Conventional Buddhist texts illustrate meditation as a condition of relaxed alertness that must fend against extreme hypoarousal  and extreme hyperarousal (restlessness). Theoretical, neurophysiological, and neuroimaging investigations of meditation have highlighted the relaxing effects and hypoarousing without emphasizing the alertness-promoting effects. Here we performed a systematic review supported by an activation-likelihood estimate (ALE) meta-analysis in an effort to counterbalance the surfeit of scholarship emphasizing the hypoarousing and relaxing effects of different forms of Buddhist meditation. Specifically, the current systematic review-cum-meta-analytical review seeks to highlight more support for meditation’s wake-promoting effects by drawing from neuroimaging research during wakefulness and meditation. In this systematic review and meta-analysis of 22 fMRI studies, we aim to highlight support for Buddhist meditation’s wake-promoting or arousing effects by identifying brain regions associated with alertness during meditation. The most significant peaks were localized medial frontal gyrus (MFG) and precuneus. We failed to determine areas ostensibly common to alertness-related meditation such as the medial prefrontal cortex (mPFC), superior parietal lobule, basal ganglia, thalamus, most likely due to the relatively fewer fMRI investigations that used wakefulness-promoting meditation techniques. Also, we argue that forthcoming research on meditation, related to alertness or wakefulness, continues to adopt a multi-modal method to investigate the correlation between actual behaviors and neural networks connected to Buddhist meditation. Moreover, we recommend the implementation of fMRI paradigms on Buddhist meditation with clinically diagnosed participants to complement recent trends in psychotherapy such as mindfulness-based cognitive therapy (MBCT). Meditation can be defined as a set of mental workouts-cum-exercises that regulate cognition, the self, and emotion, where a specific directing of attention and awareness influences mental and related somatic events. The practice of meditation has gained significant attention in recent years due to its potential to regulate cognition, emotion, and the self. Derived from Buddhist traditions, meditation involves specific directing of attention and awareness toward mental and somatic events, leading to a state of mind characterized by reduced negative emotions and improved positive states of mind . ResearcThe popularity of meditation programs and practices derived from Buddhist traditions in the West has resulted in these practices being primarily deconstructed from their actual Buddhist meditational goal of “awakening”  and recoIt is observed that in some recent research, the objective of meditation work has aimed beyond relaxation and decreased arousal . Such reWhen it comes to hypoarousal-related activities, Buddhism views attentive wakefulness as a significantly deep shift in a practitioner’s insight. This shift in perception is called “awakening.” The balance between mental laxity and agitation is achieved through meditation. The act of meditation helps the practitioner to reach a relaxed state that is imbued with zeal, courageous energy, and an alert and sharp awareness in a manner that the meditator is committed to wakefulness and fended against the fetters of sleepiness and tiredness . BuddhisWhile meditation programs and practices have gained popularity in the West, their original goals from Buddhist meditation have been altered to fit contemporary needs. However, some modern-day research aims to explore beyond relaxation and decreased arousal associated with meditation practices. Future studies should aim to identify brain regions associated with the wake-promoting or arousing effects of Buddhist meditation, in addition to exploring traditional Buddhist goals, to comprehensively understand the effects of meditation on cognitive , affectiMeditation is a widely practiced technique for improving cognitive control and emotional regulation. The different types of meditation practices are often classified into two styles: Focused Attention Meditation (FAM) and Open Monitoring Meditation (OMM). FAM involves focused attention on a given object, while OMM emphasizes open monitoring of experiences . In receSamatha”  in Buddhist meditative practice. FAM also involves modulating attentional focus and noticing distractions generated by internal or external sources  involves non-reactive observation of experiences. This type of meditation is concerned with witnessing upcoming feelings, thoughts, and sensory occurrences within an open “background” of attention. In the event of shifting from an FAM to an OMM form of meditation, the item as the main attention is slowly substituted by maintaining an open presence or awareness , 2008a. Apart from FA and OM styles of meditation, LKM and CM are the other two notable types of Buddhist meditation. The practice involves unconditionally executing the sensations and concerns to oneself, other distinctive beings, or all living beings. Visualizing the mental image of the objects or intrinsic rays of light from one’s heart to others or concentrically everywhere to induce compassion and loving-kindness sensations and intentions is an essential component of LKM and CM practices . These tExpert practitioners of LKM or CM trigger limbic regions and brain systems linked with processing mental states of other individuals , especially in the right hemisphere. Highly intense forms of CM activate the right inferior parietal lobule in the medial-posterior part of the right insula, dorsal ACC, and the somatosensory cortices . SimilarFurthermore, bilateral activation in the dorsal medial prefrontal cortex and the rostral anterior cingulate cortex was noticed in Vipassana experts compared to beginners . The actDuring breath-focused meditation (a form of FA style of meditation) , it is oIn other meditation studies, researchers examined Theravada Buddhist monks, who were experienced in both Vipassana (OM/LKM/CM) and Samatha (FA) meditations and noticed that Samatha induces a series of increased activations in the right medial anterior prefrontal cortex and the right and left anterior cingulate cortex while witnessing deactivations in the left hemisphere . In contWith reference to well-established approaches to the study of attention, attention can be divided into conflict monitoring or executive attention, alerting, and orienting attention . AlertinIn this study, we discuss the phenomenon of alerting, which refers to achieving and sustaining a state of mental readiness that is highly responsive to incoming stimuli. Alerting can be categorized into two types: phasic alertness, which involves enhancing reaction following a warning signal or cue, and tonic alertness, also known as vigilant attention or intrinsic alertness , which rIn the field of meditation, it is mainly observed that the deliberate training of attention (either in an open and receptive or focused and directed way) is an essential part of any meditation. This systematic review underlines open monitoring (OM) and focused attention (FA), the two common forms of attentional training that are paramount in Buddhist and many non-Buddhist meditational practices .Tonic alertness  is a broLikewise, tonic alertness has been expressed in terms of improved vigilance or sustained attention  but not Our study presents an activation-likelihood estimate (ALE) meta-analysis of functional neuroimaging studies on alertness-related meditation. Our study aims to integrate prior fMRI works on meditation that induce arousal or wakefulness effect, yielding insight into the brain networks that are most commonly associated with alertness-related meditation techniques. To identify studies for the meta-analysis, we included 22 fMRI studies that analyzed activation foci reflecting arousal, wakefulness, or alertness-related activation. We analyzed the operationalization of meditation techniques and experimental paradigms employed by these studies, allowing us to identify disparities within the brain networks associated with various aspects of alertness-related meditation.PUBMED database was searched for functional imaging studies focusing on effects of Buddhist Meditation (BM) and Buddhist-derived Meditation Techniques (BdMT) on brain regions underlying tonic alertness or relaxation. As of October 2, 2021, the search terms were the following:  +  + );  +  + );  +  + );  +  + ) and  + ). Searches were without limit on publication date and language. Also, the Boolean operators “OR,” and + was used to make the search more precise and accurate. Using of ‘AND’ was avoided because the search engine use this particular Boolean operator by default. The asterisk ‘*’ was used as a wildcard character to search for all words that contain the letters entered. For example, neuro* would find “neuroimaging” or “neurology” or “neuropathy.” A total of 685 exclusive fMRI studies were acknowledged see .The following are the inclusion-exclusion criteria for the systematic review-cum-meta-analyses:(1)Articles that cited relaxation, arousal, tonic alertness, alertness, Buddhism, neuroimaging, mindfulness, and fMRI within the keywords, abstract, and title were considered and articles that did were rejected. At this screening stage, 202 of the 685 articles met the criterion.(2)Research articles that employed fMRI were considered, whereas the work that utilized other techniques  was rejected. Additionally, references of screened articles were carefully searched to identify more studies dealing with the brain systems responsible for arousal in Buddhist meditation practices. Further, the inclusion criteria held clinical sound adults and experiments where participants performed BM/BdMT during the fMRI procedure. Amidst a total of 202 studies, only 33 papers met this criterion.