Treatment decision-making for patients with incurable non-small cell lung cancer (NSCLC) is complex due to the rapidly increasing number of treatments and discovery of new biomarkers. Decision support systems (DSS) could assist thoracic oncologists (TO) weighing of the pros and cons of treatments in order to arrive at an evidence-based and personalized treatment advice. Our aim is to inventory (1) TO’s needs with regard to DSS in the treatment of incurable (stage IIIB/IV) NSCLC patients, and (2) preferences regarding the development of future tools in this field. We disseminated an online inventory questionnaire among all members of the Section of Oncology within the Society of Physicians in Chest Medicine and Tuberculosis. Telephone interviews were conducted to better contextualize the findings from the questionnaire. In total, 58 TO completed the questionnaire and expressed a need for new DSS. They reported that it is important for tools to include genetic and immune markers, to be sufficiently validated, regularly updated, and time-efficient. Also, future DSS should incorporate multiple treatment options, integrate estimates of toxicity, quality of life and cost-effectiveness of treatments, enhance communication between caregivers and patients, and use IT solutions for a clear interface and continuous updating of tools. With this inventory among Dutch TO, we summarized the need for new DSS to aid treatment decision-making for patients with incurable NSCLC. To meet the expressed needs, substantial additional efforts will be required by DSS developers, above already existing tools. Lung cancer, of which roughly 80–85% is non-small cell lung cancer (NSCLC) , is one Individually tailored palliative cancer treatment is essential to ensure that patients receive the treatment that optimally matches their values and preferences, avoiding under- or overtreatment, and optimally utilizing all available healthcare resources. Decision-making in the palliative phase is complex due to the large heterogeneity in this population with regard to histological tumor type, biomarker profile, treatment response, and the marginal expected treatment benefit and the potentially severe toxicity of systemic therapy. Particularly with the rapid developments and breakthroughs in the fields of genomic technologies and molecular therapies for lung cancer, treatment decisions will become more multi-factorial and personalized, and it will become increasingly important to support thoracic oncologists (TO) in staying up-to-date.Treatment guidelines are quite extensive and general, and do not allow for individual tailoring of treatment. Decision support systems (DSS), as add-ons to existing guidelines, can assist TO in formulating an evidence-based treatment advice by comparing various treatment options for an individual patient. Such tools ideally weigh the pros  and cons of treatments , as well as the cost-effectiveness. DSS can consist of (multiple) prediction models, nomograms, and decision trees, which are often based on patient and tumor characteristics. Multiple DSS have been developed for incurable NSCLC patients , such asAlthough there are a large number of DSS available to aid palliative treatment decisions for incurable NSCLC patients , it remaWe developed an online inventory questionnaire (using the Surveymonkey platform). The inventory first covered background information of the respondents, the available DSS and clinical parameters that they use in decision-making, and whether they have access to a palliative care team in the hospital. Next, we inventoried what the decisive reasons are for not using a DSS, whether they express a need for future tools, and what they would require in terms of future DSS for palliative care decision-making for patients with incurable NSCLC. The online inventory questionnaire was disseminated among the members  of the Section of Oncology (SON) within the Society of Physicians in Chest Medicine and Tuberculosis (NVALT). The research protocol was approved by the ethical committee of the VU University Medical Center and all respondents provided written informed consent.Respondents who indicated in the inventory that they were willing to provide additional information about their DSS needs were contacted. Semi-structured phone interviews were then used to explore TO’s needs and preferences concerning (future) DSS in more detail. The aim of the interviews was to put the findings from the questionnaire in context.Descriptive analyses were performed on the inventory data. The interviewer (DR) extracted key points from the telephone interviews, and incorporated them into the data from the inventory questionnaire.In total, 58 TO filled out the online inventory, of which 37 completed the entire questionnaire Table . The majWith the online inventory and the in-depth interviews, we aimed to shed light on the needs and preferences of TO who treat incurable NSCLC patients. Figure In addition to the existing tools, 39 TO reported that they would welcome new DSS for their own decision-making and/or for shared decision-making Table . When weOnline inventory questionnaires were filled out by 58 Dutch TO about their needs and preferences regarding DSS for the treatment of incurable NSCLC patients. The majority of the respondents reported that there is a need for newly developed, up-to-date and validated DSS. Based on the results of the current inventory, recommendations can be made for future DSS development. For optimal use in clinical practice, such tools should integrate all relevant treatment options, weigh the benefits and harms of treatments, facilitate communication between caregivers and with patients, and be kept up-to-date.To support TO’s decision-making, DSS are a useful and time-efficient complement to clinical guidelines for treatment decision-making. Guidelines could even incorporate DSS that are ready for use in clinical practice. Currently, a large number of DSS have been developed for this population, as shown in our previously published systematic review . Even thKRAS, EGFR, BRAF), tumor suppressor genes , and gene rearrangements  have been found to be important [EGFR and KRAS, or rearrangements of, for example, ALK and ROS1 [Various separate factors, such as performance status, ability to cope, preferences, and the impact on quality of life were reported to be important in clinical decision-making. These are often already incorporated in DSS, but are measured relatively subjectively. Future DSS will need more objective markers, such as genetic and serum markers, in order to reduce unwanted treatment variety and correct use of expensive medication. In the past decades, great progress has been made in the understanding of underlying biological processes of cancer cells. This has led to the discovery of several onco-pathways, which are controlled by oncogenes and tumor suppressor genes. Biological markers are becoming highly influential prognostic and predictive factors for clinical decision-making, as they determine the effectiveness of targeted and immune therapies. In adenocarcinoma and squamous cell carcinoma, various important onco-pathways  , 13, oncmportant –16. Furtmportant . In addimportant , 19. Curand ROS1 –23, but To overcome the reported limitations and to create an adequate tool for future clinical practice, various steps have to be undertaken. It is obvious that oncologist cannot keep up with the current literature to choose the optimal evidence-based treatments, based on a balance between survival gain, side effects, quality of life, patient preferences, and even cost-effectiveness. In addition, the wide array of factors that influence clinical decision-making renders it too complex for the human cognitive capacity. In general, guidelines based on systematic reviews that summarize the evidence of pros and cons of the various treatment options are very useful. Regular updates of the existing guidelines are necessary, but apart from these, DSS can give guidance to decide on the optimal treatment of individual patients. Using the infrastructure of electronic health records for clinical DSS could support personalized medicine practices by providing the tailored information at the right time. Various researchers have discussed the advantages of incorporating DSS in electronic health records in combination with smart algorithms, such that continuous updating and rapid adaptation of DSS are ensured , 24–27. There are some ethical issues that were raised in conversations with TO, which should be kept in mind as well. A DSS can support the oncologist in giving treatment advice based on the best available evidence. If the DSS is available online and easy to understand, the given information about pros and cons of treatments can be visualized for patients. Nevertheless, this decision-making process should not be automated, even when good DSS become available; oncologists remain essential in the decision-making process. Furthermore, although the oncologist is offering the best treatment options based on available evidence and clinical knowledge, ultimately, the patient decides. However, patients might not feel capable of choosing between the available treatment options.The strengths of this study were the fact that we had access to the entire Section of Oncology (SON) of the group of Physicians in Chest Medicine and Tuberculosis organization (largest TO organization in the Netherlands), and these TO were distributed over various hospital settings. Considering the fact that the vast majority of our sample used existing DSS, and reported a need for new tools, it is likely that TO with unmet needs have been more inclined to participate than the oncologists who have less knowledge about or need for DSS. Nevertheless, the current group of responders provided valuable insight in TO’s needs and preferences for new DSS.In conclusion, TO in the palliative settings reported a need for newly developed DSS when it comes to clinical decision-making in the palliative phase of NSCLC. DSS can be an aid in clinical practice by summarizing and visualizing the current fast-moving area of biomarker-based palliative lung cancer treatments. Future DSS should include novel important prognostic and predictive factors, such as genetic and immune markers, and provide estimates for both survival rates, toxicity, and cost-effectiveness of the available treatments. Future DSS developers should find methods to ensure the continuous updating of DSS and their implementation into daily clinical practice.


