillance. Moreover, for reference and public health laboratories, the possible limited availability of referred samples and/or isolates resulting from POCT/POIT and self-testing could impact on the detection of transmission pathways, source attribution and the detection of emerging new strains, antimicrobial resistance patterns etc.This special issue aims to focus on the emerging role of POCT/ POIT and self-testing in contemporary communicable disease diagnostics, their utilisation and interpretation by public health experts and scientists and the range of benefits and challenges associated with their increased use.Topics of interest may be, but are not limited to:The use of POCT/POIT and self-testing results in surveillanceIllustration of solutions to improve linkage to carePossible role of POIT in outbreaksPossible role of POIT in populations moving across bordersPossible role of rapid diagnostics in informing public health interventions (e.g. immunisation)Quality assurance, certification, accreditation in the public health contextPolicy and regulatory aspects of harnessing these new technologies for public healtheurosurveillance@ecdc.europa.eu.The submission deadline is 07 June 2019. If you would like to submit a paper or ask for more information, please see our instructions for authors regarding article formats or contact the editorial team at


Here, we review the neural circuit bases of habits, compulsions, and addictions, behaviors which are all characterized by relatively automatic action performance. We discuss relevant studies, primarily from the rodent literature, and describe how major headway has been made in identifying the brain regions and neural cell types whose activity is modulated during the acquisition and performance of these automated behaviors. The dorsal striatum and cortical inputs to this structure have emerged as key players in the wider basal ganglia circuitry encoding behavioral automaticity, and changes in the activity of different neuronal cell-types in these brain regions have been shown to co-occur with the formation of automatic behaviors. We highlight how disordered functioning of these neural circuits can result in neuropsychiatric disorders, such as obsessive-compulsive disorder (OCD) and drug addiction. Finally, we discuss how the next phase of research in the field may benefit from integration of approaches for access to cells based on their genetic makeup, activity, connectivity and precise anatomical location. When we look at living creatures from an outward point of view, one of the first things that strike us is that they are bundles of habits”  also demonstrate an enhanced tendency for dominance of habitual behavior  include the striatum, midbrain dopaminergic nuclei, and regions of cortex that project to the striatum. These circuits are the primary focus of this review article, although it should be noted that the amygdala, thalamus, pallidum, and other limbic regions that are part of the broader basal ganglia circuitry are also involved in these behaviors. It has long been known that the striatum and its associated circuitry play a pivotal role in reinforcement learning and the development of behavioral automaticity found in habits, compulsions and addictions. The circuit composed of the ventral tegmental area (VTA) midbrain neurons projecting to the ventral striatum is considered to be the main circuit mediating reward and reward prediction error in the brain. Drugs of abuse target this circuit by either directly  or indirectly  increasing midbrain dopamine neuron activity, and therefore enhancing dopamine signaling at release sites in the ventral striatum, or by directly inhibiting dopamine’s reuptake upon its release  over-training , and a lateral aspect, the dorso-lateral striatum (DLS), both of which receive substantial cortical inputs. While the sensorimotor DLS receives major inputs from somatosensory and motor-cortical regions, the associative DMS receives major inputs from associative frontal cortical areas, such as orbitofrontal cortex , and in each of them, the major circuit phenotype observed has been disruption of cortico-striatal synaptic transmission, particularly involving inputs from OFC  in striatum was increased 6-fold, suggesting that it is M2, and not lOFC inputs, that drive compulsive grooming  have been observed in OCD patients  are SPNs, which are roughly evenly split between Dopamine D1 receptor (Drd1)-expressing direct pathway SPNs  and Drd2-expressing indirect pathway SPNs , a reduction in the number of striatal PV neurons was observed, leading to a reduction in feed-forward inhibition, potentially reducing inhibition of cortico-striatal inputs . These mechanisms are extensively summarized elsewhere  of a cluster of striatal neurons defines its recruitment to encoding a given S-R behavioral association . Recently, it has been appreciated that unique patterns of dSPN and iSPN activity in locally concentrated clusters of SPNs correlate with the performance of specific actions  expression (using FISH and single-cell RNA-seq) will be invaluable. To date, many studies have examined neural activity in single brain regions, using tetrode recordings or calcium imaging, where at most hundreds of cells can be monitored. The unbiased identification of neuronal activity in basal-ganglia relevant neuronal populations and their genetic identity will be accelerated with scRNAseq, smFISH, and similar molecular techniques, followed by approaches using targeted recording of neuronal activity in defined neuronal populations (Jun et al., This achievement will enable investigators to ask crucial questions about cellular and synaptic plasticity in behavioral automaticity. Since the striatum is composed of repeating microcircuit elements, common rules are likely to prevail for the encoding of diverse actions within the striatum. Some major questions are: during the encoding of a habit, compulsion, or addiction, is the activity of dSPNs or iSPNs modulated to a greater degree? Do dSPNs and iSPNs representing the same behavior sit adjacent, in the same locally concentrated cluster? If so, do they vie for control over the same behavior, or do iSPNs primarily function to inhibit competing behaviors (Tecuapetla et al., Once the ensemble representation of a defined S-R trace has been clearly demarcated, it will accelerate the investigation into the rules governing microcircuit organization and plasticity, as has been partially achieved recently by isolating the trace of a particular auditory stimulus within the striatum (Xiong et al., In order to realize this goal, one can gain genetic access to cells participating in a given S-R association, by utilizing activity-dependent, cell-specific targeting approaches such as TRAP mice (Guenthner et al., Next, it will be important to test the necessity of activity patterns in genetically targeted neurons for the encoding and actuating of particular behaviors. For instance, during the development of habitual cued lever-pressing, how necessary are the striatal cells active during lever-pressing for expression of this behavior? Using optogenetic and chemogenetic approaches in combination with cell-specific targeting tools, it can be tested whether the activity of a particular ensemble or synapse-type is indispensable for a given automatic behavior and whether activation of the ensemble can induce it.Finally, a rapidly increasing body of evidence acquired from humans with genetic mutations (Hancock et al., Habit formation, expression, and related disorders are among the most fundamental topics in behavioral neuroscience, and significant progress has been made in this field. We anticipate that the next decade of research into the roles of cortico-basal ganglia circuits in supporting behavioral automaticity will involve integrating innovative molecular techniques and overlaying the different anatomical and functional representations of striatal organization. Such combined high-resolution approaches will be instrumental in pinpointing specific circuits and synapses, as well as defining basic rules of microcircuit function within the vast cortico-basal ganglia circuitry driving the development and expression of habits, compulsions, and addictions.DL, BG and AC wrote 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.