(3)N = 6), and anatomical studies showing structural changes (N = 7) were removed. This exercise ensured that the chosen neuro-imaging contrasts were as similar as possible . However, when this homogeneity was not feasible, other comparisons were considered in the selecting articles (like meditation vs. control task). Following the above-stated criteria, data from a total of 22 papers  on brain regions underlying tonic alertness or relaxation. Any discrepancies between the two reviewers were resolved through discussion or with a third reviewer.After removing duplicates, the titles and abstracts of the remaining studies were screened for eligibility based on predetermined inclusion and exclusion criteria. Full texts of potentially relevant studies were then assessed for eligibility.Data extraction was performed independently by two reviewers using a standardized data extraction form. Extracted data included study characteristics , participant characteristics , intervention details , outcome measures , and results .Any disagreements in data extraction were resolved through discussion or by consulting the third reviewer. If necessary, we contacted authors for additional information or data.The risk of bias assessment for the included studies was conducted using the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials . The fol(1)Random sequence generation: Was the allocation sequence adequately generated?(2)Allocation concealment: Was allocation adequately concealed?(3)Blinding of participants and personnel: Were participants and personnel blinded to the intervention?(4)Blinding of outcome assessment: Were outcome assessors blinded to the intervention?(5)Incomplete outcome data: Were incomplete outcome data adequately addressed?(6)Selective reporting: Was the study free of selective outcome reporting?(7)Other sources of bias: Were there other potential sources of bias, such as funding or conflicts of interest?The risk of bias assessment see  was perf1 The current systematic review-cum-meta-analyses included data from 1,139 participants and 302 activation foci.Over-all, 40 experiments, where all voxels that explicitly reflected significant arousal-related brain activity, were assessed. All the coordinate spaces  were made uniform by transforming coordinates reported in Talairach coordinates into the MNI space using the mni2tal algorithm  and vicex, y, and z coordinates in the MNI space. The meta-analysis was performed using the most recent version  at p < 0.05 and used a 0 mm3 volume to define a cluster. The ALE thresholded maps values were laid on a canonical T1-weighted structural scan make use of Mango, a multi-image analysis viewer.3 The ALE meta-analysis also provided other outputs, such as information of location, anatomical labels, and cluster size, among others.A Statistical plot was developed using lists of  version , 2012 of results . An adva results . Here, t results , 2012. T results , 2012. T results , 2012 usp < 0.05, when we used the uniformed MNI space as the input coordinates. But interestingly, we did find significant ALE activation when we inserted the uniformed Talairach space  at pace see . Furtherstem see .Our ALE analysis displayed invariant activation within the medial frontal gyrus (MFG) in the right hemisphere  was again only observed with uncorrected The current study seeks to come up with meta-analytical evidence of wake-promoting or arousal effects in Buddhist meditation by rendering from the recent neuroimaging works. In the Buddhist forms of meditation, mindfulness is one of the primary aspects of the technique, exercised by means of executive attention focused on the mind (thought), body, and speech (breathing). An analysis of the neuroimaging studies related to Buddhist meditation practices has been a complex and challenging work due to the following reasons: data collected from various studies comes from multiple forms of meditation (our study reports data collected from more than three types of Buddhist meditation); huge deviation in meditational experiences among different groups of practitioners, varying from a few weeks for novice participants going through MBSR training or comparable programs to hundreds and thousands of hours for adept practitioners and monks; examining various stages of Buddhist meditation .These disparities make it difficult to analyze and interpret the results in a consistent manner, which likely may lead to incorrect conclusions . Our sysWakefulness and sleep tendency are linked to distinctive brain regions, which are also noticed to get activated during different meditation practices - both during tasks/at rest (in a trait-related manner) and during meditation (in a state-related manner). In general, reduced alertness and the shift in the wakeful state to the sleeping state are linked to receding activity in most brain regions, mainly frontal regions, whereas the observed increase in activity in the default mode network (DMN) . Tonic aOur systematic review-cum-meta-analyses show a string of activation clusters, located in two regions: right MFG, and left precuneus. Activation of MFG is considered to be engaged in both social cognition  and perfActivation of MFG is accompanied by dorsolateral prefrontal cortex , anterior prefrontal cortex (BA 10), and dorsal anterior cingulate cortex . En masse, these front part areas are correlated with a broad spectrum of multifarious processes, which comprises language , executiThe second activation cluster observed in our ALE analysis predominantly involves the left precuneus along with the engagement of the dorsal posterior cingulate cortex . Both precuneus and PCC are a part of the default mode network (DMN), along with the medial prefrontal cortex (mPFC) and inferior parietal lobule (IPL). And it has been demonstrated that DMN constitutes the neural basis of self-referential processing (for example mind-wandering) , and thep-value activated medial frontal gyrus and precuneus. The uncorrected p-value gives two additional clusters comprising left insula, and right IPL  and uncorrected  IPL see . The lef IPL see . Another IPL see . Thus, iAdditionally, the right IPL has been shown to be involved in attentional control and cognitive flexibility, and some studies have suggested that meditation may enhance these abilities . Thus, iIn the neuroscience of meditation, Insula is observed to be a significant brain area. Invariably, it is noticed to sustain interoceptive awareness such as bodily internal and visceral states alongside meta-cognitive awareness . Apart fTherefore, the involvement of the left insula and right IPL in Buddhist meditation likely reflects the enhanced interoception, self-awareness, self-other processing, decentering abilities, attentional control, and cognitive flexibility that are often associated with meditation practice.The findings on the involvement of the medial frontal gyrus (MFG), precuneus, insula, and inferior parietal lobule (IPL) in Buddhist meditation have implications for clinical practice. These brain regions are involved in various cognitive processes, including attention, emotional regulation, and self-awareness, which are relevant to many clinical disorders. For example, studies have suggested that dysregulation of the MFG and precuneus is associated with symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) . The invThe increased activation of the MGF and precuneus during meditation has been associated with improvements in attention, emotional regulation, and self-awareness, which are important factors in the treatment of various psychiatric disorders such as anxiety, depression, and addiction. The insula and IPL, on the other hand, have been linked to interoception and empathy, which are critical for the treatment of somatic disorders and certain personality disorders. Furthermore, recent studies have also shown that mindfulness-based interventions, which involve the cultivation of attention and awareness through Buddhist meditation practices, can be effective in reducing symptoms of various psychiatric disorders and improving overall well-being . TherefoThe present study aimed to provide a systematic review and meta-analysis of neuroimaging studies that investigate the arousing effects of Buddhist meditation practices. However, the analysis of these studies has been complicated by several methodological concerns, including the use of various forms of meditation, differences in participants’ meditational experiences, and the examination of different stages of meditation. Therefore, the results should be interpreted with caution due to the inconsistency of methods used across the studies. Additionally, the sample size of the included studies was limited, which may affect the generalizability of the findings. Furthermore, the studies employed different measures to assess wake-promoting or arousal effects, which may limit the conclusions that can be drawn from the results. Moreover, the heterogeneity in participant characteristics, including age, gender, ethnicity, and cultural background, may have influenced the results and restricted the generalizability of the findings. One limitation of Activation Likelihood Estimation (ALE) in our meta-analysis is that it relies on reported coordinates from neuroimaging studies, which can introduce publication bias. Studies with statistically significant results are more likely to be published, leading to an overrepresentation of significant findings in the meta-analysis. This bias can affect the accuracy of the ALE results and may not fully represent the entire body of research on the given topic. Additionally, some of the included studies did not have control groups, which may limit the interpretation of the results. Thus, the current study’s findings should be interpreted cautiously, and future research should address these limitations to provide more robust evidence of the effects of Buddhist meditation practices on brain function.post hoc analyses of different subsets of meditation to tell apart the cortical activation linked with the different forms of meditation. Furthermore, we consider that future research will be able to link neural data to objective behavior by evaluating clinical