Stroke, the most prevalent cerebrovascular disease, causes serious loss of neurological function and is the leading cause of morbidity and mortality worldwide. Despite advances in pharmacological and surgical therapy, treatment for functional rehabilitation following stroke is limited with a consequent serious impact on quality of life. Over the past decades, mesenchymal stem cell (MSCs)-based therapy has emerged as a novel strategy for various diseases including stroke due to their unique properties that include easy isolation, multipotent differentiation potential and strong paracrine capacity. Although MSCs have shown promising results in the treatment of stroke, there remain many challenges to overcome prior to their therapeutic application. In this review, we focus on the following issues: the scientific data from preclinical studies and clinical trials of MSCs in the treatment of stroke; the potential mechanisms underlying MSC-based therapy for stroke; the challenges related to the timing and delivery of MSCs and MSC senescence. Stroke, one of the major diseases of the central nervous system, is a global health problem with limited treatment options. It is classified as hemorrhagic (13%), caused by rupture of blood vessels, or ischemic (87%), caused by disruption of blood supply . With anOver the past decades, stem cell-based therapy has attracted great interest as an emerging treatment in stroke in the hope that it can repair the damaged central neural networks . Stem ceMSCs are pluripotent, non-hematopoietic stem cells with the ability to differentiate into a diverse number of cell lineages, including chondrocytes, osteoblasts, and neuron-like cells . They caThe application of MSCs in the treatment of stroke has been studied for nearly two decades. Several recent animal studies are summarized in It has been estimated that about 75% of strokes occur in the elderly . Shen etComorbidities in humans can profoundly affect stroke pathophysiology, lesion development, and recovery . DespiteAlthough preclinical studies have shown that MSCs displays beneficial effects on stroke , the safRecently, Human umbilical cord-derived MSCs (hUC-MSCs) have great advantages for stroke treatment due to low immunogenicity and no substantial ethical problems . A PhaseAlthough MSC transplantation has been proven to be safe and feasible in small phase I/II trials, no significant improvement was observed in a randomized controlled intravenous phase II trial . Their eCurrently, the underlying mechanisms of MSC-based therapy for stroke have not been fully elucidated. Many experimental studies have revealed that MSCs protect against stroke through multiple mechanisms including direct differentiation, paracrine effects and mitochondrial transfer .MSCs are pluripotent adult mesenchymal cells with the ability of self-renewal and multi-differentiation . In the There is accumulating evidence that the ability of MSCs to differentiate into neuron cells cannot on its own explain the predominant benefits of MSC-based therapy . CompareNotably, exosomes are the most important agents in the process of information transmission and inducing repair for many secreted cytokines . The parin vivo and in vitro resulted in metabolic benefits. The researchers tagged BM-MSCs and tracked the transplanted mitochondria. They observed the mitochondria transfer and a protective effect on the damaged cerebral microvascular system in rats with cerebral ischemia . It has been reported that stroke can cause an increase in reactive oxygen species, activation of immune cells and production of pro-inflammatory cytokines in the acute phase, thus aggravating the secondary brain injury. MSC exosomes display immunomodulatory and neuroprotective effects, especially in the acute phase of stroke . In contAnother challenge is to determine the best treatment. Although MSCs have shown general immune evasion and tolerance in clinical studies of stroke, an increasing number of preclinical studies have proved the therapeutic efficacy of conditioned medium (CM) and extracellular vesicles (EVs) derived from MSCs that reduces the dependence on and need for cells . These cThird, the route of MSC administration is another major challenge. Previous studies have used both systemic and direct approaches such as IV, IA, and IC. Compared with more invasive routes , minimally invasive routes  may cause less damage at the injection site although each route has its own advantages and disadvantages. How to choose a simpler and safer delivery route for MSCs is a major hurdle to their clinical application with much greater care required by the clinician.Fourth, the best source of MSCs for stroke treatment has not been determined. Although most preclinical studies (>90%) use fresh MSCs from healthy, young donors, half of the clinical studies used autologous MSC products. Autologous MSCs may circumvent the logistical ethical problems and have been proven to be more effective than those obtained from healthy donors . NonetheFifth, another challenge is the heterogeneity in study designs. The poor methodological rigorism of both preclinical and clinical studies may have contributed to the current conflicting results. Preclinical studies rarely adopted randomized or blinding designs, or carried out confirmatory studies, a pre-requisite of clinical trials . SimilarSixth, senescence of MSCs has attracted extensive attention in recent years. The passage times of MSCs are limited. Extension of expansion time will inevitably lead to replicative senescence. Moreover, MSCs isolated from the elderly exhibit an aging phenotype with a decline in function, leading to decreased therapeutic efficacy . TherefoFinally,the comorbidities of patients are also the challenges for MSC therapy . Many stMSCs have many advantages: they are immune evasive, easy to harvest, expand and store for a long time, and convenient to manage in various ways. Additionally, their clinical use does not raise many ethical issues. Increasing evidence supports the potential of MSCs to treat stroke, but there are challenges to overcome. We have systematically reviewed the safety and efficacy of MSCs in the treatment of ischemic stroke and hemorrhagic stroke. In preclinical studies, MSC treatment has shown considerable efficacy in some neurological function tests, but there remains no large-scale randomized, double-blind, multicenter clinical study to prove their effectiveness. The heterogeneity of MSCs is the main barrier to their clinical application and therapeutic effect. Key parameters such as the source of MSCs, dosage, route of administration, administration time and other key parameters directly affect the application effect. More importantly, many clinical trials have similar limitations in detecting the role of MSCs, including small size, lack of a control arm, and inconsistent methods for use of MSCs. Homogenization and quality control are key issues in their clinical application. Future preclinical and clinical studies should consider adoption of a well-designed randomized controlled study design, method rigor and intervention measures, so as to determine the effect of MSC therapy in the treatment of stroke . NonetheWL and LS searched the literature and wrote the manuscript. BH, YH, and HZ searched the literature and provided comments. XL and YZ designed the study and wrote the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Heavy metal ions and pesticides are extremely dangerous for human health and environment and an accurate detection is an essential step to monitor their levels in water. The standard and most used methods for detecting these pollutants are sophisticated and expensive analytical techniques. However, recent technological advancements have allowed the development of alternative techniques based on optical properties of noble metal nanomaterials, which provide many advantages such as ultrasensitive detection, fast turnover, simple protocols, in situ sampling, on-site capability and reduced cost. This paper provides a review of the most common photo-physical effects impact on the fluorescence of metal nanomaterials and how these processes can be exploited for the detection of pollutant species. The final aim is to provide readers with an updated guide on fluorescent metallic nano-systems used as optical sensors of heavy metal ions and pesticides in water. Industrial human activities and technological advancements are increasingly burdening the environment with the release of large quantities of hazardous waste, such as heavy metals, metalloids and organic pollutants. This pollution has inflicted serious damage on ecosystems . The buiThe use of pesticides in commercial agriculture has led to an increase in farm productivity . Sure, tIn order to monitor the amount of heavy metal ions and pesticides accumulated in nature, a wide range of sample types, such as soil, water, air, food, beverage, plant and animal-derived products, needs to be tested routinely. The most widely used analytical methods to detect the presence of contaminants in real samples are: atomic absorption spectroscopy (AAS) ,7, atominanoparticles, fluorescent and sensor) jumped from 3 in 1999 to 285 in 2019. While the An analysis of publication data from the Scopus website highlights that the scientific interest on the fluorescent nanomaterials for sensor applications increased in the last twenty years (1999–2019), as reported in Nanosensors are sensors used to detect the presence of chemical species on the nanoscale. Fluorescent nanomaterials such as inorganic quantum dots (QDs) ,20,21 peThis review aims to describe the most common photo-physical effects involved in the fluorescence of the noble metal nanostructures and their modifications induced by the presence of pollutant species, such as heavy metal ions and pesticides, which are the widest diffused and harmful water and environmental contaminants. Photoinduced electron transfer (PET) and photoinduced charge transfer (PCT) processes, fluorescence resonance energy transfer (FRET) mechanism, aggregation-induced emission (AIE) effect and the inner-filter effect (IFE) are the kind of photo-physical effects commonly exploited in nanosensing. Moreover, we discuss a number of recent and promising systems used for detection of heavy metal ions and pesticides, highlighting their performances in terms of linear range, selectivity and limit of detection (LOD).The nature of the metal nanomaterials and the pollutant species is the key element to determine the type of interaction and the effect on the fluorescent emission band. In this section, the most important interaction mechanisms between the probe system and the pollutants will be discussed.Photoinduced electron transfer (PET) sensors are based on molecules having a fluorophore moiety, responsible for the light emission and an ionophore part, involved in the interaction with the heavy metal ion see a. When tConversely, a cation interacting with an acceptor group enhances the electron-attraction character of this group; consequently, the cation stabilizes more efficiently the excited state rather than the ground state, causing a red shift of the absorption and emission spectra see b 44]..44].d between donor and acceptor dipoles is represented in abscissa. An electromagnetic wave of appropriate wavelength excites the donor (process ①). Two relaxation mechanisms for the donor can occur following excitation. The first one is through radiative emission . The second one is through FRET, where the de-excitation process ③ occurs and the excess of energy  is transferred to the acceptor moiety, exciting the acceptor itself (process ④). Finally, the acceptor loses the excess of energy returning to the fundamental state by radiative or non-radiative emission (process ⑤) . I. I111]. The use of aptamers that can be chosen to bind specifically to some molecules, allows the development of optosensors highly selective to a particular target pesticide. Specific aptamers have been used to monitor malathion contents in adulterated tap water . The aptThe proposed nanosensor showed an efficient, specific and simple approach for the detection of diazinon in food, with a high potential for food safety and quality control.A fluorescent aptasensor in aqueous solution was proposed for the detection of carbendazim (CBZ), a widely used, systemic, broad-spectrum benzimidazole fungicide; it used CBZ-specific aptamer as sensing probe and AuNPs/RB as indicator, respectively . The nakA colorimetric and fluorometric method using AuNPs, up-conversion nanoparticles (UCNPs) and an acetamiprid-binding aptamer (ABA) has been proposed for ultrasensitive and selective detection of the neonicotinoid pesticide acetamiprid . The ABAAlternatively, the inner filter effect of AuNPs with respect to fluorescence of carbon dots has been modulated by S-18 aptamer depending on the presence of acetamiprid .Various biological molecules, such as antibodies ,117, nucThe simultaneous modification of the corresponding antibodies and fluorescently labelled oligonucleotides on the probe surface achieved the goal to realize a multi-labelled AuNP probes for the three tested pesticides see . The thrFluorescent probes based on noble metal nanomaterials represent a multi-versatile detection tool that has excellent sensitivity for the detection of a wide range of pesticides or heavy metal ions. These capabilities combined with other advantages, such as faster detection times, simpler protocols, in situ sampling, portability and reduced cost, promote these materials as valid alternatives with respect to the most common analytical techniques.We have reviewed the most recent achievements in the field of metal nanostructures for environmental pollutant detection based on fluorescence. We have discussed the most common photo-physical effects acting on the fluorescence of the noble metal nanomaterials and the effects induced by the presence of pollutant species. More in detail, we have described photoinduced electron transfer and photoinduced charge transfer processes, fluorescence resonance energy transfer mechanism, aggregation-induced emission effect and the inner-filter effect. In conclusion, we have presented a list of recent and promising systems used for detection of heavy metal ions and pesticides, highlighting the performances in terms of sensitivity, linear range, selectivity and limit of detection.