Emotion-related disorders  include some of the most common, burdensome, and costly diseases worldwide. Central to many, if not all of these disorders, may be patterns of rigid or inflexible emotion responses. Indeed, theorists point to emotion in-flexibility as a potential cause or maintaining factor in emotion-related diseases. Despite the increasing prominence of emotion inflexibility in theories of affective disease, a comprehensive review of the developing empirical literature has not yet been conducted. Accordingly, this review will examine the three dominant lines of inquiry assessing emotion flexibility. These include: (1) the capacity to use and vary deliberate emotion regulation strategies, (2) the context sensitivity of spontaneous emotional responses, and (3) flexibility in the appraisal of emotional events and experiences. Moreover, current evidence suggests that each of these three lines of research may converge to suggest the interplay of two key biological dimensions in emotion inflexibility, threat sensitivity, and cognitive control, known to be impaired in patients with affective disorders. In short, this developing body of work suggests a path by which future research could explicate and even exploit the ties between emotion inflexibility and affective disease, contributing to the development of improved models of risk, assessment, and intervention, with broad implications for psychological health. The prevalence of emotion-related psychiatric disorders has reached nearly epidemic proportions . Rates fEmotion flexibility is increasingly viewed as a cornerstone of psychological health. Theorists largely agree that emotion flexibility encompasses automatic, implicit, as well as deliberate emotion regulatory processing and is defined as the ability to respond to shifting demands with contextually sensitive modulation of emotional responses . Indeed,A key element of emotion flexibility is the ability to inhibit or down-regulate emotional responses. Indeed, poor emotion inhibitory processing is well recognized as a significant predictor of the most prevalent affective disorders, including depression , post-trIn contrast, research and theory argue convincingly for a link between emotion flexibility and adaptation. For example, most contemporary models of emotion posit that emotions evolved to serve discrete functions in order to facilitate survival and adaptation to specific environmental threats and demands. Accordingly, there is clear evidence for discrete functions for emotions such as fear , sadnessWhile emotional flexibility shares some conceptual overlap with the broader construct of psychological flexibility, it also is distinct from psychological flexibility and incrementally informative toward our understanding of psychological health and dysfunction. Psychological flexibility is broadly defined as the ability to modulate cognitive and behavioral actions in pursuit of a goal across shifting contexts . ResearcResearch on emotion in-flexibility and disease has proceeded along three primary lines of inquiry. Much of the work has occurred within the context of stressful life events and the potential for new onset or resurgence of symptoms. However, some research has focused explicitly on clinical groups diagnosed with affective disorders. In particular, researchers aiming to capture emotion flexibility have relied heavily on lab paradigms or sampling that can capture variability within person rather than relying simply on between-person variability. Indeed the study of emotion flexibility demands repeated assessment of the individual across contexts, circumstances, and/or time, so as to provide ample opportunity to capture changing responses, whether directed deliberately or spontaneously emerging.Researchers have defined emotion flexibility as the capacity to vary the use of deliberate emotion regulation strategies. Based largely on recent elaboration of dominant models of emotion regulation  researchvia static images and asking participants to select a regulatory strategy (often one of two) including, for example, an option like reappraisal, which forces engagement with the emotional content, or alternatively, distraction, which facilitates disengagement from emotion material  is conceptualized as flexibility. This paradigm has been influential, demonstrating the clear association between emotion regulatory flexibility and psychological health . Bonanno and colleagues developed this within-subject paradigm in which individuals are directed to either visibly suppress or express emotional expression in response to evocative pictures. A higher combined score capturing both behaviors  was associated with poor adjustment across a variety of community samples , population of concern, and emotion(s) targeted . Such meThere is a broad literature demonstrating the association between flexibility in the appraisal of emotional experience and physical and psychological health. Indeed, how individuals appraise or conceptualize emotional experiences is increasingly emphasized in contemporary models of affective disorders and in the development of new interventions for affective disease  has been associated with a number of maladaptive outcomes including: higher perceived and objective indicators of stress e.g., , 2002, pThe Dynamic Model of Affect: both individual differences in the phenomena as well as contextual variability, a point emphasized in recent research demonstrating only moderate stability over time  as an individual differences variable. However, Zautra and colleagues invested decades in examining this phenomenon, demonstrating through a variety of both experimental lab and observational field paradigms that the polarity of an individual’s appraisal of emotional events or experiences will shift depending on available resources  of external and daily events and experiences. Indeed, Kuppens and colleagues have amassed a considerable body of research demonstrating clear associations between rigidity of negative emotional appraisals  and poor psychological health, with particularly strong associations to depression . Other aSeveral limitations regarding appraisal flexibility deserve mentioning. One limitation surrounds the inconsistency in experience sampling paradigms that may contribute to heterogeneous findings . For exaIn sum, the new field of research on emotion flexibility has capitalized on rigorous measurement of real-time emotion across domains, contexts, and response modes that is less typical in conventional emotion regulation research. Indeed, a key strength of the body of emotion flexibility research is that across lines of inquiry, results are broadly consistent: emotion flexibility predicts psychological health and adjustment and emotion in-flexibility predicts affective dysfunction and maladaptive behavior consistent with affective disease. Although emotion in-flexibility research in clinical samples has typically targeted high-risk groups where emotion dysfunction is particularly evident , that similar findings are present in stressed community samples, where presumably psychopathology is normally distributed, suggests that these findings are likely trans-diagnostic and due to underlying deficits in emotion processing circuitry.activating fear versus inhibiting fear and both of these regions have extensive reciprocal connections with the amygdale  combined with low top-down control resources may broadly be the source of most affective impairment, including patterns of emotion responding consistent with emotion in-flexibility. For example, recently Coifman and colleagues investigated how varying cognitive control resources impacted the flexibility of emotion responding in high-threat-sensitive adults during an ostracism simulation . AlthougAlthough the foundation for understanding emotion flexibility is growing, there is a significant need for greater research attention so as to maximize the utility of this construct in understanding psychological health and risk for affective disease. Indeed, each of the current lines of inquiry has contributed broadly to an increasingly dominant view that flexibility in emotion processing is broadly healthy and that rigidity or in-flexibility is risky and may be characteristic of affective disease. However, the current work suffers from several key limitations that must be overcome in order to move the field further.A clear weakness of the burgeoning literature on emotion inflexibility is a lack of cross-validation. Rarely do researchers investigate more than one operationalization of flexibility in a given sample and therefore it remains wholly unclear if emotion regulation flexibility is associated with apprasial flexibility or flexible context-sensitive emotion. Theoretically, all three manifestations of emotion flexibility should cohere but it may be that a particular operationalization of the construct has greater predictive utility when evaluating risk or modeling symptom development. This has yet to be explored or tested explicitly. Indeed, very little is known not just about the relations between the “types” of flexiblity, but also about the stability of these constructs over time. With two notable exceptions , there hOne possible solution to the challenge of both cross-validation and stability is the increased collaboration of scientists across disciplines and methodological domains. A particular challenge of emotion flexibility as it has been studied is that the construct relies on diverse methodology, spanning the laboratory to the field, from the psychophysiology suite to