data, which in turn may help the scientific community to further appreciate the mental health benefits of meditational practice focusing on alertness and wakefulness.We performed the foremost meta-analysis on neuroimaging data related to arousing or wake-promoting effects in Buddhist meditation and determined five distinctive brain areas that were correlated to alertness or wakefulness during meditation. They were localized in the frontal and subcortical brain areas. Further, somewhat to our surprise, our ALE analysis failed to find evidence indicating the contribution of brain regions such as mPFC, superior parietal lobule, basal ganglia, and thalamus, which previous studies have suggested crucial to alertness-related Buddhist meditation . This coThe original contributions presented in this study are included in this article/All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Background: Food environments are crucial spaces within the food system for understanding and addressing many of the shared drivers of malnutrition. In recent years, food environment research has grown rapidly, however, definitions, measures, and methods remain highly inconsistent, leading to a body of literature that is notably heterogeneous and poorly understood, particularly within regions of the Asia-Pacific. Aim: This scoping review aims to synthesize the nature, extent, and range of published literature surrounding the role of the food environment on influencing dietary behaviour and nutrition in Southeast Asia. Methods: A systematic search of 5 databases was conducted following PRISMA guidelines for scoping reviews. Eligible studies included peer-reviewed research with adult participants living in Southeast Asia that examined the food environment as a determinant of dietary behaviour or nutrition. Results: A total of 45 articles were included. Overall, studies indicated that dietary behaviours in Southeast Asia were primarily driven by social, cultural, and economic factors rather than physical  features of food environments. Food price and affordability were most consistently identified as key barriers to achieving healthy diets. Conclusion: This work contributes to the establishment of more robust conceptualizations of food environments within diverse settings which may aid future policymakers and researchers identify and address the barriers or obstacles impacting nutrition and food security in their communities. Further research is needed to strengthen this knowledge, particularly research that explicitly explores the macro-level mechanisms and pathways that influence diet and nutrition outcomes. Malnutrition in all of its forms is the leading cause of poor health globally . The coeFood environments are considered crucial spaces within the food system for understanding and addressing many of the shared drivers of malnutrition . DefinedIn response to this rapidly growing field of research, efforts have been made to synthesize food environment research from different settings to better capture the state of science within distinct contexts. While several review articles have been recently published exploring food environment research in Latin America and Africa, authors have recognized a notable gap in knowledge synthesis in regions of the Asia-Pacific . Indeed,In Southeast Asia, some progress has been made towards achieving global nutrition targets, however, recent data suggest that the prevalence of undernourishment has been stagnant since 2015 while the prevalence of overweight and obesity have been steadily increasing . HoweverScoping reviews are particularly useful for synthesizing diverse and emergent bodies of evidence which are harder to capture with more structured review formats such as a systematic review . Food enWe use the conceptual food environment framework developed by We conducted a systematic search using PubMed, PsycINFO, CABI Global Health, Web of Science Core Collection, and CINAHL. The search included all relevant articles published in English up to December 31, 2020. A research librarian was consulted during the protocol phase of this review and informed the selection of databases and search terms. The search string combined groups of keywords for three main components: geographic location; food environment dimensions; and dietary behaviours/nutrition. Published, peer-reviewed research of any design  were included if they examined at least one dimension of the food environment (e.g. food availability) as a determinant of dietary behaviour or nutrition among adult (≥ 18 years) populations living in Southeast Asia. Southeast Asia refers to the following 11 countries: Indonesia, Malaysia, Philippines, Timor-Leste (East Timor), Cambodia, Laos, Myanmar (Burma), Thailand, Vietnam, Singapore, and Brunei. Food environment dimensions were defined based on the All citations were downloaded to DistillerSR (Evidence Partners) for eligibility screening and duplicate detection. Following deduplication, all articles underwent title and abstract (level one) screening by two independent reviewers (J.G. and A.A.) using an eligibility form developed for this review. Articles that passed level one screening proceeded to full text (level two) screening using a more detailed version of the eligibility form, again by the two independent reviewers (J.G. and A.A.). The reviewers met regularly throughout the screening process to resolve conflicts. The Kappa statistics for level one and level two screening were 0.72 (moderate agreement) and 0.81 (strong agreement), respectively .Data were extracted by the primary reviewer (J.G.) in DistillerSR using a charting form designed for this project. Extracted study characteristics included the year of publication, study location by country and community (if applicable), study design, food environment dimensions assessed, outcome variable(s) description, and primary findings reported. Data were imported into Microsoft Excel for analysis and quality assessment. The latest version of the Mixed Methods Appraisal Tool (MMAT) was used for quality assessment . ResultsDue to the multiple methodologies employed by studies, full-text articles were imported into NVivo 12 for thematic analysis . The useThe electronic database search yielded 3998 records after duplicates were removed, of which 267 were eligible for full-text screening . One addOne-third (n = 15) of the articles included only women participants, with an additional two mixed-methods studies having research components that focused only on women. The remaining 28 articles included both men and women. Urban populations were the most frequently studied, with 16 articles focusing solely on urban environments and nine articles comparing urban and rural communities. Nine articles reported on research that included rural Indigenous communities within four different countries.Various study designs and methods were utilized across the included articles, as described in Approximately 16% of articles (n = 7) exclusively used qualitative methods. Interviews (n = 5) and focus group discussions (n = 3) were the most prominent data collection tools; however, one paper also incorporated an ethnographic component into its design. Fourteen articles featured mixed-method designs and used similar methodologies to those mentioned above, including interviews (n = 12), market-based measures (n = 6), focus groups (n = 7), surveys (n = 10), and/or spatial measures (n = 4).All food environment dimensions, as defined by Eighteen articles directly mentioned the ‘food environment’ as a concept used to frame their research, whereas the other twenty-eight articles only defined the specific food environment dimensions measured but did not explicitly reference the food environment in their work. Of the eighteen papers that used a food environment framework, nearly half (n = 8) focused on the retail food environment, evaluating the geographic distribution and characteristics of various retailing outlets or products in relation to consumer behaviour and/or nutritional outcomes . Four arAmongst the included articles, a wide range of outcome variables were examined, with definitions, indicators, and measurement tools not being used uniformly across studies  and did not analyse or discuss factors related to undernutrition. Indeed, most articles in this review focused on outcomes of either overnutrition or undernutrition in isolation. The DBM was discussed in only two articles when looking at national trends in underweight and overweight/obesity prevalence. No articles examined DBM outcomes at the community, household, or individual level.Availability was assessed in all but 5 of the included articles. Multiple sources (n = 6) remarked on the steady annual increase in overall food availability in Southeast Asia . Three oPerceived availability of healthy food varied between populations. For example, urban residents in Yogyakarta, Indonesia, reported healthy foods were readily available . MeanwhiThe impact of food prices on diet and nutrition was studied in 18 articles. Time-series data from Vietnam showed that food prices have substantially increased since 1996, with nutrient-rich, diverse diets becoming increasingly expensive, especially when compared to the price of NNDFs . Focus gWertheim-Heck and colleagues observed significant differences in the price of vegetables between traditional markets (wet markets or street markets) and supermarkets in Vietnam, with the latter being 35% more expensive . SimilarResearchers often classified vendor and product properties as either ‘modern’ or ‘traditional’. ‘Modern’ was used to characterize national or transnational retailing structures such as supermarkets, convenience stores, and NNDFs, whereas ‘traditional’ referred to long-established retail structures such as wet or open-air markets, mobile vendors, and locally produced, minimally processed food. Several articles (n = 3) used modern retailers as a proxy for food safety due to having greater regulation, advanced infrastructure, and higher hygiene standards , 2019. FVendor