Functional disorders and injuries of urinary bladder, urethra, and ureter may necessitate the application of urologic reconstructive surgeries to recover normal urine passage, prevent progressive damages of these organs and upstream structures, and improve the quality of life of patients. Reconstructive surgeries are generally very invasive procedures that utilize autologous tissues. In addition to imperfect functional outcomes, these procedures are associated with significant complications owing to long-term contact of urine with unspecific tissues, donor site morbidity, and lack of sufficient tissue for vast reconstructions. Thanks to the extensive advancements in tissue engineering strategies, reconstruction of the diseased urologic organs through tissue engineering have provided promising vistas during the last two decades. Several biomaterials and fabrication methods have been utilized for reconstruction of the urinary tract in animal models and human subjects; however, limited success has been reported, which inspires the application of new methods and biomaterials. Electrospinning is the primary method for the production of nanofibers from a broad array of natural and synthetic biomaterials. The biomimetic structure of electrospun scaffolds provides an ECM-like matrix that can modulate cells’ function. In addition, electrospinning is a versatile technique for the incorporation of drugs, biomolecules, and living cells into the constructed scaffolds. This method can also be integrated with other fabrication procedures to achieve hybrid smart constructs with improved performance. Herein, we reviewed the application and outcomes of electrospun scaffolds in tissue engineering of bladder, urethra, and ureter. First, we presented the current status of tissue engineering in each organ, then reviewed electrospun scaffolds from the simplest to the most intricate designs, and summarized the outcomes of preclinical  studies in this area. The normal function of different organs in the urinary tract could be compromised in several clinical conditions . FunctioDuring the last two decades, tissue engineering through the integration of cell-based methods, material and engineering sciences, and biomimetic approaches has developed promising outlooks for finding novel and innovative strategies for recovering of compromised functions of diseased organs. To this end, numerous works have been conducted to study new biomaterials and fabrication techniques. Today, tissue engineering is still in its infancy, but in the near future, it will definitely have an indisputable role as a regenerative modality for patients.TM, Zeus Inc.), vascular access graft , dural patch , and synthetic bone   of that specific tissue to efficiently support the cells colonization, differentiation, and tissue remodeling . To mimi., Ltd.) .This review article gives a brief overview of the anatomy and function of the lower urinary tract and the current state of achievements in the tissue engineering of urologic tissues. Then critically evaluates the advantages of different biopolymers and design strategies for the development of electrospun-based scaffolds for the engineering of these tissues.in vitro and preclinical works were included in this study. Specific search filters for bladder, urethra, ureter, tissue engineering, and electrospinning were customized. The search filter for each organ was combined with tissue engineering, and electrospinning filters, and the search was carried out in PubMed. Scopus and Google scholar were also searched for pertinent studies that have not been found by PubMed search engine. The search results in each field (organ) were trimmed by removing studies not related to the specific organ, no tissue engineering strategy applied, not being original, without electrospinning fabrication method and, lack of full text  should be tolerable for regenerating and adjacent tissue. In addition, these products have to be easily removable through physiological metabolic processes . In vivod tissue . On the ®, Cook Urological, Spencer, IN, United States) for augmentation of the bladder in five patients with exstrophy–epispadias complex   . SIS proVarious electrospun scaffolds have been constructed with different biomaterials, fabrication methods, and designs for bladder tissue engineering so far. The fibrous structure of electrospun scaffolds provides an ECM-resembling matrix for cells, resulting in an ideal substrate for cells’ growth and differentiation. Besides, the electrospinning procedure can be tailored in a way to achieve fibers with nano-sized dimensions which is proved to have several important advantages for bladder tissue engineering including increased cell attachment, proliferation, regeneration, ECM components production, and inhibition of calcium oxalate stone formation . Generalin vitro studies, electrospun scaffolds can be an appropriate substrate for investigating cells’ behavior ex vivo and provide a useful tool for basic studies regarding differentiation status and the effects of bioactive agents on the cells. In this regard, it has been shown that electrospun scaffolds of PLLA and PLGA were capable of supporting the attachment and proliferation of human bladder cells , poly (ether-urethane) urea (PEUU) and, PCUU] and found the PCUU scaffold as the most resembling scaffold with bladder mechanics. Then, they employed the PCUU scaffold for bladder augmentation in a bladder outlet obstruction rat model. After 3 weeks of follow-up, increased survival, bladder capacity, and voiding volume were observed . Pokrywcin vitro assays and tissue engineering . The structural integrity of the hybrid scaffold was stabilized by continuous rehydration of BAM during the electrospinning procedure. The functionality of the hybrid scaffold for bladder reconstruction was compared with BAM in a rat model of bladder partial cystectomy (50%). After 8 weeks, the restoration of bladder urothelium and smooth muscle layers was reported. Moreover, the bladder capacity was maintained at the normal level in the hybrid scaffold implanted group compared to the distended bladders of the BAM group . In a foConsidering three classes of solvents based on ICH  guideline , most ofBesides, scale-up and robustness of electrospinning are critical challenges specially when converting an electrospun construct from R&D to a manufacturing scale . Low proThe urethra is a narrow fibromuscular tubular tissue connecting the urinary bladder to the urinary meatus that is responsible for urine removal. In males, the urethra is much longer than females (20 vs. 4 cm) and also carries semen. The male urethra is divided into different segments: prostatic urethra and membranous urethra (posterior urethra), and bulbar urethra, penile urethra, and fossa navicularis (anterior urethra) . The malStricture of the urethral wall is a common and challenging urological condition, affecting 0.2 to 0.9% of men . The higNumerous synthetic and natural matrices, with diverse fabrication methods and post-production treatments, have been utilized for urethral tissue engineering to date. In this area, tissue-engineered constructs with tubular (seamless), tubularized, and onlay configurations in conjunction with stem cells or progenitor cells have been studied in animal studies and human trials . AlthougSimilar to many organs treated by tissue engineering methods, collagen-based naturally derived scaffolds were among the first preferred options for reconstruction of urethra. This is because of the superior biocompatibility of these materials, and their supportive nature for cell attachment, growth, colonization, and remodeling of regenerating tissues . El-TabeChung et al. prepared a bi-layer fibroin silk scaffold composed of a porous layer and a compact film layer. The outcome of onlay urethroplasty with this scaffold in rabbit was compared with SIS for 3 months, and it was reported that both scaffolds were equally efficient in urethral reconstruction as no stricture, fistula, and stone were observed in regenerated normal caliber urethras . FurtherCollagen-based scaffolds were always among the most interesting options for investigators in different contexts of tissue engineering. There has been a continuous effort for upgrading and optimizing the characteristics of these scaffolds. In this regard, Pinnagoda et al. created a tubular scaffold of rat-tail collagen type I and reconstructed a 2 cm segment of rabbit urethra without cell seeding. After 9 months of follow-up, in 40% of animals fistula or stenosis were observed. The cyto-architecture was gradually developed further by increasing the postoperative regeneration time. The implanted bare scaffold was spontaneously re-populated by urothelium and SMCs with different speeds, 1 and 6 months, respectively .El Kassaby et al., in a comparative study, evaluated the efficiency of human cadaveric acellular bladder matrix for stricture repair in human and compared the outcomes with standard urethroplasty with buccal mucosa graft. They found that the quality of urethral bed  has a significant role in the performance of implanted bare scaffold. They reported that eight of nine patients with an intact, healthy urethral bed showed patent grafts, while two of six in unhealthy cases revealed patency . These fThe cell seeding approach was also examined in human trials. PGA:PLGA scaffold, which was previously reported to be suitable for bladder reconstruction , was empIn conclusion, the results of urethral tissue engineering in humans are much more promising than corresponding works in the bladder. This point may be attributed to the less complex structure and function of the urethra in comparison to the bladder. However, these findings can only provide a basis for further future studies concentrating on more elaborate constructs for the regeneration of long and complex urethral strictures via tissue engineering methods.Electrospinning, thanks to the numerous influential controllable process parameters, can potentially be an ideal method to make a suitable urethral scaffold with desired permeability, porosity, biocompatibility, topography, and mechanical properties . Severalin vivo study. Autologous dog bladder UCs were isolated, and the stretched electrospun silk fibroin scaffolds were pre-seeded before implantation. The dorsal urethra was reconstructed with this scaffold and assessed after 24 weeks. It was demonstrated that animals in the reconstructed groups possess wide caliber urethra without stricture and fistula. Also, histological analysis revealed the formation of a well-developed urothelium layer  peristaltic contractions of muscular layer in the wall of the ureter and, (ii) pressure gradient of urine . The ureAlthough the ureteral injury is a relatively infrequent problem, the proper functioning of the ureters is vital for normal kidney performance. The normal function and structure of ureter can be seriously damaged in some clinical conditions. Urolithiasis, chronic inflammation, infection, and ureteral carcinoma can reason the formation of ureteral stricture . HoweverAn ideal construct for ureter tissue engineering should be flexible and retains the luminal patency to ensure safe urine passage. In addition, it should be non-immunogenic and impermeable to urine while providing a suitable substrate for cell colonization and tissue remodeling. The complexity of surgery procedure, toxic effect of urine, and high level of minimum requirements for candidate constructs have hindered the advances in this area. Different strategies of preparation and application of tissue-engineered constructs for ureter tissue reconstruction have been studied so far . As urinPre-seeding of scaffolds is a generally accepted strategy for preventing fibrosis and graft shrinkage. The cultured cells could also improve remodeling, neovascularization, degradation rate, and immune tolerance of the engineered constructs . In thisPreimplantation of scaffolds in heterotopic sites [functionally unrelated sites such as omentum  or subcuScaffold plays a vital role in the regeneration of ureteral tissue and must possess several special biophysical and biochemical properties. The scaffold has to be biocompatible and provide a suitable microstructure for urothelial and SMCs colonization and growth . It shouin vivo microenvironment. In order to eliminate the chance of ureteral obstruction caused by degrading stent fragments in the distal ureter, which may lead to hydronephrosis and renal damages, ®, a standard biostable stent, considering foreign-body reactions, tissue inflammation, and edema. Although a broad range of biomaterials can be studied for the ureter reconstruction by electrospun seamless tubular scaffolds, few works have been dealt with this issue. It seems that complex surgical procedures for implantation of the ureter constructs and the essential need for big animal models imposed the main limitations in the development of this field.Considering the fact that electrospinning enables the production of biomimetic nanofibrous structure to native ECM with controllable composition, most of the studies have designed composite