behavioral coding. Indeed, rarely do affective scientists necessarily have methodological specialization across domains. Perhaps an increased emphasis on cross-validation or replication from lab to field would encourage greater collaboration and a more robust test of this construct, as well as some evidence of stability within and between individuals.In addition, there is a clear need to tie specific patterns of emotion flexibility more tightly to clinical phenomena, rather than clinical populations. For example, what is the unique association between up-generation of positive emotion in positive contexts and specific symptoms of affective disorders? Arguably, poor regulation of positive emotion is one of the most clear risk factors across a constellation of affective disorders. Yet it remains unclear if poor generation of positive emotion contributes to specific symptoms more than others. Moreover, what is the relative contribution of poor generation of positive emotion as compared to poor inhibition of negative emotion in risk for disease? Patients also likely vary across these phenomena and comparing specific manifestations of emotion inflexibility within and between patient groups might better specify models of disease onset, progression, maintenance, and even relapse.a priori pathways for testing; instead, significant pathways are uncovered empirically . Indeed, one of the shortcomings of this burgeoning area of research is the relative absence of a developmental framework to inform these three lines of research on emotional inflexibility. Despite a lack of explicit integration, considerable developmental research illustrates the critical role early experience plays in shaping emotional flexibility c.f., . For exaIn addition, there is also a need for less costly methods to index emotion flexibility. Across lines of inquiry, there is consistency in findings which is a great strength and likely dependent, in part, on heavy reliance on objective indicators of emotion assessed multiple times, across contexts. However, the benefits of objective indices come with a considerable price tag, one that makes it virtually impossible to assess emotion inflexibility in an applied setting. Indeed, the least costly line of research has involved experience sampling, which still demands considerable researcher time to clean and aggregate data in order to analyze it effectively. This limitation is compounded by the increasing evidence of the weaknesses of self-report instruments. Although often a preferred cheaper alternative, self-report indices of emotion and emotion regulation demonstrate consistently poor concordance with behavioral indices and weak predictive utility e.g.,  as well Finally, there is need to more closely tie patterns of emotion in-flexibilty to the imblance of the constituent dimensions that underlie all emotion processing. Apart from a handful of recent studies, there has been little work tying emotion inflexibility with top-down cognitive control and bottom-up activation. For example, Myruski and colleagues adapted a task designed to assess responsivity to emotional context for use with EEG, demonstrating some association between context sensitivity and behavioral facilitation  and well-being . However-flexibility in features common across affective disorders, including enduring negative mood, rumination or negative repetitive thought, and maladaptive behaviors known to maintain disease . In short, this developing body of work suggests a path by which future research could explicate and even exploit the ties between emotion in-flexibility and affective disease, contributing to the development of improved models of risk, assessment, and intervention, with broad implications for psychological health.Broadly, theory and now burgeoning evidence suggest that flexible emotion processing, characterized by variable and responsive up- and down-regulation of emotions to meet individual needs and contextual demands, is a core feature of psychological health and adaptation. Increasingly, it is clear that patterns of emotion in-flexibility, including poor up-generation and poor down-regulation of negative and/or positive emotions, could be a phenotype for a range of affective diseases. This research has proceeded along three well-defined lines of inquiry: targeting meaningful differences in the within-person variability in emotion regulatory strategy implementation, the context-sensitivity of spontaneous emotional output, and the complexity and variability of appraisals of emotional events or experiences. These processes, like all emotion processing, are driven by a complex interplay between bottom-up threat-related neural activity and top-down cognitive control processes. There is much work still to be done to be able to maximize the construct of emotion in-flexibility as a marker for affective disease, most notably by tying patterns of in-flexibility to core symptoms of affective disorders. Some work is already underway linking emotion inflexibility to specific patient populations, but we would argue that given the trans-diagnostic features of emotion inflexibility, targeting specific symptom constellations or paths, might prove even more fruitful. Indeed, it may be that each of the three lines of research may converge to support the role of emotion inBoth KC and CS developed the review ideas and wrote 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.


In Uruguay it is mandatory to review all cases of positive HIV or reactive syphilis tests in pregnancy and peripartum. We compared the rates of mother-to-child transmission of syphilis and HIV detected by case reviews to those obtained from the usual surveillance system and described the characteristic of vertical transmission cases.This is a cross-sectional study performed with secondary data obtained from official government sources, for all the country cases of maternal to child transmission of HIV and syphilis from 2012 to 2017, with descriptive analyses. For congenital syphilis analyses, the following pregnancy characteristics were investigated: number of antenatal checks, gestational age at pregnancy diagnosis, gestational age at syphilis test and diagnosis, adequate treatment, and treatment of partners. Sociodemographic characteristics included type of health care (public/private), maternal age, distribution of ethnic minorities, maximum educational attainment, presence of partner, planned pregnancy, drug and alcohol use, domestic violence, previous maternal diagnosis of syphilis, and previous children with congenital syphilis.Coverage of syphilis case reviews increased from 82% in 2014 to 97.4% in 2017. For HIV, this coverage reached 100% in 2017 and elimination of mother to child transmission was achieved. A marked decline in congenital syphilis was noted in the public health care sector, especially in the capital Montevideo, whereas the private sector has remained below the elimination target. Variables related with congenital syphilis in exposed children were late pregnancy diagnosis, < 5 antenatal checks, delayed diagnosis of gestational syphilis, lower rate of correct treatment for gestational syphilis, untreated partner, low maternal schooling, unplanned pregnancy, history of syphilis, and having other children with syphilis.The use of case reviews provided knowledge regarding the accurate number of mother-to-child transmission cases and the evolution of elimination of mother to child transmission in the country. The results suggest that rates must be adjusted, providing an opportunity to improve the reliability of surveillance data, and point the need to address specific gaps in order to improve the quality of care during pregnancy, delivery, and the neonatal period. Case reviews of congenital syphilis in Uruguay have produced better knowledge regarding the accurate number of cases.Case reviews allow assessments of EMTCT status.Surveillance rates must be adjusted according to case reviews.Several prevention strategies could be implemented at the primary care level to improve care and reduce congenital syphilis.The global community has set the elimination of mother-to-child transmission (EMTCT) of HIV and syphilis as a public health priority. In 2007, an initiative for the EMTCT of HIV and syphilis led by the World Health Organization (WHO) was launched, based on a foundation of quality maternal and child health services, as advocated by the Millennium Development Goals (MDGs), and aimed at reducing child mortality and improving maternal health –3. ThoseIn any country, specific strategies for dual EMTCT of HIV and syphilis are influenced by local characteristics, including HIV and syphilis epidemiology, service delivery models, coverage of health services, and available resources .Sistema Nacional Integrado de Salud, SNIS) and creation of the National Health Insurance . The SNS translated into increased population access to public health care services. The national health care policy, including health surveillance and inspection activities, is managed by the Ministry of Public Health .Regarding MTCT of HIV, reporting via the routine information system was 100%. Nevertheless, the case reviews focusing on infected newborns are still useful as an opportunity to identify points of system failure, including delayed pregnancy diagnosis, delay in the definition of maternal infection status even in women who began antenatal care after 14 pregnancy weeks, and lack of treatment adherence, among others. Regarding HIV, despite an early pregnancy diagnosis (on average 12 weeks), gestational age at HIV