and product properties influenced purchasing patterns by catering to different consumer needs. Consumers primarily used modern retailers to purchase packaged and processed foods, while traditional markets were the primary source of fresh and staple foods . ResultsThe least studied food environment dimension was marketing and regulation (n = 11). Six articles examined the influence of national policies on consumer shopping trends and/or nutrition outcomes . For exaRegulations at the vendor level were explored in one mixed-method study in the context of safe vegetable provisioning in Hanoi, Vietnam. Wertheim-Heck and colleagues found that less than 3.8% of vegetables sold at traditional markets provided any sort of food safety claim, such as product labelling or food safety certification, however, despite this, over 95% of total vegetables consumed by the study population were sold at traditional markets .Numerous articles (n = 35) explored the variable effects of food accessibility on dietary behaviours and nutrition. Several articles (n = 5) reported non-significant relationships between geographic proximity to food vendors and dietary outcomes, including measures of dietary diversity and food shopping patterns, across a range of populations , 2019. HAccessibility of natural food environments, including wild and cultivated food sources, was studied in four articles and found to positively impact nutrition and diet . For insTwenty-five articles looked at the impact of affordability on dietary behaviour and nutrition. Several qualitative articles (n = 5) reported affordability and lack of purchasing power were major barriers to achieving healthy and adequate diets . SimilarPerceived affordability varied by food item. Vegetables were widely regarded as inexpensive, particularly when sold by traditional vendors , whereasConvenience, related to vendor properties (e.g. opening hours), product properties (e.g. ready-to-eat), and accessibility (e.g. market location), was examined in 13 articles. Women described a lack of time and busy work schedules as reasons for eating out or purchasing ready-to-eat meals in Singapore  and IndoDesirability, as defined in the Social influences were highlighted predominantly within qualitative and mixed-method studies . Living Social networks were also seen to impact dietary practices. Evidence from both Thailand and Vietnam indicated that consumers viewed food shopping as a valuable social activity . These sCultural factors, including religion, traditional foods and customs, and ethnicity, were also important determinants of dietary behaviour. Two articles from Malaysia reported that religion was ranked as the most important factor in food selection, above other factors including price, food safety, and health . AdditioFood preferences were another common driver of dietary behaviours. Women reported family food preferences, particularly children's food preferences, strongly influenced food purchasing decisions . In SingSix articles identified links between nutrition knowledge and dietary outcomes. For example, in Malaysia, cross-sectional evidence reported positive correlations between nutrition knowledge and diet quality , and levEach of the eight dimensions of the food environment, while distinct, are intrinsically interconnected. We identified multiple connections between the various dimensions, as depicted in This review aimed to explore and synthesize literature pertaining to the role of the food environment in determining dietary behaviour and nutrition in Southeast Asia. We identified 45 articles from 39 studies that investigated the effect of food environments on dietary behaviour and nutrition in eight Southeast Asian countries. These studies used various study designs and assessment methods to investigate food environment dimensions and outcome measures. Studies most commonly used quantitative design methodologies, followed by mixed-method approaches and then qualitative designs. The majority of articles reported on outcomes related to food acquisition and consumption patterns, while only five articles examined nutritional health outcomes. This is consistent with other reviews of food environment literature which have found an emphasis on quantitative research designs, in addition to a lack of evidence related to nutritional health outcomes .Overall, we found a paucity of evidence clearly articulating the conceptualization of food environments in this region. Of the studies that explicitly used a food environment framework, most did not define or explain how these concepts were being applied. Further, while urban and retail food environments featured prominently, workplace food environments and natural food environments were given little attention. All eight dimensions of the food environment were assessed by various studies, with the internal domain featuring most prominently. This differs from the results of a scoping review published in 2019, which found the external domain to be the primary focus of food environment research within LMICs . These oAvailability and accessibility were the two most frequently assessed dimensions of the food environment amongst included articles but were shown to have variable effects on dietary behaviour and nutrition. Their prominence in the literature may reflect the influence of the food environment discourse taking place in high-income country settings, which often focuses on quantifying characteristics related to food availability and accessibility . It is wActions targeting food environments as a way to improve diets and nutrition must be informed by the specific needs and characteristics of the target population. Notably, we found considerable research documenting the retention of traditional diets and consumption patterns across the region. Practices related to traditional food cultures, such as shopping at fresh or wet markets, were observed to hold high social value and were a means of cultivating community and cultural solidarity . PolicymThrough our analysis, we identified that the influence of social, cultural, and economic factors on dietary behaviours were more strongly emphasized in the literature rather than physical  factors, which are common in western contexts. Food price and affordability were regularly considered key barriersto achieving healthy diets. Studies reported significant associations between household income and diet quality , food seWe identified several gaps in the literature that highlight areas for additional research and attention. Echoing the sentiments of numerous other reviews , the incThis review was subject to several limitations. First, we were restricted to articles available in English which may have excluded relevant research published in other languages. Second, due to the nature of food environment literature, there was substantial heterogeneity within study characteristics and design. The range of study populations, indicators, measurement tools, and study designs limits our ability to integrate and compare research findings. Third, this review does not cover literature published after December 2020 and does not capture any emerging research on the impacts of the COVID-19 pandemic. Due to the profound and ongoing disruptions resulting from the pandemic, food environments, diets, and nutrition outcomes described in this review may not be reflective of the current circumstances in Southeast Asia.Findings from this review reaffirm the highly contextual nature of dietary behaviours, which depend on complex interconnected personal and external factors. We found that while all dimensions of the food environment have been studied in Southeast Asia, there is a need to better integrate the external and internal domains to explore specific mechanisms and pathways that influence diet and nutrition outcomes. In recent years, there has been a notable rise in publications examining food environments, signalling growing recognition of their importance and role in mediating diets and nutrition. It is widely recognized that substantial, sustainable progress in combatting malnutrition requires long-term, system-wide change. Establishing a robust conceptualization of the food environment would ensure policymakers, researchers, and programme developers are able to identify and address the barriers or obstacles that impact nutrition and food security in their communities.Click here for additional data file.Supplemental material, sj-docx-1-nah-10.1177_02601060221112810 for The influence of food environments on dietary behaviour and nutrition in Southeast Asia: A systematic scoping review by Josephine Gaupholm, Andrew Papadopoulos, Aiza Asif, Warren Dodd and Matthew Little in Nutrition and Health