electrospun structures to address the complex requirements of a ureteral scaffold . Shen etAlthough pioneer works at the beginning of the third millenium opened very exciting vistas for reconstructive urology through tissue engineering strategies, these achievements were not followed and improved by future studies. Therefore, new biomaterials and novel innovative fabrication methods  for tissue engineering of urinary tract organs are still welcomed. Control and optimization of cells’ function and delivery of bioactive molecules are issues that were neglected in primary works. The electrospinning procedure by providing a relatively simple and versatile method for the fabrication of nanofibers has provided an interesting platform for addressing these issues.Resilient and load bearing nature of bladder mandate the integration of electrospinning procedure with other fabrication methods to construct hybrid scaffolds capable of withstanding the cyclic mechanical loads while providing the ECM mimetic nanostructure. These types of constructs will possess suitable mechanical features, cell-controlling cues, and favorable nano-sized urine interface in the same context.The urethra, on the other hand, has simpler structure and functions and its regeneration majorly relies on cellular interaction. Therefore, electrospun scaffolds can offer very encouraging substrates for concurrent implantation of cells and delivery of bioactive agents that conduct the proper regeneration by inhibition of the cells that participate in the formation of strictures. Application of electrospun scaffolds for urethra tissue engineering stands in its very beginning steps of development, and numerous regenerative schemes in this area can be designed.Among the three organs reviewed in this article, the ureter is the least studied one due to the relatively few cases requiring ureter reconstruction. However, the challenging nature of ureter reconstruction justifies reconstructive approaches via tissue engineering methods. The electrospinning technique has easily adaptable configures for the fabrication of tubular constructs, and different biomaterials can be integrated through this method for the production of composite constructs that are more compatible with the natural structure of the ureter.Taken together, the electrospinning method offers very interesting and diverse options for researchers who are investigating tissue engineering of urinary tract organs. This method provides appropriate constructs for studying cells interaction, biomaterials integration, innovative molding, and functional evaluation.MZ and MN wrote the manuscript. NS and SR reviewed the article before publication. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Socioeconomic inequality in child malnutrition is well-evident in Bangladesh. However, little is known about whether this inequality differs by regional contexts. We used pooled data from the 2011 and 2014 Bangladesh Demographic and Health Survey to examine regional differences in socioeconomic inequalities in stunting and underweight among children under five. The analysis included 14,602 children aged 0–59 months. We used logistic regression models and the Concentration index to assess and quantify wealth- and education-related inequalities in child malnutrition. We found stunting and underweight to be more concentrated among children from poorer households and born to less-educated mothers. Although the poverty level was low in the eastern regions, socioeconomic inequalities were greater in these regions compared to the western regions. The extent of socioeconomic inequality was the highest in Sylhet and Chittagong for stunting and underweight, respectively, while it was the lowest in Khulna. Regression results demonstrated the protective effects of socioeconomic status (SES) on child malnutrition. The regional differences in the effects of SES tend to diverge at the lower levels of SES, while they converge or attenuate at the highest levels. Our findings have policy implications for developing programs and interventions targeted to reduce socioeconomic inequalities in child malnutrition in subnational regions of Bangladesh. Child malnutrition is a significant global health problem, and it remains a major threat to the reduction of poverty and the achievement of sustainable development. Child malnutrition accounts for almost 3.1 million child deaths worldwide and is responsible for 45% of under-five child deaths . Child mDespite the rapid improvement of social and health indicators, poor maternal and child nutrition is highly prevalent in Bangladesh. According to recent estimates, about 36% of children under five were stunted, and 33% were underweight in 2018 . Half ofStudies of social determinants of health documented a strong socioeconomic gradient in child and adult health ,19,20. TAlthough the protective role of SES is widely acknowledged in current public health research, it is less clear how the individual-level SES interacts with macro-level factors such as community or regional contexts, especially in low-income settings. A growing body of research, especially in the context of developed countries, indicates that regional or community contexts moderate or mitigate the effects of individual-level SES on child and adult health outcomes. These studies commonly demonstrate that growing up in deprived communities  exacerbates the effects of individual-level SES on child and adult health ,30. ThesIn the pursuit of promoting equity in health and equitable gains from development efforts in many low-income countries, policymakers strongly emphasize the reduction of regional inequality in health and wellbeing. Examining the regional variation in child malnutrition may provide a new lens to policymakers to design interventions specific to regional inequality in SES. Some studies have reported significant geographic variation in the prevalence of undernutrition in developing countries ,34,35. FTo date, some studies ,23,39 haWe pooled data from two recent rounds of the Bangladesh Demographic and Health Survey (BDHS) conducted in 2011 and 2014. The BDHS is a nationally representative survey on maternal and child health, mortality, fertility, family planning, and nutrition. It also has an extensive collection of sociodemographic and socioeconomic variables such as education, household assets, and occupation. The BDHS used a multistage cluster sampling technique, which allows estimations at both national and regional levels. A detailed description of the survey methodology, sampling design, and primary finding of the BDHS is available in the National Institute of Population Research and Training (NIPORT) report . We usedThe BDHS collected data from ever-married women aged 15 to 49 years and their children aged 0–59 months using pre-tested structured questionnaires. The response rate in the BDHS survey was about 98% . TrainedChild malnutrition is the outcome variable of this study. In the BDHS, child malnutrition is measured by standard anthropometric indicators of height-for-age (HAZ) z-scores and weight-for-age (WAZ) z-scores as defined by the World Health Organization (WHO) . StuntinWe followed previous studies to model the relationship between child malnutrition and its associated factors ,43. The The BDHS does not collect data on income. Instead, the BDHS collects a wide range of household assets and dwelling characteristics, ranging from ownership of a radio/TV, a refrigerator, farmland, farming animals, materials used for the construction of houses, water, and sanitation infrastructure and so on ,45. The We used multivariable logistic regression models to examine the associations of wealth index and education with two outcome variables (stunting and underweight). We included interaction terms between wealth, education, and region in the adjusted models to assess whether associations of wealth and education with malnutrition outcomes differed by region. We employed the Concentration index (CI) as the summary measure of socioeconomic inequality to quantify the degree of wealth- and education-related inequalities in stunting . The valWe applied Wagstaff’s normalization (Wagstaff Index or WI) and Erreygers’s correction (Erreygers Index or EI) to take into account the binary nature of outcome variables in this study ,48. The The Bangladesh Demographic and Health Survey received ethical approval from the Inner City Fund (ICF) Macro Institutional Review Board, Maryland, USA and the National Research Ethics Committee of Bangladesh Medical Research Council (BMRC), Dhaka, Bangladesh. Each participant gave informed consent before participating in the survey. The de-identified data for this study were obtained from the DHS online . InstituThe multivariable logistic regression analysis shows a significant association between child undernutrition and wealth index . ChildreThe approximately flat predicted probability curves for the three western regions, such as Rangpur, Rajshahi, and Khulna, show that the level of inequality was not responsive to the level of mother’s education . HoweverThis study examined socioeconomic inequalities in child malnutrition and whether these inequalities differ by subnational regions in Bangladesh. Results suggested that stunting and underweight were more concentrated among children from poorer households and those born to less-educated mothers in Bangladesh. We found significant wealth- and education-related inequalities in child malnutrition in the north-eastern  and southern and eastern regions  compared to other regions. Further, there was a differential protective effect of mother’s education and household wealth across the regions in Bangladesh. The regional differences in the effects of SES tend to diverge at the lower levels of SES and converge or attenuate at the highest levels.Our analysis found some notable trends in the prevalence of stunting and underweight and how they differ by the subnational regions. The prevalence of stunting and underweight was disproportionately higher in southern and eastern regions, including Barisal, Chittagong, and Sylhet. Earlier studies in Bangladesh also found similar regional patterns in the prevalence of stunting and underweight. In particular, prior studies noted that eastern and south-eastern regions in Bangladesh have the highest concentration of severe child wasting and stunting, with the severity of wasting exceeding the WHO critical threshold level .Regarding the socioeconomic inequalities in child nutritional outcomes, we found a higher concentration of stunting and underweight outcomes among low SES children and these inequalities varied across the regions. The highest extent of wealth-based inequality in stunting was found in Sylhet for stunting and it was the higest in Chittagong for underweight. In contrast, the lowest levels of wealth-related inequalities in stunting and underweight were found in Khulna. Education-related inequalities in stunting and underweight also varied across the regions. The highest inequality in stunting was observed in Sylhet and the lowest was observed in Rajshahi. Education-related inequality in underweight was the highest in Chittagong and the lowest in Rangpur.Parental education and household wealth (the two measures of SES) appeared to be the most robust determinants of child malnutrition outcomes in the regression analysis. The findings imply that children born to parents with higher levels of education and wealth were the most advantaged in terms of having favourable nutritional status. Although parental SES measures are protective factors for child health, in Bangladesh and other developing countries ,22,50,51The observed regional differences in our analysis fairly corroborate with a few recent studies in Bangladesh and elsewhere. Studies in Bangladesh have shown that wealth-based inequalities in health, especially in maternal health and child mortality, were relatively larger in the eastern and south-eastern regions in comparison to the western regions in Bangladesh ,52. ThesThis study has some limitations. First, our findings do not allow us to infer any causal relationship between SES and child malnutrition outcomes due to the cross-sectional study design. Second, we could not control for other regional factors that could potentially shape the associations between SES and outcomes in our analysis. Future research may investigate the association of other structural and contextual factors, such as community-level poverty, physical and financial barriers to health facilities, and an array of cultural and local contexts contributing to the regional differences in child health.Child malnutrition is a major public health issue in Bangladesh. Reducing socioeconomic inequalities in child health has remained to be a critical challenge for policymakers. Subnational regional variation in socioeconomic inequalities in child malnutrition in Bangladesh requires further public health attention. Understanding regional differences in socioeconomic inequalities could provide useful information to help formulate strategies to reduce social inequalities in malnutrition.