diagnosis has remained at 18–19 weeks. This might be explained by the use of immunoenzymatic assays as screening technique for HIV at the first routine testing in pregnancy, with communication of results only after a confirmation is obtained by Western-Blot, a deep-rooted practice among technicians, which persists despite the changes in diagnostic protocols. A decrease was noted in the diagnosis performed at delivery or immediate puerperium (rapid test).Our study has strengths as the high coverage of the audits and the fact that the audits also take in account all positive mothers, not only positive neonates, increasing their capacity to find cases. These also allow the identification of weakness in the health care process and to perform feedback for the improvement process. As limitations we consider that, as a retrospective analysis, the identification of positive women occurs during delivery and post-partum. The ideal scenario was that a positive test in a pregnant woman, both for syphilis and HIV, would trigger an alert in the system allowing supervision of medical conducts and the adequate follow -up, helping to avoid cases of maternal to child transmission.Case reviews of congenital syphilis in Uruguay have produced knowledge regarding the real number of cases and allowed an assessment of the status of EMTCT in the country. The results suggest that rates must be adjusted and provided an opportunity to improve the reliability of surveillance data. Also, there is a need to maintain routinely congenital syphilis case- studies as surveillance tool. For HIV, the case reviews showed the need to better inform health care professionals regarding diagnostic protocols. In relation to congenital syphilis, several prevention strategies could be implemented including encouraging women to attend antenatal care before the 4th month of pregnancy thus increasing the odds of pregnant women and their partners being diagnosed and treated earlier and improving health care workers training in congenital syphilis diagnostic and management.Additional file 1: Table S1. Sociocultural characteristics among congenital syphilis cases after a maternal diagnosis, Uruguay, 2015–2017. Table S2. Analysis of cases resulting in vertical HIV transmission, Uruguay, 2013–2017. (DOCX 34 kb)


This paper presents a review of recent studies on reinforced concrete (RC) structural components, such as beam-column joints (BCJs). These members are internally or externally reinforced with corrosion free shape memory alloy (SMA), fiber reinforced polymers (FRP), or a combination of the two materials. Bonded FRP sheets or near surface mounted (NSM) FRP bars are used in external strengthening cases. The use of FRP and SMA materials in RC structures can offer great potential benefits including lifetime cost saving, durability, safety, and post-earthquake serviceability for RC structures. Although FRP materials are well known for their corrosion resistance, high strength-to-weight ratios, ease of application, and constructability; SMA materials as reinforcement allow the structures to regain their original shape after the termination of the load without any permanent large residual deformation. In summary, the presented literature review provides an insight into the ongoing research on the use of these materials for retrofitting or strengthening of RC structural components and the trends for future research in this area. The cost and durability are also discussed. One of the causes of deterioration of RC structures is due to the corrosion of embedded reinforcing bars followed by the formation of cracks in concrete resulting in putting the structures out of service. For many decades, the problem of corrosion has remained an alarming issue. Likewise, the damage caused due to earthquakes is another severe issue posing a threat to the safety of structures, particularly for those built prior to 1970s, which were designed for the gravity loads with no seismic provisions. Since then, changes were made to the design code to prevent the newly built structures from collapse under seismic event ,3,4,5,6.On the other hand, super-elastic (SE) shape memory alloys (SMAs) are the type of materials, capable of undergoing large deformations and returning to their original shape and position upon the removal of applied forces. As a result, the use of SMAs as structural reinforcement reduces the damage to the overall structures even after being hit by an earthquake. SMAs are used in the form of sheets and strips. However, few researchers have recently used SMA as internal reinforcement bars in the plastic hinge regions where the damage can cause failure of the whole structure ,14,15. SFRP and SMA materials offer a viable reinforcement solution that is noncorrosive as oppose to traditional steel reinforcement which decays over time when exposed to harsh and alkaline environment. The aim of this paper is to provide an insight into the performance of corrosion free concrete BCJs reinforced with FRP, SMA, and a new composite material made out of FRP and SMA. It is called hybrid when the joint has SMA bars in a region and FRP bars in another one, while it is called composite when the bars are made of a mixture of both FRP and SMA materials.In recent years the use of fiber reinforced polymers (FRP) and shape memory alloys (SMA) in RC structures has gained popularity due to their superior material properties and resistance to corrosion. The application of these smart materials could easily replace the traditional steel reinforcement in newly built concrete structures, or can be used for the retrofit of existing structures. BCJs are one of the most critical assemblies in the structural system. Furthermore, investigations on BCJs are more spar as compared to beams or columns. In the following sections BCJs reinforced with SMA, FRP and hybrid or composite SMA-FRP as internal and FRP as external reinforcement are discussed.Investigations on BCJs internally reinforced with FRP bars are limited as oppose to more common method of external FRP reinforcement. Most of these studies have commonly used glass fiber reinforced polymer (GFRP) material for reinforcement bars . Said anOn the other hand, Saravanan and Kumaran  conducteTwo other experiments in 2011 were conducted by Mady et al.  and HassSimilarly, Hasaballa and El-Salakawy  tested sfc′ or higher.Similar to the latter reference, Ghomi and El-Salakawy  performeDespite the advantages of SMA materials such as, energy dissipation, and self-centering, limited studies have been performed on the use of SMA bars in BCJs. Furthermore, due to their cost, SMA bars have particularly been used in crucial regions of BCJs at the location of plastic hinges, while the other regions are typically reinforced with conventional steel bars. This type of bar reinforcement arrangement is referred to as hybrid SMA-steel. Researchers have noted that reinforcing structures with SMA bars provided remarkable results in terms of capability of regaining their original shape without any residual displacement after the load is diminished e.g., ,14,15). ,15. 14,1SMA-FRP hybrid or composite reinforcement of concrete structures offers an advantage to efficiently strengthen the most critical locations in structures like BCJs. Experimental studies conducted by Zafar and Andrawes ,17 were Another study was conducted using SE-SMA bars in the zone of plastic hinge and FRP in other zones of a steel-free BCJ under cyclic loading . It was The use of near surface mounted (NSM) FRP or SMA reinforcement has become an attractive method for enhancing the flexural and shear capacities of RC beams or columns. The process of NSM FRP or SMA technique starts with cutting grooves on the surface of concrete elements, without any need for surface preparation. Then, the SMA or FRP bars are installed in the grooves using epoxy filling. This method is less time consuming as compared to other external reinforcement techniques.Several studies have been performed on external reinforcement of beams and columns with the NSM technique using FRP or SMA bars. However, to the best of authors’ knowledge, NSM technology with bars has not been fully extended to BCJs. One study by Prota et al.  examinedRecently, a modified NSM CFRP-strengthening technique of RC BCJs has been investigated experimentally . This teIn the recent years, the FRP materials have been widely used to externally reinforce and retrofit the RC structures. The aim of using these materials is either to increase the structural load capacity or to repair the deteriorated structures along with the application of other materials such as mortars. The increase in the load capacity maybe necessary in order to address new code requirements, errors in the design or construction process, or to sustain an extra live load. In external reinforcement, the propagation of microcracks is a factor that plays an important role in affecting the bond strength. To that end, multiscale analytical models have been developed to predict either the delayed debonding of FRP external strengthening or the bond lifetime e.g., ,22. HoweFew experimental investigations on BCJs have used steel anchorages for the FRP sheets ,26,37,40Similarly, a more recent study was conducted on seismically deficient RC BCJs using steel plates with different shapes  in addition to threaded steel rods, to anchor the CFRP sheets  in strengthening either damaged or undamaged joints . The joiThe same idea was applied by Al-Salloum and Almusallam  in theirMost experimental studies have been performed on scaled-down with few on full-scaled