Background: MYB proto-oncogene is verified as a transcription factor. Although emerging evidence showed that MYB plays a critical part in tumor progression and immunity, a systematic pan-cancer analysis of MYB still remains to be performed for determining whether MYB could serve as a biomarker for cancer screening, prognosis prediction and accurate therapy design in various human cancers.Methods: In the present study, we performed qRT-PCR, wound healing assay and transwell assay to validate the expression level and biological function of MYB in bladder cancer. Then, we utilized several open-source databases including UCSC Xena database, TCGA, GTEx, etc. Online tools was used to process the raw data from UCSC Xena database.Results: We found that the expression level of MYB is significantly higher in bladder cancer cell lines than urothelial cells. Further experiments confirmed that overexpression of MYB enhanced the ability of migration in bladder cancer. Next, we found that the expression level of MYB is significantly higher in most cancers. Meanwhile, MYB expression was positively or negatively related with the prognosis in different cancer types. In addition, MYB expression is significantly related to immune score and immune cells in most cancer types. Moreover, MYB act as an immunotherapy biomarker superior to several traditional immunotherapy biomarkers. Finally, deep deletion was the most frequent genetic alteration of MYB.Conclusion: MYB may serve as a powerful biomarker for tumor screening, prognostic, individualized treatment strategy in a broad range of malignancies. Cancer remains the dominant cause of morbidity and mortality globally and lead to huge burden for public health and economics. In the United States, it is estimated that there would be 1,918,030 cancer cases newly diagnosed in 2022, which means approximately 5250 new cases would be identified each day . HoweverPEX cells, a cluster of cells identified from the precursors of exhausted T cells via single-cell RNA sequencing. These cells have superior self-renewal, multipotency and long-term proliferative capacity but loss of MYB impairs the differentiation of these cells and finally destroy the complete CD8+ T-cell response. Moreover, MYB accounts for the functional exhaustion of CD8+ T cells during chronic infection. Thus, MYB related two key properties of exhausted CD8+ T cells: no function and longevity.Tumor cells and tumor immune microenvironment (TIME) are closely related and affect each other. Tumor cells gradually escape from immune surveillance by shaping an immunosuppressive TIME in its progression and an immunosuppressive TIME promotes tumor growth by various mechanisms including the depletion of tumor-infiltrating T cells, the inhibitory role of immune checkpoint genes such as VISTA, TIM-3 and LAG-3 and inhibitory immune cells like Tregs, TAMs and MDSCs . Therefoin vivo involving SP70/HSC70 chaperone pathway. It is reported that momentary exposure with mebendazole is enough to inhibit the colony formation ability of AML cells, and further study confirmed mebendazole availability for impairing AML progression in mouse xenotransplantation experiments. Meanwhile, this exposure did not impair normal cord blood-derived cells, indicating that MYB represents a safe and novel therapeutic approach for AML  . We firsTo identify the potential role of MYB in tumor progression and immunity, we explored the expression of MYB in different molecular subtypes and immune subtypes in human cancers. The results proved that MYB expression showed significant difference among several immune subtypes and molecular subtypes in most cancers, which could demonstrate that MYB is a valuable pan-cancer diagnostic biomarker and involved in the tumor immune environment regulation. In order to further identify the association between MYB and tumor immune environment, we calculated the immune infiltration score and explored the immune cell infiltration. According to our analysis, in a series of cancer types the expression level of MYB is significantly related to immune score and in approximately a half of these cancer types the MYB expression is positively related to immune score. This result suggests that MYB is correlated to tumor immune microenvironment in human cancers. Next, we analyzed the exact immune cell infiltration in tumor immune microenvironment and found that MYB expression had a strong correlation with B cell, CD4 T cell, neutrophil and DC in most cancer types. Tumor-infiltrating B cell mediates antitumor immunity via promoting maturation of tumor-associated tertiary lymphoid structures, while B cells and mature tertiary lymphoid structures is an important predictor of immunotherapy response . CD4 T cGene alteration analyze of MYB was also conducted in our study. As a result, deep deletion was the most frequent alteration type of MYB, followed by mutation and amplification. Subsequently, the copy-number alterations of MYB were analyzed. Amplification was the most common type of copy-number alterations in MYB, followed by gene gain, diploid, shallow deletion and deep deletion. Copy-number alterations are a vital component of genetic diversity and may contribute to rapid adaptive development and progression of human heritable and somatic diseases such as cancer .Although we have comprehensively exhibited the prognostic and immunological roles of MYB in pan-cancer, we have to admit that some limitations still remain in our study. First, we only analyzed open-source data and we are unable to include all the data published, so the publication bias and selection bias are unavoidable. Second, there is heterogeneity between diverse databases and some contradictory results needed further affirmation. Third, we failed to confirm the role of MYB in most human tumors through experiments.We confirmed that the expression level of MYB is significantly higher in bladder cancer cell lines than in urothelial cells through qRT-PCR. Further experiments validated that overexpression of MYB enhanced the ability of migration in bladder cancer via wound healing assay and transwell assay. Based on our pan-cancer analysis of MYB, we found that MYB was differentially expressed between tumors and normal tissues, and there was a connection between MYB expression and prognosis. We conclude that MYB may serve as a powerful biomarker for tumor screening, prognostic, individualized treatment strategy in a broad range of malignancies. Moreover, MYB expression is related to the tumor microenvironment and immune cell infiltration in different cancer types. Different types of tumors respond differently to its effects on tumor immunity. In the future, more precise and personalized immunotherapy may be achieved by elucidating the role of MYB in tumor development.Click here for additional data file.Click here for additional data file.


Mycobacteria tuberculosis (M.tb), however surrogate models involving other mycobacteria, M.tb Purified Protein Derivative or genetically modified forms of M.tb either exist or are under development. These utilise varying routes of administration, including via aerosol, per bronchoscope or intradermal injection, each with their own advantages and disadvantages. Intranasal CHIMs with SARS-CoV-2 were developed against the backdrop of the evolving Covid-19 pandemic and are currently being utilised to both assess viral kinetics, interrogate the local and systemic immunological responses post exposure, and identify immune correlates of protection. In future it is hoped they can be used to assess new treatments and vaccines. The changing face of the pandemic, including the emergence of new virus variants and increasing levels of vaccination and natural immunity within populations, has provided a unique and complex environment within which to develop a SARS-CoV-2 CHIM. This article will discuss current progress and potential future developments in CHIMs for these two globally significant pathogens.Controlled Human Infection Models (CHIMs) involve deliberately exposing healthy human volunteers to a known pathogen, to allow the detailed study of disease processes and evaluate methods of treatment and prevention, including next generation vaccines. CHIMs are in development for both tuberculosis (TB) and Covid-19, but challenges remain in their ongoing optimisation and refinement. It would be unethical to deliberately infect humans with virulent  With the implementation of modern ethical frameworks and considered study design (Controlled human infection models (CHIMs) involve the deliberate inoculation of volunteers with a pathogen under carefully controlled conditions, facilitating detailed study of host-pathogen immunobiology. Validated models can then be used to expedite the development of novel vaccines and therapeutics by allowing efficacy testing in small scale clinical trials, prior to field efficacy studies. Dating back to Edward Jenner’s 18y design Figure 1y design .Tuberculosis (TB) remains a major global health issue, second only to COVID-19 as the leading cause of death from a single infectious pathogen . The COVThe only licenced vaccine against TB, Bacillus-Calmette Guérin (BCG), provides good protection against severe forms of infant TB, but highly variable efficacy against pulmonary TB and therefore limited impact on disease transmission. Ongoing challenges also exist in the accurate diagnosis of both TB infection and active disease, increasing drug resistance and treatment burden even for fully sensitive disease . DespiteMycobacterium tuberculosis (M.tb) would not be ethical, with the potential for significant morbidity and mortality. Even if these are avoided, long treatment duration with the risk of significant drug side effects, risk of M.tb transmission to others, inability to prove cure at the end of treatment and possibility of disease recurrence are all substantial arguments against a CHIM with wild-type M.tb. Therefore, researchers must pursue the use of alternative challenge agents , where tuberculin Purified Protein Derivative (PPD) is injected intradermally, has traditionally been used as a diagnostic test for latent TB infection (LTBI). It has been employed as a challenge agent to investigate immunological responses to mycobacterial antigens at the site of skin challenge, for example identifying exaggerated Th17 responses in those with active TB disease as a potential target for host directed therapies , 13, 24.via passage from Mycobacterium bovis (M. Bovis), that does not cause disease or latency in healthy humans  BCG as a mycobacterial challenge agent have been developed and are able to detect a known BCG vaccine effect in animals and humans , 27–29. M.tb infection. BCG delivered via aerosol  or instilled directly into the lungs per bronchoscope  acknowledged the potential benefits of a SARS-CoV-2 CHIM, for example to allow rapid prioritisation of vaccine candidates. A working group was promptly established to consider the practicalities, feasibility and ethics . InitialAccruing data suggested that infection of young, healthy adults in whom disease was generally much milder could be justifiable. This prompted UK manufacture of a challenge virus under GMP conditions and development and rigorous ethical review of study protocols for both a UK SARS-CoV-2 naïve CHIM (NCT04865237) and one in previously infected volunteers (NCT04864548) . GMP manDespite