The unpredictable future of this epidemic has been exacerbated by myths and misinformation, often driven by erroneous news reports and the public's misunderstanding of health messages, thus causing anxiety in the public. It has been reported that the outbreak of COVID-19 in China has caused public panic and mental health stress , solution-focused brief therapy, family therapy and mindfulness, etc. If school teachers notice that a student shows some symptoms of psychological disorders such as anxiety or depression, they will refer the student to school psychology teachers who will assess his/her psychological level through interviews and assessment scales such as the Psychological Symptom Checklist (SCL-90). Based on interviews and case conceptualization, and also taking into account the results of the scales, school psychology teachers will offer intervention to students at risk of psychological trouble through a variety of approaches, including cognitive behavior therapy (CBT), mindfulness, social emotional learning (SEL), etc. CBT is used to alleviate anxiety, mindfulness for relaxation or self-regulation, and SEL to teach communication skills  ; parent outcomes (e.g. attitudes toward the services and changes in their children); teacher and school administration outcomes, etc. Such studies would inform both researchers and practitioners of potential issues in the implementation of the TTPSS with an eye to ensure its effectiveness.


Characterizing both neurodevelopmental and aging brain structural trajectories is important for understanding normal biological processes and atypical patterns that are related to pathological phenomena. Initiatives to share open access morphological data contributed significantly to the advance in brain structure characterization. Indeed, such initiatives allow large brain morphology multi-site datasets to be shared, which increases the statistical sensitivity of the outcomes. However, using neuroimaging data from multi-site studies requires harmonizing data across the site to avoid bias. In this work we evaluated three different harmonization techniques on the Autism Brain Imaging Data Exchange (ABIDE) dataset for age prediction analysis in two groups of subjects . We extracted the morphological features from T1-weighted images of a mixed cohort of 654 subjects acquired from 17 sites to predict the biological age of the subjects using three machine learning regression models. A machine learning framework was developed to quantify the effects of the different harmonization strategies on the final performance of the models and on the set of morphological features that are relevant to the age prediction problem in both the presence and absence of pathology. The results show that, even if two harmonization strategies exhibit similar accuracy of predictive models, a greater mismatch occurs between the sets of most age-related predictive regions for the Autism Spectrum Disorder (ASD) subjects. Thus, we propose to use a stability index to extract meaningful features for a robust clinical validation of the outcomes of multiple harmonization strategies. The structure of human brain changes throughout the lifespan, giving rise to different processes with typical patterns in specific time intervals . Brain mBrain age prediction models have been improved by the joint application of large datasets and advanced machine learning algorithms. By using magnetic resonance imaging (MRI) features and multivariate analyses, several biomarkers have been identified to accurately describe both neurodevelopment and aging processes ,22,23,24Initiatives to share open access morphological data contributed significantly to the advance in brain structure characterization. Indeed, such initiatives allow large brain morphology cross-sectional datasets to be shared, which increases the statistical sensitivity of the outcomes and promotes the development of reproducible research methods . HoweverThe aim of this work is to compare different harmonization strategies to investigate the effect of statistical harmonization on a multi-site neuroimaging dataset. In particular, the Autism Brain Imaging Data Exchange (ABIDE) dataset was adopted in order to extract morphological features and predict the biological age of both control and ASD subjects by using machine learning regression models. We provide a robust framework to compare the performance of the machine learning models and quantify the stability of the most relevant anatomical features. The performance of the models and the most significant morphological features were analyzed to: (i) verify whether different harmonization techniques influence the accuracy of predictive models; and, (ii) investigate the effects of the harmonization on the anatomical regions with the most significant impact on age prediction for both groups of subjects.http://fcon_1000.projects.nitrc.org/indi/abide. Initial contributions were sought from members of the ADHD-200 Consortium conducting autism research . Invitations to participate were extended based on personal communications, recent publications, and conference presentations. All of the investigators willing and able to openly share previously collected MRI data from individuals with ASD and age- and sex-group matched TC were included. Institutional Review Board (IRB) approval to participate, or explicit waiver to provide fully anonymized data, was required prior to data contribution. All of the participating sites received local Institutional Review Board approval for acquisition of the contributed data. We only considered male subjects due to the high imbalance between male and female subjects in the data sample. For quality assessment, we firstly evaluated a comprehensive index of anatomical quality metrics by computing the principal component analysis of the contrast to Noise Ratio, percent of artifact voxels, and signal to noise ratio. Subsequently, we used the median absolute deviation (MAD) criterion [The Autism Brain Imaging Data Exchange (ABIDE) cohort includes imaging data from 1112 participants. ABIDE represents a consortium effort to aggregate MRI datasets from individuals with autism spectrum disorder and age-matched typically-developing controls (NC) . ABIDE writerion  to excluhttps://surfer.nmr.mgh.harvard.edu/) was used to extract the morphometric properties of both cortical and sub-cortical brain structures. In particular, the recon-all pipeline of FreeSurfer v.5.3.0 [https://surfer.nmr.mgh.harvard.edu/fswiki/recon-all. The Desikan-Killiany atlas [volume, intensity mean, standard deviation, minimum, maximum, and range of 40 sub-cortical brain structures and white matter parcellation of brain cortex;volume, surface area, Gaussian curvature, mean curvature, curvature index, folding index, thickness mean, and thickness standard deviation for the 34 cortical brain regions of each hemisphere; and,global brain metrics, including surface and volume statistics of each hemisphere; total cerebellar gray and white matter volume, brainstem volume, corpus callosum volume, and white matter hypointensities.The software tool FreeSurfer ;gortical metrics ;sub-cortical metrics ; and,WM metrics (408 features resulting from six metrics for the 68 regions of interest).For the sake of clarity, we divided all the FreeSurfer features into four categories:P morphological features.Each anatomical metric was divided by total intracranial volume (ICV) of the corresponding subject in order to normalize the statistical features to brain size and reduce their variance. We also performed additional analyses without correcting ICV to test the impact of this correction on harmonization and no differences were found between the two methods. Finally, the ABIDE cohort was described by two matrices Usually, age prediction is performed while using multiple features that were extracted from one or more imaging modalities. A dataset is then defined by including multiple subjects’ features and their true ages. The dataset is fed into a supervised machine learning algorithm that learns to predict the subjects’ ages from their brain imaging features. The machine learning algorithm aims at predicting the brain age of a given subject while minimizing the deviation from the true age and avoiding overfitting. Different metrics, such as Mean Absolute Error (MAE), are commonly employed in order to evaluate the delta between the predicted age and true age of the subjects. In addition, several feature selection techniques can be applied to remove irrelevant, noisy, and redundant features, avoiding overfitting and improving prediction performance, reducing the computational complexity of the learning algorithm, and proving a deeper insight into the data, which highlights which of the features are most informative for age prediction ,39.compare multiple harmonization strategies;identify the most effective age predictive model;select only the most significant features among the total set of features; and,compare the stability of the most age-related anatomical regions of interest across harmonization strategies.A schematic overview of the framework is shown in In this study, a machine learning framework was developed in order to:i, for participant j and feature Z is the matrix of site indicators; Z for feature W is the matrix of biological covariate of interests; Linear regression is the most popular method for performing harmonization, adjusting the images for site effects. It does not take into account the potential confounding between the site variables and the biological covariates of interest in the study. For the regression model, the morphological measurement i, for participant j and feature i for feature The ComBat harmonization model extends the adjusted residuals harmonization model presented in Equation  and assuribed in ,31.For the removal of site effects, three different harmonization procedures were compared: (i) absence of harmonization (no harmonization), which considers as an additional feature the site number identifier expressed as deviations from a baseline site resulting in Mean Absolute Error (MAE):Coefficient of determination  is an ensemble learner of tree-structured base learners. Each tree individually predicts the target response while the final predictions result from the average of the individual tree predictions . Two souThe permutation-based MSE reduction criterion  has beenLasso (Least Absolute Shrinkage and Selection Operator)  regressiTuning the robust rank aggregation (RRA) algorithm  to combifrequency-based criterion with a fixed threshold to retain the most frequent features selected in each round of Lasso regression.The output of each regression algorithm is a list of performance metrics; moreover, the ranked features and the number of features tigation . In ordetigation . Here wek top elements are available.The RRA approach computes the position of each item in the final ranking by comparing its position in all of the ranked lists to a non-informative null model of random permutations of the items. A numerical score for each item is then assigned according to the reference