BCJs  and epoxy resin matrix used . MoreoveWhile the upfront cost of FRP materials might be higher than the steel, the maintenance and damage repair expenses would be reduced over the life of structures when using FRP as an internal and external reinforcement .As oppose to FRP, limited use of SMA has always been associated with high cost of its composition of Nickel and Titanium (Ni-Ti). However, shaping the alloys by different composite materials like Cu-Zn-Al, and Cu-Al-Ni resulted in a decrease in cost ratio while providing comparable properties to traditional SMA composition. Depending on the shape and required material quantities, the cost ratios range from 1 to 10 for Cu-Zn-Al and from 2 to 20 for Cu-Al-Ni, while it ranges from 10 to 100 when Ni-Ti material is used. From this analysis, a significant reduction in cost was observed when the Ti was removed and Ni was replaced with another component, such as Zn .BCJs reinforced with FRP, SMA, and hybrid FRP-SMA longitudinal bars and stirrups performed better in improving overall load carrying capacity as compared to their counterpart one reinforced with traditional steel bars.At the same drift ratio, composite SMA-FRP BCJs bars showed higher ductility and energy dissipation than its counterpart reinforced with GFRP only.Under the same PGA values, GFRP reinforced BCJs exhibited higher drift ratio as compared to the counterpart composite SMA-FRP reinforced joints. However, joints reinforced with SMA-FRP bars sustained small amount of residual displacements in contrast to the ones with steel and GFRP.The performance of hybrid SMA-FRP reinforced BCJs under seismic loading was enhanced, specifically in the plastic hinge zone region. Furthermore, considerable improvements in ductility, residual drift, and energy dissipation were observed when compared to the joints reinforced with GFRP bars.Even though, in some cases, GFRP reinforced joints showed ductile behavior under reversed cyclic loading, the performance of traditional steel or hybrid SMA-steel reinforced joints were superior under earthquake loading particularly in terms of load carrying capacity and residual displacement.To assure the occurrence of plastic hinge away from the joint following the capacity design rule (strong column weak beam concept), sufficient anchorage is needed in the FRP-reinforced joint core region. While for hybrid SMA-FRP reinforced joints, placement of SMA bars in the joint core is essential.FRP and SMA materials can offer unique replacement for steel reinforcement bars due to their noncorrosive property along with the high strength. In the case of FRP-SMA or SMA reinforcement, small residual displacements can also be achieved. This will result in less repair and maintenance and lower life cycle cost.For externally reinforced BCJs, more layers of FRP sheets provided higher joint’s load-carrying capacity.Using steel elements such as plates or angles, as anchorages for the FRP sheets, prevented FRP sheets from debonding, as well as increased the joint capacities .In some cases, FRP external strengthening could change the mode of failure from joint shear failure to flexural failure of the beam.In general, it was noted that for the same amount of reinforcement ratio, CFRP sheets confined the joint core more effectively than GFRP sheets.The increase of column’s axial load helped in enhancing the load-carrying capacity and stiffness of the joints in the case of both internal and external FRP reinforcement.Strengthening with FRP and SMA helped in improving the fatigue capacity while providing protection against harsh environment and corrosion for RC beams.Although the high cost of SMA material limits its field applications for strengthening old or new structures with SMA elements; replacing Ni-Ti traditional SMA with other compositions such as Cu-Zn-Al, and Cu-Al-Ni of the same shape and quantity, makes it more economical while providing comparable results. Whereas, using FRP as external reinforcement reduces the maintenance cost in the long term.The performance of concrete BCJs reinforced with innovative smart and corrosion free materials such as FRP, SMA, and hybrid and composite SMA-FRP are discussed in this paper. Based on the present literature review conducted in this study on RC BCJs, the following conclusions are drawn in the order of internal, external reinforcement of the BCJs and the effect of durability and cost.Significant research work conducted on FRP and SMA in the past few decades has paved the way to utilize such smart materials as reinforcement in concrete structures. The most important factor for potential use of FRP and SMA is their cost which could possibly limit the wider applications of such materials in the field of structural engineering. In the last decade, the price of SMA material has significantly decreased up to considerable amount due to its new composition. It is expected that the price will further reduce once it becomes widely and commonly used like FRPs. The application of SMA in RC structures will not only increase the cost due to material, but also costs associated with equipment and labor charges. However, FRP and SMA materials have superior quality to resist corrosion. In RC structures, the use of SMA in the plastic hinge zones could reduce cracks formation. Due to the re-centering capability, SMA could regain its original shape and size after experiencing larger inelastic deformations under high seismic loadings thereby assuring serviceability and reduction in maintenance of the structure. The effectiveness of FRP and SMA is exceptional in minimizing risks to human life associated with unpredicted natural disaster events. Further research could be carried out by using FRP and SMA in structures subjected to blast and fire. Moreover, coupling SMA with FRP and steel bars could also be effective in providing ductility.Recently, NSM has become a popular method of externally strengthen RC elements, such as beams and columns, with FRP bars; however, the study of NSM technique on the BCJs can further be investigated.Furthermore, the use of steel elements such as plates or angles as anchorages for the FRP sheets can be dispensed in future studies to prevent the joints from corrosion, since the FRP material is non-corrosive.


Babesia bovis, Babesia bigemina and Babesia divergens is vastly underappreciated. These parasites invade and multiply asexually in bovine red blood cells (RBCs), undergo sexual reproduction in their tick vectors  and have a trans-ovarial mode of transmission. Babesia parasites can cause acute and persistent infections to adult naïve cattle that can occur without evident clinical signs, but infections caused by B. bovis are associated with more severe disease and increased mortality, and are considered to be the most virulent agent of bovine babesiosis. In addition, babesiosis caused by B. divergens has an important zoonotic potential. The disease caused by B. bovis and B. bigemina can be controlled, at least in part, using therapeutic agents or vaccines comprising live-attenuated parasites, but these methods are limited in terms of their safety, ease of deployability and long-term efficacy, and improved control measures are urgently needed. In addition, expansion of tick habitats due to climate change and other rapidly changing environmental factors complicate efficient control of these parasites. While the ability to cause persistent infections facilitates transmission and persistence of the parasite in endemic regions, it also highlights their capacity to evade the host immune responses. Currently, the mechanisms of immune responses used by infected bovines to survive acute and chronic infections remain poorly understood, warranting further research. Similarly, molecular details on the processes leading to sexual reproduction and the development of tick-stage parasites are lacking, and such tick-specific molecules can be targets for control using alternative transmission blocking vaccines. In this review, we identify and examine key phases in the life-cycle of Babesia parasites, including dependence on a tick vector for transmission, sexual reproduction of the parasite in the midgut of the tick, parasite-dependent invasion and egression of bovine RBCs, the role of the spleen in the clearance of infected RBCs (IRBCs), and age-related disease resistance in cattle, as opportunities for developing improved control measures. The availability of integrated novel research approaches including “omics” , gene modification, cytoadhesion assays, RBC invasion assays and methods for in vitro induction of sexual-stage parasites will accelerate our understanding of parasite vulnerabilities. Further, producing new knowledge on these vulnerabilities, as well as taking full advantage of existing knowledge, by filling important research gaps should result in the development of next-generation vaccines to control acute disease and parasite transmission. Creative and effective use of current and future technical and computational resources are needed, in the face of the numerous challenges imposed by these highly evolved parasites, for improving the control of this disease. Overall, bovine babesiosis is recognised as a global disease that imposes a serious burden on livestock production and human livelihood, but it largely remains a poorly controlled disease in many areas of the world. Recently, important progress has been made in our understanding of the basic biology and host-parasite interactions of Babesia parasites, yet a good deal of basic and translational research is still needed to achieve