the widespread availability of highly effective vaccines against SARS-CoV-2, there remains a justifiable role for SARS CoV-2 CHIMs. A clear advantage of a CHIM over natural infection field studies is the known-timepoint of infection; allowing the detailed characterisation of both viral kinetics and the host immune response post-exposure. The dose of virus can also be carefully controlled and adjusted, providing crucial information about how the infectious dose affects the clinical and immunological response to the virus. Importantly, CHIMs also allow the collection of pre-exposure samples. These baseline samples can be assessed against clinical outcomes to identify immune correlates of protection (CoP).Whilst current literature clearly defines the role of neutralising antibodies (nABs) as a correlate for sterilising immunity against SARS-CoV-2 –46, emerFurthermore, the ability to control confounders such as inoculum strain, route of exposure, viral load and patient heterogeneity in a CHIM allows direct comparison of vaccine and therapeutic candidates as well as dosing regimens. With the roll-out of successful vaccines, it is unfeasible and unethical to maintain an unvaccinated placebo group for the testing of new vaccine candidates. Non-inferiority trials require large sample sizes and sufficient naturally acquired infection which can be time consuming and expensive. A CHIM could be of particular use in assessing novel vaccines, including those developed to be mucosally-delivered, which may have differing end-points  that would be extremely difficult to study without a defined timepoint of infection. Whilst field studies are considered gold standard for vaccine licensure, there are instances where CHIMs have been used directly as proof of efficacy .To date there are three registered SARS-CoV-2 CHIMs  offers strong resistance to homologous re-infection , 58. AchMuch of knowledge of re-infection rates was obtained prior to the emergence of variants such as Delta and subsequently Omicron, which are known to escape immunity. Both variants have antigenic divergence due to mutations in the spike protein and have been shown to demonstrate reduced neutralisation titres compared to pre-Alpha strains in vaccinated and hybrid cohorts –62. One There are pros and cons to the use of Delta or Omicron in a CHIM. Neutralisation against the Omicron variant is more markedly reduced than delta and associated with a higher rate of breakthrough infections , 61, 64 Studies using currently prevalent variants are arguably more relevant both for the development pipeline of vaccines and therapeutics and understanding CoP. Limitations to this approach are that manufacturing a new challenge strain under GMP conditions takes at least 6 months . FurtherTuberculosis and Covid-19 represent two deadly, but distinct, respiratory diseases. Whilst highly efficacious vaccines against Covid-19 were developed at unprecedented speed against the backdrop of the evolving pandemic, progress in improving on the limited overall efficacy of the BCG vaccine against TB has been much slower. All possible research approaches that can be utilised to expedite progress should be harnessed to improve this situation. We must also remain vigilant against the potential for further SARS-CoV-2 mutations and need to have methods available to be able to rapidly assess new vaccines and therapeutics.M.tb and SARS-CoV-2 represent an important knowledge gap for both pathogens. The ability to abort infection at its point of entry could prevent LTBI and provide epidemic control by blocking onward transmission of SARS-CoV-2. These initial mucosal responses can only really be studied in an experimental setting with a known timepoint of infection.CHIMs may prove to be useful tools in our armoury against both of these pandemic pathogens, despite their unique situations and challenges. There are no validated CoP in TB and use of CHIMs to interrogate human immunological responses following a defined timepoint infection could increase our understanding in this area. Whilst validated CoP, for example in the form of nABs, do exist for Covid-19, these are clearly not the only factor contributing to immunity, particularly against initial infection and transmissibility. The early host mucosal immune response to M.tb is unethical and therefore any deployable TB CHIM will only provide partial information about the true protective efficacy of a tested vaccine or therapeutic against M.tb. Progress is underway to identify surrogate agents which could be utilised and, given the differing advantages and disadvantages of various agents and routes of challenge  on minimally invasive samples from the oral or nasal mucosa for SARS-CoV-2. The sampling and quantification of mycobacteria, particularly from the respiratory tract, for a TB CHIM remains much less straightforward, for example due to the fastidious and slow growing nature of mycobacteria and colonisation of the respiratory tract with organisms including non-tuberculous mycobacteria. One potential entirely non-invasive solution under development is the use of specially adapted face masks, containing a collection matrix to sample exhaled pathogens, which are then detected l for TB , these aApplicability of CHIMs utilised in young, healthy adults to real world populations of interest is an area of consideration for both pathogens. In TB, there is a drive to deliver CHIMs in TB endemic settings, to ensure information derived and interventions tested are relevant to eventual target populations . In CoviWith multiple studies ongoing to develop and optimise CHIMs within both TB and Covid-19, this is an area of considerable scientific interest and promise. Momentum gained in research during the Covid-19 pandemic should be harnessed to ensure CHIMs for these, and other, pathogens continue to be developed and to exploit their full potential, in particular the fields of vaccine development and to further our understanding of host-pathogen immunobiology.HMo and SJ contirubuted equally to this work and share first authorship. HMo and SJ wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.


Wound healing is a coordinated process that can be divided into three general phases: inflammatory processes, tissue formation and tissue remodeling. The molecular and cellular events involved in healing, repair and regeneration are still poorly understood, and current therapies are limited. As a result, defective wound healing affects millions of people worldwide every year. Beyond the current wound healing dogma, new mediators and regulatory nodes are continuously being discovered, opening new therapeutic avenues .There are several common features of healing, repair and regeneration between animals and humans, such as the processes involved in re-epithelialization, extracellular matrix degradation and remodeling, and regulation of immune response genes, etc. However, there are also many differences; for example, regeneration can occur by blastema formation , without proliferation , or by epimorphic regeneration and morphallaxis . It is nevertheless unclear whether regeneration involves similar molecular mechanisms that are conserved in distantly related taxa, or whether the ability to regenerate damaged tissues is a trait that has evolved or devolved in mammals .Ambystoma mexicanum) is the poster child for limb regeneration, as it has a remarkable ability to heal wounds without scarring and to regenerate most of its structures. Axolotls thus provide us with an opportunity to learn about healing and regeneration in complex organisms. A better understanding of what drives these processes in the axolotl could lead to the development of therapies to improve tissue repair after injury and treat diseases , which they studied at the amputation site in axolotl and in digit-amputated neonatal mice (as a non-regenerating control) using polysome sequencing to identify pre-existing mRNA transcripts bound to ribosomes , differences were evident in the intracellular distribution of mTORC1 within tissues: mTORC1 was localized cytoplasmically in mice, whereas in axolotl a pool of mTORC1 was constitutively localized in lysosomes, which might allow its rapid mobilization .To search for an explanation for the different global and specific translational behavior between axolotl and mouse, the authors looked at the primary amino acid sequence in mTOR across more than 100 metazoan species (mostly vertebrates) including 9 species of urodele amphibians. Analysis revealed that although axolotl mTOR (AxmTOR) is highly conserved, it contained two highly conserved peptides or inserts in the M-HEAT region within amphibian orders: insert 1 has 8 residues within the M-HEAT region critical for RHEB-mediated activation and is conserved in three orders of amphibians; insert 2 contained 20 residues within the M-HEAT domain and was exclusive to urodele amphibians. Moreover, insert 2 expanded the M-HEAT and N-HEAT interface between AxmTOR proteins in the AxmTOR dimer, suggesting a role in dimerization .To demonstrate the functional relevance of these insertions, the authors genetically modified HEK293 cells to express an ‘axolotized’ version of mTOR. Upon nutrient deprivation, they found that AxmTOR localization in lysosomes was less sensitive to fasting than was mTOR in wild-type HEK293, and that a pool of AxmTOR persisted in lysosomes. They tested whether the insertions affected mTOR function by quantifying mTOR activity under conditions of nutrient and amino acid stimulation, as nutrient-mediated signaling has been suggested to play an important role in tissue regeneration . ResultsDuring organogenesis, mTOR is pivotal in regulating physiological cell growth and proliferation. In adult organisms, mTOR is involved in several tissue/organ regeneration processes, for example, the regeneration of appendages such as limbs, tails or fins, which involves the proliferation and remodeling of numerous cell types. In the mouse, regeneration processes have been shown to use the same steps of wound closure, blastema configuration, cell proliferation and differentiation. In mammals, however, regeneration is limited to epithelial and connective tissues . Zhulyn A fundamental activity of our body is to build new cells and destroy damaged ones. This delicate balance is modulated by mTOR , which pDespite the importance of the findings , it remain vivo in gain- and loss-of-function animal models such as “axolotlized mice” and “mice-like axolotls”?; iii) can the same biological program of gene remodeling associated with elevated de novo cellular translation be established in the absence of healing, injury or organ repair/regeneration to treat pathologies such as cancer or inflammatory diseases such as obesity, diabetes and myocardial infarct; iv) could hypersensitized mTOR be reproduced by generating new specific drugs and/or nutrients  that increase its selective translational activity without unwanted side effects?; and v) could personalized medicine use cell lines expressing hypersensitized mTOR to trigger early wound healing and stimulate tissue regeneration in situations such as injuries from accidents, burns from fires, ulcerations associated with diabetes and other human pathologies with anomalous healing?Notwithstanding these unresolved issues, the findings of de novo protein production in response to injury. These findings have far-reaching implications for healing in mammals, and highlight future cell therapy strategies to advance regenerative medicine.In summary,