beta distributions of order statistics and the Bonferroni correction is applied to compute the P-values and to find the list of statistically significant items. The P-values are then sorted to obtain the final ranking. The algorithm was also extended for accounting partial rankings, i.e., lists, where only the jth feature has been selected at the round ith. Subsequently, we applied a frequency-based criterion by selecting as significantly stable features those that occurred in at least Because the output produced by Lasso is a sparse matrix of weights, we considered as features that are relevant to the target variable within each round of cross validation those corresponding to non-zero weights. Consequently, the matrix of selected features is a binary matrix, where 1 is found at the A and B are two sets of ROIs. This index represents the proportion of agreement between the two sets of features and it is related to the stability of the features selected with respect to machine learning algorithm [In order to verify whether the harmonization strategies affected the most significant age-related regions of interest, we evaluated the overlap between the two sets of selected ROIs that resulted from two different harmonization strategies. In particular, the Jaccard index was used as a measure of the percentage of overlap between two sets, as:lgorithm . In thisy is the chronological age of the subject. The adjusted explained variance The predictions of brain age that result from the different cross-validation rounds were averaged for each subject in order to obtain the final age prediction of each regression model and each harmonization strategy. For each of the nine combination , we evaluated three model fits of chronological age vs. predicted age relation, i.e., linear, quadratic, and cubic fit for each population:To assess the deviation of each model from the ideal age model fit  and “age covariate harmonization”  for each of the two groups NC and ASD. The resulting stability index is In this study, three different regression algorithms were used for age prediction for the three harmonization strategies. The results shown in 6R20.87) ,53,54,55ted MAE2 ,52,54,55analysis ,53,56. OThe analysis of the importance of the features by category , shows that for the strategies of statistical harmonization with age as covariate and for no harmonization, the features related to cortical and white matter statistics, are equally the most important for both classes of subjects, highlighting a greater contribution of cortical areas than subcortical and global structures in the age regression problem. This finding confirms the results of previous work, in which the authors investigated age-related changes of the simultaneous contribution of cortical thickness, regional WM volume, and diffusion characteristics of the brain, concluding that none of the measures are redundant and their integration yields a more complete understanding of brain maturation .For the best performing age regression models, we found that the most informative features for age prediction in control subjects mainly refer to fronto-parietal areas. In particular, the superior frontal cortex is identified in both the harmonized dataset and in the non-harmonized dataset. The precuneus/posterior cingulate (PCC) is also a significant region in both datasets. It is worth noting that several studies confirmed age-related cortical associations of such regions of interest. Both neurodevelopmental and aging analysis revealed distinct chronological structural patterns of different shape metrics in frontal lobe, several parietal regions and cingulate cortex ,57,58,59In summary, the age-covariate harmonization does not affect the performance of the age prediction models; however, on one hand, it shows less significant effects on predictive features in the control population, but, on the other hand, a greater mismatch of the selected anatomical features between the two strategies was found in ASD subjects, which indicated a more relevant effect of harmonization on the predictive features. Harmonizing a dataset is a fundamental step for multi-site analysis and it is often performed on imaging-derived data before any further analysis. Our results suggest that this process should be embedded into the complete analysis framework in order to assess its effects both on the performance of the algorithms or analysis methods and on the anatomical regions that are relevant to the performed analysis.Although this study shows important consequences of harmonization on age prediction in a multi-site dataset, it presents some limitations. We estimated the brain age of subjects using different methods and a final index was computed to assess the deviation of each model from the ideal age model fit. In some recent works, various sources of bias in estimating brain age delta have been highlighted, such as the non-Gaussian distribution of subject ages ,68,69. TAnother limitation concerns the data sample: only male participants were included in the analysis due to strong prevalence of male subjects in the ABIDE dataset. Moreover, the dataset does not include multiple MRI measures from the same individual: for further validations of the method, a dataset with multiple measurements should be used to perform the test-retest reliability of the results.Finally, although cross-validation is commonly used to test the models ability to generalize to an independent dataset while avoiding problems, like overfitting or selection bias , indepenIn this work, we proposed a novel machine learning framework to evaluate three different harmonization techniques of a cross-sectional dataset for age prediction analysis in two groups of subjects . Our analysis aimed to verify the effects of the different harmonization strategies on the final performance and on the set of features that are relevant to the age prediction problem both in the presence and absence of pathology using a stability index to provide a final robust overlap index between the features selected by each ML algorithm for each harmonization strategy.The results show that the age covariate harmonization and no-harmonization techniques yield comparable results in terms of performance for both groups of subjects, while the statistical harmonization seems to affect the most age-related predictive features. This finding suggests carefully evaluating the effect of the harmonization preprocessing step when planning to predict age on the basis of anatomical measures, especially when analyzing neurodevelopment- or aging-related diseases. The steps performed in the proposed framework can be generalized in order to provide a robust set of relevant features by means of an objective comparison of the outcomes that result from different harmonization strategies to potentially strengthen the relevance of clinical considerations.


Emphysematous cystitis (EC) is a rare entity caused by bacteria, which produce gas filled cysts in the bladder wall. We present a case of EC in a 72-year-old woman admitted to Vascular Surgery Department because of diabetic foot syndrome. During the hospital stay, the patient's general condition deteriorated. CT established EC diagnosis. Surgical treatment was inevitable. Salvage cystectomy was performed. Despite macroscopic removal of necrotic tissues, the condition of the patient didn't improve, 75 days past diagnosis of EC she died due to the multi-organ failure. Prompt diagnosis provided by imaging plays a key role in the treatment of EC. Emphysematous cystitis (EC) is a rare type of infection characterized by the presence of gas in the bladder wall and lumen. There are a few confirmed risk factors of EC like recurrent urinary tract infections (UTI), neurogenic bladder disorder, atherosclerosis, female gender, but diabetes seems to be the most important, due to its pathogenesis. An accurate diagnosis of the disease gives good results. Our case study presents a patient with EC revealed by computer tomography (CT) scan during hospitalization in the Vascular Surgery Department (VSD) due to diabetic foot syndrome.Escherichia coli infection was confirmed in intraoperative bacterial cultures and in urine culture. Pathological report revealed pyogenic cystitis and peritonitis. Histopathologic findings were severe, but not specific for EC, lack of multinucleated giant cells did not meet the criteria for diagnosis of EC  were administrated. Laboratory tests showed persistent high levels of glucose (>200 mg/dl); inflammatory parameters were increasing ; anemia was present ; worsening of renal failure was observed . On the 7th day of hospitalization in the VSD, due to the ileus and septic shock syndrome, a CT scan was performed. CT demonstrated massive emphysema of the bladder with expansion to the right groin and colon, causing obstruction of the lower half of colon  and 700mis of EC . After tEnterobacteriacae causing production of hydrogen and carbon dioxide.In the first stage of the disease, patients with EC present mild symptoms like in uncomplicated cystitis. This phase of the disease is connected with bacterial colonization. In the second stage of the disease, pneumaturia can occur. There is no clear explanation of occurrence of gas in the EC. Since most of the cases concerned women with poorly controlled diabetes, authors postulated a theory of high glucose concentration in bladder tissues which leads to acid fermentation by The described case of the female patient was characterized by many, high risk factors of EC. The patient had decompensated diabetes, advanced atherosclerosis, underwent radiotherapy and instrumentation of urinary tract causing recurrent UTI. At the time of the diagnosis, significant local advancement of the infection was disclosed. Such advancement combined with sepsis and ileus significantly worsened the prognosis – the patient needed emergent, extensive surgery procedure which additionally weakened the patient's immune system. In the opinion of most authors of the publications concerning EC, the need for surgery worsens the prognosis of EC and should be kept to a minimum such as decompression of the bladder and removal of necrotic tissues.Availability of fast and wide imaging facilitates proper diagnosis of the disease and implementation of treatment including decompression of bladder, targeted antibiotics and diabetes compensation. Imaging plays a key role in diagnosis of EC due to the nonspecific symptoms and pathological results. Patients with UTI symptoms and risk factors of EC like blood supply disorders, anatomical and neurogenic disorders, systemic disorders, should have a basic, immediate imaging  to set a diagnosis in the appropriate moment. Extended imaging should include a CT scan which allows proper identification of local advancement of the disease and recognition of other causes of gas in the bladder. Early diagnosis of EC allows for effective conservative treatment which results in good outcomes.This research did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors. The publication was paid for by Nicolaus Copernicus University in Torun.None.