effective control of this important disease and to improve animal and human health.The global impact of bovine babesiosis caused by the tick-borne apicomplexan parasites  Members of escribed , reside escribed . These tescribed . Babesiaorganism . How apiBabesia. Babesia spp. are highly successful intracellular parasites, which acquired highly sophisticated mechanisms for survival during long term co-evolution with their hosts. As a result, these parasites have developed a complex life-cycle involving hard ticks as definitive hosts and vertebrates as intermediate hosts. Thus, Babesia spp. invade and multiply asexually by binary fission inside RBCs of their infected vertebrate hosts and produce sexual forms in the midgut of the ixodid tick vectors, their definitive hosts, where they undergo sexual multiplication  that was developed in the United States (USA) from ∼1906–1943 and beyond, based on the eradication of Rhipicephalus ticks . This campaign succeeded under very special circumstances , imidocarb dipropionate and diminazene aceturate are the usual treatment of choice , or “slow passage” (B. bigemina) in splenectomised (for B. bovis) or spleen-intact calves (for B. bigemina). The resulting production of pairs of virulent and derived-attenuated strains, generated by this process, suggested the possibility of comparative genomic and transcriptomic studies towards identifying virulence and/or attenuation factors  Proceedings of the First International Congress of Parasitology, Pergamon, pp. 276–277). Babesia ovata and Babesia orientalis are predominantly found in Asia with B. orientalis being the major causative agent of babesiosis in buffalo . Further, sporozoites that reside and reproduce asexually in the salivary glands of the larvae of the next generation of ticks (B. bovis) or nymphal (for B. bigemina) stages, thereby completing the lifecycle. The impact of Babesia spp. infections on the tick has not been thoroughly characterised, but some evidence suggests that infection may result in an overall decrease in tick fitness  or nymphal (B. bigemina) tick stages  which is an important goal for controlling arthropod-transmitted parasites in general. It is currently accepted that gametogenesis in k stages . The devB. bovis that are differentially expressed in tick stages. The first of such studies focused on the members of the CCp and 6-cys gene families. A highly conserved family of six multi-domain adhesion proteins, termed the CCp family, was initially identified in Plasmodium parasites. Importantly, it was demonstrated that the CCp proteins in Plasmodium are expressed on the surface of gametocytes, and that knock-out (KO) of the Plasmodium CCp genes blocks sporozoite formation, thus preventing the development of the parasite in the mosquito vectors  were also identified in B. bovis and B. bigemina. Experiments performed in an in vitro system for induction of sexual stage forms of B. bigemina demonstrated significant upregulation of the expression of all three CCp genes upon induction. Increased production of all three CCp proteins was also found in induced sexual forms of B. bigemina using immunoblotting and immunofluorescence  are expressed in gametes and are prime candidates for the development of TBVs against Plasmodium . These changes include the protein and lipid composition of the RBC membrane (B. bovis-IRBCs), they lack lysosomes and, importantly, are unable to present antigens to the immune system, thus facilitating escape of the parasite from immune effectors. RBCs are also unable to phagocytose and internalise other cells or nutrients by endocytosis, implying that the parasite must be the active force required for invasion to occur  and other structures. The components of each of these organelles represent a knowledge gap in Babesia, but they are better defined in other related and more studied apicomplexans such as Toxoplasma and Plasmodium  and reside within a vacuole immediately following invasion of the RBC but, in contrast to other related apicomplexans, the PVM is rapidly lost, leaving the parasite in direct contact with the cytoplasmic content of the RBC, as is consistently observed for B. bovis, B. bigemina, and B. divergens  and high antigenic variability. While Babesia parasites have a relatively small genome (approximately 7.0–16 Mbp)  gene family comprising more than 150 genes in B. bovis. Interestingly, members of the ves family have also been identified in the genomes of both B. bigemina and B. divergens  gene family , but antigenic variation can also be potentiated, likely by the activity of segmental gene conversion mechanisms, that can provide increased sequence changes in these genes   as described in B. bovis  , comparearasites , it is eivergens . It is ke family . The conse genes . In addi surface , althougimmunity . These vructures  Fig. 2)Babesia pes genes , neitheres genes . It is pciparum) . The lac domains . In addiB. bovis . In addilciparum . Furtherbigemina .Fig. 2PsB. bovis RBC surface-exposed proteins that have been characterised in any detail. However, the parasite is able to export additional, previously uncharacterised, proteins to the IRBC membrane and expose them on the cell surface to play important roles in host-parasite interactions  is shown in B. bigemina-IRBCs (Plasmodium export element (PEXEL)-like signal was identified in exported proteins in B. bovis such as Spherical Body Protein (SBP) 2. The bipartite functional domain ‘PEXEL’ appears to be an essential component of the molecular mechanisms involved in the export of Plasmodium proteins into the host cell. This domain consists of an N‐terminal eukaryotic signal sequence followed by a pentameric conserved motif with the consensus sequence, RxLxE/Q/D   , has alss (VMSA) . Howeverrganisms  that canBabesia spp. infection, unless the animal is exposed to stress, co-infections with other pathogens, or if it is immunocompromised, for example by splenectomy, which may result in the breakdown of its immunity to Babesia spp., and the resurgence of acute disease. It is not known exactly what factors are required for the bovine to remain apparently healthy during persistent infection. It is likely that by that point the immune response maturated enough to form high affinity antibodies and a robust cellular immunity based on regulatory CD4+ and regulatory CD8+ lymphocytes that secrete adequate classes and levels of cytokines which are able to keep in check the ability of the parasites to expand in the persistently infected animals (see below). Thus, it is possible that such a balance between a relatively healthy status and acute infection is provoked by constant immune stimulation by the parasite, an example of the establishment of a symbiotic relationship between the host and the parasite upon the development of persistent infection.The concerted operation of these mechanisms results in parasites that are able to establish persistent infection of the bovine host, thus maximising their chances of transmission by tick vectors. Persistently infected bovines are apparently healthy and do not show clinical signs of 3.4B. bovis and B. bigemina. Therefore, the lack of practical and reliable experimental systems for defining in detail the mechanisms involved in the development of protection critically affects our ability to design effective vaccines. Considerable progress was made in understanding the immune responses to B. bovis infections; however, the knowledge of immune responses to B. bigemina infections remains essentially unknown. Briefly, immunity to Babesia parasites in young animals and adult animals requires the strong induction of innate immune responses and development of effective adaptive immune responses, respectively  cells and immature dendritic cells (DCs), macrophage activation by IFN-γ or parasite-derived products and priming of immune cells to release toxic macrophage metabolites including Nitric Oxide (NO)  and those required for controlling parasitemia to persistent levels in adult cattle that survive infection (adaptive immunity), is also critically important for developing strategies to induce a protective immune response by vaccination, and more research is required in order to close this important research gap.Several reviews have described models of protective immune mechanisms for B. bovis . Experimide (NO) . A closeide (NO) . Further release . Young alearance . Interes animals . The sol3.4.2Babesia parasites is characterised by both parasite-mediated exploitation of the host and infection-mediated immunopathology. During an acute infection, especially in immunologically-naïve adult animals, Babesia parasites exploit the host and reproduce mostly unchecked, resulting in important destruction of host RBCs and a dramatic drop in haematocrit . The severe pathogenesis is thought to be partially immune-mediated, and over-production of soluble mediators including IFN-γ, TNF-α, and NO    and cons2, etc.) . The AP2arasites .Babesia spp. in order to address the definition of virulence factors and attenuation markers, one of the most important remaining fundamental research gaps limiting rational vaccine design. The conclusion of genomic comparisons among virulent and attenuated paired strains was the finding of decreased population complexity in the attenuated strains compared with their virulent pairs, but the studies failed in identifying candidate genes or sets of genes responsible for increased or decreased virulence  with their attenuated derivatives resulted in the identification of a limited number of differences such as the recent