Systematic Evolution of Ligands by EXponential Enrichment (SELEX). As an alternative to antibodies, aptamers offer unique features like thermal stability, low-cost, reuse, ease of chemical modification, and compatibility with various detection techniques. Particularly, immobilized-aptamer sensing platforms have been under investigation for diagnostics and have demonstrated significant value compared to other analytical techniques. These “aptasensors” can be classified into several types based on their working principle, which are commonly electrochemical, optical, or mass-sensitive. In this review, we review the studies on aptamer-based MP-sensing technologies for diagnostic applications and have included new methodological variations undertaken in recent years.Many biological processes  are relevant to membrane proteins (MPs), which account for almost 30% of the total of human proteins. As such, MPs can serve as predictive molecular biomarkers for disease diagnosis and prognosis. Indeed, cell surface MPs are an important class of attractive targets of the currently prescribed therapeutic drugs and diagnostic molecules used in disease detection. The oligonucleotides known as aptamers can be selected against a particular target with high affinity and selectivity by iterative rounds of in vitro library evolution, known as  The biological membranes are essential for cellular life. They form and organize cells’ defining boundaries, e.g., by separating the interior from the outside environment. Most cell membranes consist of about half lipid and half protein by weight. Membrane proteins (MPs) are proteins embedded or attached to biological membranes and are thus classified as peripheral or integral. Integral MPs fully span the lipid bilayer, while peripheral MPs partially associate with the lipid bilayer or with integral MPs . MPs areFunctional characteristics of organelles and cells are determined by the protein compositions at different physiological states . ChangesApproximately 30% of the total human proteome is composed of MPs ,6. HavinReceptor tyrosine kinases (RTKs) involve a class of membrane receptors encoded by 60 human genes and participate in important functions, such as regulation of cell survival, metabolism, proliferation, and differentiation . Dysfunc+ ions  3+). Although label-free aptasensor systems reduce the burden of additional aptamer labeling procedures, they may include other labeled molecules or redox ions as reagents in the solution  the flexibility of aptamer structures where target binding induces precise conformational changes to its structure, and (ii) a binding-induced complementary strand displacement from a duplex structure. In electrochemical aptasensors, these properties allow reporting aptamer-target complexes as redox-tagged or untagged aptamers immobilized on conductive support to govern electrical communications with that support (an electrode) by means of the aptamer itself (tagged) or by other companion molecules (label-free). Aptasensors exploit one of two phenomena (or their combination) to detect signals from aptamer-target binding: (+). The first electrochemical aptasensor was constructed in 2004 with a sandwich-based design for the detection of thrombin, where a thiolated aptamer immobilized onto the gold electrode and an added glucose dehydrogenase-labeled aptamer were used . O. O225]. Li et al. developed an aptamer-based microcantilever array biosensor for the simultaneous optical readout and real-time detection of two biomarker analytes in solution . One of 3 to 5.4 × 104 cells/mL demonstrated a linear relationship with cantilever deflection; a detection limit of 213 cells/mL was obtained. Therefore, as a novel approach, the microcantilever aptasensor can be used for early-stage detection of cancer biomarkers and whole cells.Another microcantilever-based aptasensor was developed for the detection of the transmembrane epithelial tumor biomarker MUC1 . In thisAccording to the Biomarkers Definitions Working Group convened by the National Institute of Health (NIH), a biomarker  is a measurable indicator for normal biological or pathogenic processes and responses to pharmacological intervention . TherefoAptamers are unique ‘recognition molecules’ due to their high affinity and specificity towards their targets. Many studies have been carried out on the generation of aptamers against MPs, and a far larger number of studies have investigated aptamer applications in diagnostic biosensing for MPs. Clearly, properties of aptamers, such as their structural flexibility, small size, reusability, and cost-effective and easy preparation, allow their use as detection tools in biosensors. The preclinical literature dealing with aptasensors is vast; the recent global COVID-19 pandemic has further boosted the number of papers in the field. Indeed, as early as the first aptamer selection attempts, the ‘aptasensing’ strategy was extensively researched and developed to demonstrate the potential versatility  in the detection of clinical targets like small molecules, cells, and viruses.® (Pegaptanib sodium) for the treatment of wet age-related macular degeneration is the sole aptamer-based drug approved by the Food and Drug Administration in 2004. On the diagnostic front, the number of clinical trials on aptamers (and aptasensors) is limited. Currently, about 50 aptamer-related national clinical trials are ongoing, while only 11 are aimed at diagnostic purposes [Throughout this review, we cited work that shows how aptasensors   can be mpurposes . Howeverpurposes .Aptamers represent potent and unique alternative device options to be established as mainstream synthetic MP probes, thereby revolutionizing aptamer-based point-of-care diagnostics and occupying niches in the market and the clinic that are hardly taken up by other molecular devices . A majorFrom a technical perspective, more scientific investigations and improvements are needed along the developmental pipeline of aptamer-focused technologies to accelerate the translation of aptasensors into clinical settings. For example, robust ways for the identification of high-quality aptamers  are needed while reducing the duration of raising aptamers from the order months to only a few days or hours. In parallel, selection efforts must focus on clinically valuable targets; and downstream aptasensors must exhibit high stability and reproducibility and be adapted to test complex clinical samples so that a connection with “real life” applications in the clinic is created. In other words, proposed aptasensors become more than just proofs-of-concept. It is also important to take advantage of aptasensor multiplexing for high-throughput, low-cost sensing of multiple targets. The sensitivity and specificity of aptasensors can be enhanced by the incorporation of nanomaterials such as nanoparticles, quantum dots, and carbon nanotubes which are gaining great attention for their unique physicochemical properties and performance, as well as their use as alternatives to traditional fluorophores facing photobleaching issues .The majority of aptasensors are made using DNA aptamers. This is in part because producing longer RNA and the need for reverse transcription are a few extra steps with the selection of RNA aptamers against a given target. RNA aptamers, however, are known to be conformationally much more flexible and suitable for binding to an expanded repertoire of targets. After immobilization, these RNA and DNA aptamers must retain their high qualities (affinity and specificity) and stay resistant to nucleases. For this, pre-, mid-, or post-SELEX aptamer modifications can be employed. One of the technical challenges during and after surface immobilization is due to the nature of nucleic acids being negatively charged. This may lead to undesirable non-specific interactions resulting from electrostatics between the aptamer probes and their immobilization surface during fabrication ,237. TheDespite these and other stringent limitations on aptasensors, these devices will soon provide valuable and unique alternative approaches to antibody-based detection methods as described throughout. Quick pinpointing and resolution of major bottlenecks in the R&D pipeline of aptansensing technologies will propel these devices into the market to facilitate the realization of their clinical diagnosis capabilities. Interestingly, beyond aptamer-antibody comparisons, new methods are progressing to show how aptamers accompanied by monoclonal antibodies provide highly sensitive joint sensing methods ,239.