Traumatic stress exposure during critical periods of development may have essential and long-lasting effects on the physical and mental health of individuals. Two thirds of youth are exposed to potentially traumatic experiences by the age of 17, and approximately 5% of adolescents meet lifetime criteria for posttraumatic stress disorder (PTSD). The role of the stress system is the maintenance of homeostasis in the presence of real/perceived and acute/chronic stressors. Early-life stress (ELS) has an impact on neuronal brain networks involved in stress reactions, and could exert a programming effect on glucocorticoid signaling. Studies on pediatric PTSD reveal diverse neuroendocrine responses to adverse events and related long-term neuroendocrine and epigenetic alterations. Neuroendocrine, neuroimaging, and genetic studies in children with PTSD and ELS experiences are crucial in understanding risk and resilience factors, and also the natural history of PTSD. The term early-life stress (ELS) has been used to describe a broad spectrum of adverse and stressful events, including childhood trauma occurring during neonatal life, early and late childhood, and adolescence. These adverse experiences include maltreatment, neglect, separation, parental loss, starvation, extreme poverty, bullying, domestic/community/school violence etc. ELS also includes adverse exposures during fetal life including maternal undernutrition, day-to-day hassles, pregnancy-specific stressors, moderate increases in maternal anxiety, and exposure of the mother to extreme adverse experiences such as physical/sexual abuse, acts of terrorism, war or natural disasters . On the The neuropsychobiological impact of ELS constitutes a major developmental risk factor for increased physical and mental morbidity in later life ,3. ThereExposure to traumatic events is rather common in childhood and adolescence, and PTSD will occur in a significant portion of those exposed to adverse events . EstimatResearch and clinical practice are facilitated by a common definition of posttraumatic stress disorder (PTSD), which is very common in the general population and can occur at any age. In general terms, PTSD describes a cluster of symptoms that develop after direct or indirect exposure to traumatic life events involving actual or threatened death, serious injury, or sexual violence. PTSD was classified as an anxiety disorder in the fourth edition of the DSM . More recently, it was reconceptualized in order to include a broader spectrum of negative responses to traumatic experiences. The DSM-5 relocated the disorder to a new chapter of trauma- and stressor-related disorders. A subtype was also created for children 6 years and younger, lowering the diagnostic thresholds for children. The PTSD symptoms are organized into four categories for adults, adolescents, and children older than 6 years, with one or more symptoms required from each group: (i) intrusion, (ii) avoidance, (iii) negative alterations in cognitions and mood, and (iv) alterations in arousal and reactivity. By definition, symptoms must persist for at least 1 month and cause clinically significant distress or impairment in several areas of functioning. Until recently, the diagnostic criteria of PTSD were not developmentally appropriate for diagnosing PTSD in very young children. However, the DSM-5 provides an extensive description of developmental differences in symptom expression and developmentally modified criteria for children aged 6 years old and younger. This set of developmentally sensitive criteria includes three symptom groups: (i) intrusion, (ii) persistent avoidance/negative alterations in cognition and mood, and (iii) alterations in arousal and reactivity. The effects of adverse and stressful events early in life may be severe and long-lasting. They are also associated with several clinical conditions including attention deficit hyperactivity disorder (ADHD), PTSD, bipolar disorder, panic disorder, substance abuse, generalized anxiety disorder (GAD), and major depressive disorder (MDD), as well as psychotic symptoms ,21. DeprThe role of the stress system is the maintenance of homeostasis in the presence of real or perceived and acute or chronic stressors. In general, activation of the stress system leads to adequate behavioral and physical adaptive changes that improve the organism’s ability to survive. The human stress system involves central and peripheral components which drive adaptive responses via a plethora of neurotransmitters, steroid hormones, and neuropeptides. The central CNS effectors of the stress system include: (a) the corticotropin-releasing hormone (CRH) secreted by the CRH neurons. The highest concentration of CRH neurons is present in the paraventricular nucleus (PVN) of the hypothalamus. CRH is also present in limbic structures and other brain regions related to the stress response such as the bed nucleus of the stria terminalis, the central nucleus of the amygdala, the locus coeruleus, the cerebral cortex, the cerebellum, and the dorsal root neurons of the spinal cord. Moreover, CRH has been found in chromaffin cells of the adrenal medulla and sympathetic ganglia of the autonomic nervous system (ANS), and finally in peripheral organs such as immune cells, skin, and gastrointestinal tract ; (b) argThe ANS and the hypothalamic–pituitary–adrenal (HPA) axis are regarded as the key systems involved in the stress response. The immediate response to a stressor is mediated by the instantaneous activation of the ANS and the increase of catecholamines in the periphery . In respThe HPA axis and the ANS are complementary and closely interconnected components of an internal neural regulation system  . The dysExcessive and prolonged activation of the stress system might lead to increased and prolonged production of CRH, cortisol, and catecholamines, which could explain many of the long-term psychopathological and physical complications of chronic stress, such as depression, obsessive-compulsive disorder, panic anxiety, anorexia nervosa, and chronic active alcoholism, amongst others ,30. HoweThe effects of ELS depend on three main factors: (i) the developmental time window affected , (ii) thThe HPA and ANS axes have, understandably, received the most scrutiny relative to other endocrine systems that might potentially be affected by ELS . Early-lHowever, the exact timing of ELS is probably the most important factor modulating HPA axis activity later in life . More spThe activity of the LC/ANS and the HPA axis is normally complementary. The regulation of the HPA axis depends partly on vagal influences from the LC/ANS . The majThere is a large body of studies assessing structural and functional brain correlations to ELS. Early-life stress has been associated with reduced volume of corpus callosum, insula, dorsolateral prefrontal cortex (PFC), orbitofrontal cortex (OFC), anterior cingulate gyrus, and caudate, as well as decreased cortical thickness of medial and lateral prefrontal and temporal lobe regions and reduced overall brain volume in humans ,72. TherTaken together, the aforementioned findings give prominence to the programming effects of ELS on neural networks and endocrine systems involved in stress, especially during vulnerable periods of development. The neuropsychobiological changes following ELS exposure are suggested to mediate risk for adult maladjustment and psychopathology, including PTSD. Understanding the pathways susceptible to alterations as sequelae of ELS could provide new insights into the pathophysiologic trajectories and the longitudinal course of PTSD, with possible implications for therapeutic interventions for stress-related disorders.Chronic stressors such as child maltreatment  and acute stressors, such as accidents and earthquakes, are qualitative different and potentially produce qualitatively and quantitatively distinct clinical symptoms and neuroendocrine alterations . Child mNumerous studies have investigated the neuroendocrine alterations in adults with PTSD. The majority of them have demonstrated increased basal levels of corticotropin-releasing hormone (CRH) in cerebrospinal fluid (CSF) ,86, decrChildren and adolescents may exhibit different physiological responses to acute or chronic stressors compared to adults . More spThere is limited evidence regarding the pathophysiology of childhood PTSD after an acute stressor. In a sample of adolescents who lived at different distances from the epicenter of 1988 earthquake in Armenia, it was demonstrated that the more symptomatic adolescents living in the city closer to the epicenter had lower mean baseline morning cortisol levels, greater Day 2 cortisol suppression following dexamethasone, and a more rapid decline in 3-methoxy-4-hydroxyphenylglycol (MHPG) levels over the course of Day 1 . InteresIn a study conducted by our research group, children and adolescents aged 7–18 who had been involved in motor vehicle accidents (MVAs) were assessed immediately after hospitalization, and 1 and 6 months later . Those wThese findings are evidence for HPA axis alterations and SNS dysregulation in pediatric PTSD. These alterations, which are suggested to play a prominent role in the pathophysiology of pediatric PTSD, may represent a neurobiological risk factor leading to further psychopathology in adult life . The impA study of children exposed to a variety of traumatic injuries demonstrated that elevated levels of urinary catecholamines and cortisol immediately following trauma exposure were positively related to acute and 6 week post-trauma PTSD symptoms . ContrarThe longitudinal course and interactions between the HPA axis and the arousal/sympathetic system were described in a study of children and adolescents involved in motor vehicle accidents ,109. In Clinical symptoms of PTSD may thus be attributed to cortisol decrease that fails to shut down the catecholarminergic response in limbic structures. It has been suggested that an exaggerated catecholamine secretion is related to excessive consolidation of traumatic memories, which in turn may lead to the development and maintenance of PTSD symptoms, such as intrusive thoughts, flashbacks, and repetitive nightmares ,68,70. BThe pattern of heightened baseline catecholamines and enhanced HPA axis feedback, which can sometimes result in lower cortisol levels in adults with PTSD than in non-PTSD individuals, may be the result of a time-dependent stress system dysregulation beginning from childhood ,109. AltNR3C1 and the glucocorticoid receptor gene promoter 1F, are subject to stress-related epigenetic regulation throughout life [Epigenetic modifications are changes, resulting from environmental factors and to some extent reversible, that can regulate functional gene expression in a potentially inter-generationally transmissible manner . A numbeout life ,117. Theout life . More prout life . One stuout life . Furtherout life . In conclusion, epigenetic alterations provoked by ELS exposure may play a central role in the long-term and transgenerational biological trajectories of pediatric PTSD, mainly through the disruption of developmental programming of stress-related structural and molecular neurobiological pathways. A large body of evidence underscores the crucial role of the stress system and its mediators in the pathophysiology of PTSD in children and adults. These chronic neurobiological alterations  are associated with metabolic, behavioral, and cardiovascular implications that may be related to increased morbidity and mortality in individuals with PTSD. Finally, ELS exposure during vulnerable periods of neurodevelopment is one of the most important factors modulating stress system activity and plays a crucial role in the risk of developing a mental disorder later in adult life. Thus, early interventions are essential for the promotion of mental and physical health of individuals suffering from conditions and disorders related to chronic stress.