identification of the SBP2t11 gene as a marker for attenuation of B. bovis parasites  cytoadhesion assays (Critical to future research is a complete elucidation of the molecular mechanisms involved in the establishment of persistent disease by these parasites. This includes the dissection of the mechanisms of persistence at a molecular level. We must also improve our mechanistic understanding of the ability of n assays , that caB. bovis has identified the requirement of the HAP2 gene for the development of sexual-stage parasites and its link with the expression of the sexual-stage marker genes 6-Cys A and B (Babesia sexual stages from cultured parasites will facilitate the study of the antigenic and morphological changes that the parasites undergo, the definition of possible cell surface-exposed immunological targets, and the testing of the effects of specific antibodies against key antigens (Recent work has focused on development of in vitro sexual-stage induction systems, due in part to the practical difficulties associated with the study of tick stages in the tick midgut milieu. Application of this system to  A and B . The recantigens . These dTaken together, these new data and newly developed genetic manipulation systems are fundamental for the development of novel, next-generation vaccines that can target multiple stages of the parasites’ life-cycle, which may be essential for the eventual control of this disease.5Babesia parasites is heavily influenced by the constant advances in molecular and cellular biology, immunology, computational sciences and vaccinology. In this review, we have attempted to link the need for a more complete understanding of the biology of Babesia parasites, including a better and more detailed characterisation of different phases in the parasite life-cycle and the distinct phases of the interactions of Babesia parasites with their host. Overall, the road ahead is still long and winding. However, we have also presented evidence supporting that we are acquiring an appropriately-equipped toolbox for guiding us on a successful journey towards babesiosis control. In practical terms, research will require improved and reliable experimental systems, especially when the natural systems present difficult practical obstacles and ethical concerns.Advancement of research in the biology of B. bovis and B. bigemina. In addition, our ability to efficiently manipulate the Babesia genomes will be augmented by the development of CRISPR/Cas9 gene editing methods. These gene manipulation methods combined with in vitro static and haemodynamic assays for the analysis of the interactions between IRBCs and host vascular endothelial cells, as well as studies using transgenic parasites in vivo, will allow a more detailed dissection of cytoadhesive mechanisms leading to the creation of new vaccines that might interfere with parasite adhesion and sequestration. The future development of efficient sub-unit vaccines against bovine babesiosis remains a challenge. Importantly, more research is needed to better understand the nature of protective immune responses in young animals and successfully vaccinated animals, and inform effective strategies for vaccine design. Additionally, other current and future methods of analysis, such as in vitro tick artificial feeding systems (Currently, robust transfection methods are available for genetic modification in  systems , will alFinally, although we may gain understanding of the function of individual genes and their biological relevance in different life-cycle stages of the parasite, a better understanding of the ‘big picture’ of this disease is still needed. Clearly, controlling the parasite presents an immense, but important, intellectual challenge, but creative and effective use of the current and future technical resources suggest that the ‘sky is our limit’ in our search for improved control measures for babesiosis that impose an important burden for humans and for food production, with an ultimate impediment to the progress of humanity in the future.


The neuroendocrine system consists of various cells distributed in non-endocrine functional structures, able to synthesize amines and peptides with both local (paracrine) and systemic (endocrine) effects. The presence of such cells, belonging to the neuroendocrine system, is highlighted by the presence of neuroendocrine markers: the most suggestive are chromogranin A, synaptophysin, S-100B protein and glial fibrillary acidic protein. The presence of neuroendocrine markers is commonly associated to the occurrence of neuroendocrine cancers, currently representing the 0.5 percent of all malignant tumors. Nevertheless, neuroendocrine markers have been found to be overexpressed in rare oral neuroendocrine tumors, but also in quite common inflammatory conditions, such as severe periodontitis. The monitoring of neuroendocrine markers is, thus, a common factor of interest among dentistry and neurology: the analysis of neuroendocrine markers in oral diseases may be predictive and prognostic about the severity of neurological diseases, such as lateral amyotrophic sclerosis and traumatic brain injuries. The aim of this mini-review is to highlight the role of neuroendocrine molecules as advantageous diagnostic and prognostic markers for both oral diseases and neurodegenerative disorders. In the last 10 years, a growing interest about the molecular biology of cancer has allowed to identify several tumor-related biomarkers. Such markers are typically described as: prognostic markers and predictive markers. The presence/absence of a specific marker is useful for choosing the proper treatment for oncological patients, however, the right therapy is not synonym of a response to treatment. Predictive markers, conversely, have the objective of evaluating the ability of a specific treatment to improve the clinical response to oncological therapies , synaptophysin or chromogranin-A (CgA) have been studied in oral tissues, such as bundles of human dental pulp; this allowed to find potential different locations of such markers, depending from the presence of physiological or inflamed pulp; these markers have also been investigated about their use for the determination of local inflammation  and rareChromogranin A is a glycoprotein located in the neuroendocrine system; it is abundantly secreted by neurons and endocrine cells together with other hormones and neuropeptides. CgA is involved in several physiological functions, such as calcium regulation, vasoconstriction, metabolism of glucose and bacterial defense, and CgA represents the main central modulator of the neuroendocrine system. Chromogranin A can be produced in specific stress-related physiological conditions . CgA is Chromogranin A is the main secreted protein of neuroendocrine (NE) cells and is produced at high levels by those cell types. Pulmonary neuroendocrine tumors express large amounts of NE markers including synaptophysin, chromogranin A, and N-CAM . These proteins are typically produced by NE tumors, with diverse levels in the different neoplastic classes, indeed elevated frequencies are detected in carcinoids and in atypical carcinoids respect than in large cell and in small cell neuroendocrine carcinomas. Furthermore, elevated expression of pancreatic polypeptide, α and β subunits of human chorionic gonadotropin and chromogranin A are present in all types of carcinoid neoplasms .In neuroendocrine gastro-intestinal cancers the plasmatic levels of chromogranin A are augmented in more than 80% of affected patients thus, is considered the main marker for this tumor type.Chromogranin A also exert a prognostic value, especially in general midgut carcinoids cases, because of the existing correlation with the tumor load.The presence of elevated levels of CgA is detectable before radiographic evidence of gastro intestinal NE cancers occurrence .Synaptophysin is a 38 kD glycoprotein which represents the principal cytoplasmic calcium-binding protein of the membrane of synaptic vesicles of neurons. Synaptophysin and chromogranin could be considered as complementary, common NE markers; indeed, alike to CgA, synaptophysin is expressed by NE cells and consequently in their corresponding tumors.However, although secretory granules host chromogranin, synaptophysin is mainly located into micro-vesicles.Synaptophysin is also expressed by adrenal cortical tissues and in related tumors, for this reason it could not be considered as an exclusive marker for NE cells .Furthermore, immunoreactivity for synaptophysin alone is not sufficient for the definitive classification of a neoplasm as neuroendocrine; nevertheless, its presence contributes to recognize neuroendocrine features of a tissue. Synaptophysin is widely expressed in large cell undifferentiated neuroendocrine carcinoma. In a clinical study, small cell lung carcinomas stained positive for synaptophysin in the 79% of patient, whereas 47 to 60% of cases were positive for chromogranin staining. Moreover, 8% of non-small cell carcinomas showed synaptophysin labeling .S-100B protein is a 21kDa acidic protein broadly expressed in astrocytes, Schwann cells, myeloid-derived cells, and in definite populations of neurons. The secretion of S-100B in the extracellular space is activated by serotonin, glutamate, beta-amyloid peptides, TNF, lysophosphatidic acid, and IL-1β. After secretion, S-100B is able to produce their paracrine and autocrine effects on neuronal cells and glia .in vivo study, O'Callghan et al. demonstrate, by histopathological analyses, the increased expression of GFAP in “all types of nervous system injuries”  represents a structural protein of the intermediate filaments integral to cytoskeleton. This protein is responsible for the morphology of astrocytes and it also regulates the reactive responses of astrocytes during aging. In an njuries” .Human dental pulp expresses neuron-specific enolase (NSE) and S-100B protein but showed negative immunolabeling for chromogranin A and peripherin (PRP). This expression pattern is present both in normal conditions and during pulp inflammation with an amplified level of S100B and NSE of the nerve fibers detected in inflamed pulp compared to healthy samples. These evidences propose the potential role of S100B and NSE as markers for dental innervation. Moreover, these proteins may be applied for determination of the amplitude of inflamed area and could be predictive of the evolution of the inflammation process in pulp therapy. The lack of a positive chromogranin A immunostaining in human dental pulp indicate the probable absence of these common neuroendocrine protein, while the role of PRP in pulp tissues need further investigations .Neuroendocrine markers are located in specific cytotypes known as NE cells, characterized by asymmetrical shape and large dimensions and by the presence of cytoplasmic granules and round nucleus. The presence of NE cells in the dental pulp still need to be clarified. In another study, the immunohistochemical analysis of human dental pulp with streptavidin-biotin labeling revealed the expression of NSE, CgA, S-100B, GFAP, and synaptophysin all common neural crest related markers. The ontogenesis of dental pulp from neural crest is commonly accepted, developing teeth  contain The presence of synaptophysin was also registered in the para-odontoblastic zone of dental pulp.Ulterior immunohistochemical studies with Ab against NEC antigens  identified rare positive cells only in the sub-odontogenic layer of the pulp. Immunopositive cells for NSE and synaptophysin were found to be located nearly to the nerve fibers, but CgA was not detected in nerve fibers .Immunopositive NE cells were detected in caries, the number of positive cells concomitantly increased with the rising gravity of inflammation with a maximum expression corresponding to periodontitis. The overwhelming majority of cells were detected by antibodies to chromogranin A. It could be supposed that NE cells located at the interface between pulp and dentin produce peptides that induce local (paracrine) and distant (endocrine) effects, that influences the behavior of other cell types. Indeed, NE cells are involved in the regulation of the microcirculation, of the immune response and in the proliferation of fibroblasts. The detected augmented occurrence of nerve fibers in caries and pulpitis can be related to their participation in the regulation of the process of inflammation. Poor reactivity of NE cells into normal pulp to nerve crest markers can be explained by the declining expression of these antigens during cytodifferentiation. According to the described results, this ability is induced under pathological states .in situ-hybridization. Immunopositive reaction was stronger in serous cells than in ductal cells. In addition, a significant immunoreactivity for CgA was observed in the saliva matrix of ductal cavities, as demonstrated by immunoelectron microscopy and western blotting. The obtained resulted supported the hypothesis that CgA is produced by human submandibular gland and secreted into saliva  have been reported in the oral cavity.Neuroendocrine carcinoma of the tongue involves alteration on neuroendocrine markers expression. In a clinical study, the analysis of tongue biopsy revealed the presence of a squamous mucosa with neoplasm and identified group of cells characterized by round nuclei and light cytosol. Immunohistochemical study evidenced a positive staining for cytokeratin, CgA, NSE, and synaptophysin and negative reaction for leukocyte common antigen .The most common type of pulmonary neoplasm, small cell neuroendocrine carcinoma (SNEC) is a very aggressive malignancy with a high tendency for metastatic dissemination. Extrapulmonary SNECs characterize the 2.5–5% of all SNECs , and onlThe general prognosis of head and neck SNEC is poor because of the propensity for aggressive local invasion and a strong tendency for distant metastasis formation .In a 73-year-old male a rare case of SNEC of the gingiva has been registered. The diagnosis of SNEC was established on morphology and validation of origin by specific stains . SNEC maDefinitive confirmation of SNEC tumor cells presence has been established by immunoreactivity for cytokeratin and neuroendocrine markers such as chromogranin A, synaptophysin, neuron-specific enolase, and CD56 .A case of high-grade neuroendocrine tumors was registered in a 75-year-old man on the left lateral anterior tongue. The subject showed a 5 mm diameter ulcerated wound on the lateral border of the tongue, immunohistochemical analyses of biopsy revealed the typical features of a poorly differentiated neuroendocrine carcinoma of small cell type. The tumor cells were strongly positive for neuroendocrine markers including chromogranin A, synaptophysin and CD56 .Neuroendocrine proteins including CgA, S-100B protein, synaptophysin, GFAP protein, and neurofilaments, typically located in neural tissues, are commonly used as markers for neuroendocrine carcinomas. Their expression could be altered in neurogenic disorders.Several studies connected CgA to pathological features of Amyotrophic lateral sclerosis (ALS). For instance, CgA was shown to interact in a chaperone-like manner with ALS mutant SOD1 and mediate its secretion, there was a significant loss of CgA expressing neurons accompanied by decreased CgA density in the neuropil and an accumulation of CgA in the remaining neurons .Toda et al. performed a comparative study evaluating the levels of CgA in saliva of patients suffering of vascular dementia, moderate ALS and terminal ALS. They found increased values of salivary CgA only in patients affected by terminal ALS. Furthermore, the concentration of CgA is related to the Escorial score of emotional functioning rather than that of corporeal mobility, language and nutrition. The obtained results confirmed that CgA expression correlate with ALS severity and with the affective conditions of patients .A pivotal hypothesis was that hippocampal synaptic defects of patients affected by Alzheimer disease (AD) were connected with the severity of cognitive impairment.Synaptophysin levels were quantified by immunoblotting of synaptic membrane fractions isolated from entorhinal cortex, hippocampus, occipital cortex, and caudate nucleus. The concentration of synaptophysin were decreased in hippocampus when comparing AD patients to controls. These data allow to conclude that synaptic aberrations in the hippocampus are connected with the severity of memory deficit and neuropathology in individuals with AD .S-100B could be considered a biomarker of brain damage in stroke, circulatory arrest and traumatic brain injury. S-100B is also associated with chronic neurological illness and neurodegenerative diseases like Alzheimer. Additionally, S-100B may be predictive of prognosis and of the efficiency of treatment .GFAP resulted up-regulated in central nervous system damage following the reactive gliosis that typically occur after traumatic brain injuries. Numerous studies demonstrate increasing levels of GFAP in plasma of patients subjected to traumatic brain injuries, thus the quantification of this biomarker may be predictive of the severity of damage .Current biomarkers are molecules aimed to allow predictable and targeted therapy, customized on the specific case, even if several markers can be related to different seats of activity. For example, the evaluation of Epidermal Growth Factor Receptor (EGFR) expression is highly necessary for therapeutic planning of anti-EGFR drugs in patients with lung or oral cancer .In this scenario, the identification of predictive markers becomes a significant diagnostic and prognostic factor, other than, it would favor the use of certain drugs in a specific patient population. Chromogranin A, synaptophysin, S-100B protein and GFAP are well known neuroendocrine markers involved in cancer and in neurological diseases. In the brain their expression is used as predictable of severity of neuro-pathologies including ALS, AD, and traumatic brain injuries. Interestingly, neuroendocrine markers are also present in oral tissues such as dental pulp and salivary glands, probably due to the derivation from neural crest of oral structures .The take-home message is to improve the investigation on neuroendocrine markers, as they are an important cluster of molecules useful for the identification and characterization of rare forms of cancer, such as NE oral cancers, and they can be also considered valuable biomarkers in oral inflammatory diseases, such as periodontitis. Furthermore, the altered expression of neuroendocrine molecules in neurodegenerative disease would confirm their application also in the diagnosis of neurological pathologies. In conclusion, the analysis of NE molecules represents a valuable tool to be better considered in the future clinical applications.No datasets were generated or analyzed for this study.The literature search was independently performed by 3 authors . The manuscript was drafted by all the authors .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. The handling Editor declared a past collaboration with one of the authors, MT.