Central dopamine plays a key role in sexual behavior. Recently, a Dopamine Transporter knockout (DAT KO) rat has been developed, which displays several behavioral dysfunctions that have been related to increased extracellular dopamine levels and altered dopamine turnover secondary to DAT gene silencing. This prompted us to characterize the sexual behavior of these DAT KO rats and their heterozygote (HET) and wild type (WT) counterparts in classical copulatory tests with a sexually receptive female rat and to verify if and how the acquisition of sexual experience changes along five copulatory tests in these rat lines. Extracellular dopamine and glutamic acid concentrations were also measured in the dialysate obtained by intracerebral microdialysis from the nucleus accumbens (Acb) shell of DAT KO, HET and WT rats, which underwent five copulatory tests, when put in the presence of an inaccessible sexually receptive female rat and when copulation was allowed. Markers of neurotropism , neural activation (Δ-FosB), functional (Arc and PSA-NCAM) and structural synaptic plasticity  were also measured in the ventral tegmental area (VTA), Acb (shell and core) and medial prefrontal cortex (mPFC) by Western Blot assays. The results indicate that the sexual behavior of DAT KO vs. HET and WT rats shows peculiar differences, mainly due to a more rapid acquisition of stable sexual activity levels and to higher levels of sexual motivation and activity. These differences occurred with differential changes in dopamine and glutamic acid concentrations in Acb dialysates during sexual behavior, with lower increases of dopamine and glutamic acid in DAT KO vs. WT and HET rats, and a lower expression of the markers investigated, mainly in the mPFC, in DAT KO vs. WT rats. Together these findings confirm a key role of dopamine in sexual behavior and provide evidence that the permanently high levels of dopamine triggered by DAT gene silencing cause alterations in both the frontocortical glutamatergic neurons projecting to the Acb and VTA and in the mesolimbic dopaminergic neurons, leading to specific brain regional changes in trophic support and neuroplastic processes, which may have a role in the sexual behavior differences found among the three rat genotypes. Brain dopamine is involved in both motivational and consummatory aspects of male sexual behavior. Among brain areas that mediate the sexual roles of dopamine, the most studied are hypothalamic nuclei, as the paraventricular nucleus of the hypothalamus (PVN) and the medial preoptic area, the ventral tegmental area (VTA), the nucleus accumbens (Acb) and the prefrontal cortex (PFC). While the PVN receives the synapses of the incertohypothalamic dopaminergic neurons  tone. This has been found also in high and low novelty exploration responders (bNEHR and bNELR) rat lines  has been developed by silencing the gene encoding DAT by using zinc finger nuclease technology  DAT KO, HET, and WT rats should display behavioral differences in several aspects of sexual behavior  with DAT KO rats displaying a more rapid acquisition of sexual experience  and higher levels of sexual motivation and performance than HET and WT rats, in particular, shorter latencies to mount, intromit and ejaculate, and a higher intromission ratio and ejaculatory frequency; and (ii) these differences should occur concomitantly with differences in the activity of dopamine and/or glutamic acid neurotransmission at the level of the Acb shell, in particular, a higher dopamine and/or glutamic acid activity in DAT KO rats compared to their HET and WT counterparts, and in the expression of one or more markers of neurotrophism, neural activation, functional and structural synaptic plasticity in limbic brain areas relevant for sexual behavior as the VTA, the mPFC and/or the Acb  and a significantly shorter  TCR . Together with a higher level of sexual motivation and sexual activity in DAT KO rats inferred the first by the lower ML and IL, and the second by the higher EF and IR shown in the first and following tests as well, compared to WT and HET rats, these results account for faster acquisition of the ability to sexually interact stably and efficiently with a receptive female rat, of DAT KO rats compared to HET and mainly WT rats.DAT KO, HET and WT rats showed significant differences in the first copulatory test when put together with a sexually receptive female rat. Accordingly, while 60% of WT rats engaged in sexual behavior with mounts and intromissions, 75% of HET rats and 90% of DAT KO rats did so with 90% of DAT KO and 60% of HET rats achieving ejaculation already in the first test against the 50% of the WT counterpart. The differences between DAT KO and HET rats disappeared in the second test, while those between DAT KO and HET rats and WT rats disappeared in the third test when, irrespective of the belonging rat line, all rats  engaged in sexual activity and reached ejaculation. Although the Chi-square , have different basal concentrations of extracellular dopamine in the Acb shell dialysate . This finding resembles the higher levels of extracellular dopamine found in the dialysate obtained from the dorsal striatum of DAT KO rats compared to those of HET and WT rats  similar to those found after stabilization of copulatory behavior in the forth/fifth copulatory test, among DAT KO, HET, and WT rats. Indeed, also in this experiment, HET rats showed higher MF than DAT KO and WT rats mainly in the first 30 min of copulation, and a lower EF (similar to that of WT rats) than DAT KO rats, despite a similar IF among the three rat lines. Likewise, HET and DAT KO rats (which displayed more mounts than WT rats) showed also a lower TIR [total intromission ratio = TIF/(TIM + TIF)] and a significantly shorter  total copulatory rate  compared to WT rats. As expected, HET and WT rats showed also NCPEs, with HET rats showing more NCPEs than WT rats, but surprisingly these penile erections did not occur in DAT KO rats.The above differences in the pattern of release of dopamine and glutamic acid in the Acb shell and NCPEs and copulatory parameters among DAT KO, HET and WT rats, deserve some comment. First, the higher basal levels of dopamine found in the Acb shell dialysate from DAT KO rats compared to those of HET and WT rats raise the possibility that a higher basal dopaminergic tone exists in the Acb shell of DAT KO rats and that this enhanced tone may be responsible, at least in part, for the higher sexual motivation and for the higher levels of sexual activity found in these animals compared to their HET and WT counterparts (see above). Indeed, a higher dopaminergic tone may contribute to making these animals more prone to interact with the receptive female rat, thereby facilitating the first interaction with her and, as a consequence, accounting for faster acquisition of the ability to stably sexually interact with the receptive female rat than their HET and WT counterparts. In line with the above hypothesis, we have recently reported that a different mesocorticolimbic dopaminergic tone correlates with differences in several aspects of sexual behavior, from the acquisition of sexual experience to sexual motivation and performance, in RHA and RLA rats  extracellular glutamic acid levels increase in the Acb shell dialysate during sexual behavior; (ii) this increase occurs concomitantly to an increase in extracellular dopamine and (iii) it is associated to differences in the pattern of sexual behavior in DAT KO, HET and WT rats. So far, only a few other studies provided evidence for a role of Acb glutamic acid in sexual behavior. Among these, one shows that the acquisition of sexual experience causes long-term alterations in glutamate receptor expression and function  and that changes in the NMDA (NR1 subunit) and AMPA (GluA1 and GluA2 subunits) receptors are differentially associated to experience acquisition, reward and abstinence, pointing out to a complex fine-tuning  at the synaptic level of the neuroplastic processes occurring during the acquisition of sexual experience in male rats , neuronal activation (Δ-FosB), synaptic function  and plasticity , but not to basal levels of extracellular glutamic acid (which were similar among the three rat lines), and to significant differences in extracellular dopamine and glutamic acid release during sexual activity. Indeed, although both dopamine and glutamic acid concentrations increased above basal values in WT more than in DAT KO rats during sexual activity, with dopamine concentration increased during the entire period of sexual activity in all the three rat lines, glutamic acid increased in DAT KO rats only in the last period of sexual activity, at variance from WT and HET rats, in which it increased significantly already in the first period of sexual activity. It is reasonable to assume that these differential changes in dopamine and glutamic acid outputs are involved in the differences in sexual behavior among the three rat lines, since dopamine and glutamic acid, together with the neuropeptide oxytocin, are key neurotransmitters of a complex brain circuit that interconnects hypothalamic, limbic and cortical areas involved in both the motivational and performance aspects of the male rat sexual behavior , like those due to DAT gene silencing or to chronic treatment with psychostimulants  in laboratory animals, may be useful for modeling the behavioral, neurochemical and molecular features not only of psychopathological conditions such as psychotic states and attention-deficit/hyperactivity disorders (ADHD) but also to characterize the neural substrates underlying conditions such as hypersexuality and altered sexual behavior.The datasets generated for this study are available on request to the corresponding author.The animal study and the experiments were reviewed and approved by the Ethical Committee for Animal Experimentation of the University of Cagliari.FS, AA, and MM designed the study. FS and JB designed, performed and analyzed the data from sexual behavior and microdialysis experiments. MS, MQ, and MB performed the Western Blot experiments and analyzed Western Blot data. RG, DL, and SE bred and selected DAT KO, HET and WT rats. FS, AA, MM, and MQ supervised the study. FS, AA, MM, and MQ wrote the manuscript. All authors discussed the results and commented on 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.