There were no changes in diagnostic modalities between the two time periods. The reported prevalence of and mortality from COVID-19-associated pulmonary aspergillosis (CAPA) may have resulted in higher rates of prescribing antifungal drugs for critically ill patients with COVID-19. Antimicrobial stewardship programs should develop and apply tools to facilitate more effective and appropriate antifungal use.Significant increases in antibacterial use were observed during the COVID-19 pandemic. However, subsequent analyses found this increase in antibiotic use to be excessive in comparison with the relatively low rates of bacterial coinfection. Although patients who are critically ill with COVID-19 may be at an increased risk for pulmonary aspergillosis, antifungal use in these populations remained underreported, particularly in later phases of the pandemic. This single-center, population-level cohort analysis compares the monthly use rates of mold-active antifungal drugs in the medical intensive care unit during April 2019–March 2020 (baseline) with those during April 2020–November 2022. The antifungal drugs included in the analysis were liposomal amphotericin B, anidulafungin, isavuconazonium, posaconazole, and voriconazole. We found that during 2020–2022, the usage of antifungal drugs was not significantly different from baseline for all included agents except isavuconazonium, which was used significantly more ( The principles of antimicrobial stewardship experienced significant setbacks during the COVID-19 pandemic. Multiple reviews note significant increases in the prescribing of antibacterial drugs to prevent potential bacterial pneumonia in cases of COVID-19, despite reportedly low rates of bacterial coinfection (3.5–14.3%) .Over the course of the pandemic, reports emerged of COVID-19 pneumonia being complicated by fungal superinfections . AlthougAspergillus galactomannan (GM) assay and reservations about performing aerosolizing procedures such as bronchoalveolar lavage (BAL) made it increasingly difficult to confirm suspected cases of CAPA beyond the patient’s clinical condition and radiographic findings. This diagnostic uncertainty was further complicated by poor clinical response despite best available therapy, difficulties in diagnosing mold infections, and early clinical reports of relatively high rates of invasive pulmonary aspergillosis (up to 39% in some cases) in patients critically ill with COVID-19. Consequently, concern for potential CAPA in these patients likely contributed to increased use of antifungal agents in intensive care populations.Consistent with American and European guidelines for the management of aspergillosis, initial therapeutic reviews on CAPA emphasized early initiation of antifungal therapy in critically ill patients with a high suspicion for IPA ,16,17. TWhile most reviews to date have focused on antibacterial use during the COVID-19 pandemic, we hypothesize that the pandemic also impacted the use of antifungal agents in critically ill patients. Limited data from Spain and France found elevation in the use of several mold-active antifungals, including amphotericin B, echinocandins, and voriconazole ,19. To dp = 0.009) during 2020–2022, but there was no statistically significant difference from baseline in the usage of liposomal amphotericin B (L-AMB), anidulafungin (AFG), posaconazole (POS), or voriconazole (VRC) during this period. However, monthly usage of POS and VRC was numerically higher during 2020–2022 than during the baseline period, with DOTs per 1000 PDs being approximately 1.5× and 2× higher than baseline, respectively  positive for presumptive aspergillus. In total, 24 patients with a lower respiratory sputum or BAL culture were identified as being presumptively positive for aspergillus, regardless of whether a GM index was ordered  of antifungal agents per 1000 patient days (PDs) in the medical intensive care service were broadly similar between the two time periods. There was a statistically significant increase in monthly DOTs/1000 PDs of isavuconazonium (ISA) from baseline  overestimated the rates of CAPA among critically ill patients . DespiteAspergillus GM to confirm suspected cases of invasive aspergillosis. [Aspergillus spp.  criteria used for the diagnosis of invasive fungal diseases utilize categories of proven, probable, and possible IPA to distinguish infection from colonization These criteria rely heavily on invasive sampling, histopathologic examination, and the testing of BAL samples for illosis.  During tillosis. ,28. Theslus spp. . Interesobtained  suggestsIn the absence of high quality serologic or histopathologic evidence to support a diagnosis of CAPA, there is intense interest in developing scoring and prediction algorithms to help identify those most at risk for CAPA. However, despite the knowledge related to CAPA and other invasive fungal diseases that was accumulated during the COVID-19 pandemic, there remains a lack of standardization and consensus related to diagnostic approach, risk factors, and treatment. Numerous research definitions for CAPA have been proposed with little overlap and an overall lack of specificity . MultiplDespite the high mortality associated with CAPA, it is prudent to consider that no antimicrobial agent is benign. The benefits of antifungal treatment must be judiciously weighed against the risk for potential toxicity and development of resistance. Unnecessary antifungal use puts patients, particularly those who are critically ill, at high risk for avoidable adverse events. Overuse of other, less toxic agents can impact financial costs associated with drug treatment and, in some cases, risk compromising efficacy. Several of these agents, notably the azole antifungals, have the potential for serious drug-drug interactions and toxicities associated with their use. The preferred first line treatment for invasive aspergillosis, voriconazole, is frequently associated with cardiac arrhythmias, neurotoxicity, and hepatotoxicity ,34,35. TMuch like with antibacterial agents, antimicrobial stewardship programs (ASPs) can play a significant role in the responsible use of antifungal drugs. The core elements of antibiotic stewardship, including prospective audits and feedback, development of locally validated screening tools and treatment protocols, and preauthorization to minimize unnecessary antibacterial use, are easily adaptable to antifungal therapy . ASPs caOur review of antifungal usage in ICU patients during the COVID-19 pandemic is not without limitations. Our analysis is limited to a single-center, retrospective, population level review in a limited subset of critically ill patients. This study also lacks patient level evaluations related to immunosuppressive therapy , length of stay, mechanical ventilation history, outcomes, drug related adverse events, and specific diagnoses. However, the diagnosis of CAPA remains difficult, in part because its clinical definitions are highly variable. Considering this and the frequent use of empiric antifungal coverage at the authors’ institution, we believe that rates of confirmed, probable, and possible IPA or CAPA are likely to add little to the discussion surrounding changes in prescribing practices and antifungal use in this patient population. Our analysis was also limited by our inability to definitively rule out the use of antifungals for other COVID-19-associated fungal infections  that might occur concomitantly with CAPA. However, given differences in locale, appropriate therapy, and associated timeframes, we believe that these were minor factors driving the usage of selected antifungals at the authors’ institution.Aspergillus GM testing is one of the primary assays used for the diagnosis of aspergillosis at the authors’ institution, GM test data were also reviewed for patients admitted to the medical intensive care service. BAL and additional sputum specimens were also reviewed.To investigate the potential impact of the COVID-19 pandemic on antifungal use, we examined antimicrobial usage data associated with the institution’s medical intensive care service. Days of therapy (DOT) per 1000 patient days (DOT/1000 PDs) were the units selected for evaluation, as these are currently the standard employed by the CDC’s National Healthcare Safety Network Antimicrobial Use and Resistance module. A day of therapy is defined as one calendar day (24 h) in which a specific antimicrobial is administered to an individual patient, regardless of dosing . These dWhile other intensive care areas provided additional capacity in times of high COVID-19 caseloads, medical intensive care was the primary service involved in the treatment of critically ill COVID-19 patients at the authors’ institution. This service is exclusively staffed by the pulmonary critical care provider group, which provided a relatively consistent approach to prescribing practices. Our hospital is a 710-bed tertiary referral and academic medical center in eastern Tennessee in the U.S. that serves as one of the primary centers of acute care for the surrounding areas, including eastern Tennessee and portions of southeastern Kentucky and western North Carolina.A two-sample T-test of unequal variances was employed to test the hypothesis that monthly antifungal usage in the medical intensive care service between April 2020 and November 2022 differed from baseline. Baseline antifungal usage for the medical intensive care service was calculated on a monthly basis using the DOT/1000 PDs from April 2019 through March 2020. This date range was selected to consider seasonality associated with prescribing trends and disease occurrence, as well as its temporal proximity to subsequent COVID-19 mitigation measures and local surges. An F-test was used to evaluate statistical variances and select the appropriate test based on the distribution. All antifungal agents exhibited unequal variances between the two time periods.Isavuconazonium usage in our medical intensive care patients increased significantly from baseline following the start of the COVID-19 pandemic in the U.S. Voriconazole and posaconazole also experienced numerically higher rates of usage, but these were not statistically significant. This suggests that during the COVID-19 pandemic, the use of antifungal drugs, like that of antibacterial agents, increased as a result of various COVID-related factors. Initial reports that suggested high rates of CAPA prevalence likely exaggerated the clinical suspicion and concern for the disease. This, coupled with diagnostic uncertainty and risk-benefit analyses that favored the use of antifungal drugs in poorly responding patients, most likely led to increased antifungal use in critically ill patients.Aspergillus GM indices. Research efforts to standardize the diagnosis and risk factors of CAPA will aid in the selection of patients likely to benefit from empiric antifungal treatment while mitigating unnecessary treatment of low-risk patients.At present, the limited available literature makes it difficult to appropriately assess the scale of antifungal use in critically ill patients with COVID-19. Further studies should be conducted to elucidate the use of antifungal agents in this patient population, particularly those with extended durations of analysis from across the U.S. Beyond antifungal use, issues remain regarding the diagnosis of IPA and CAPA. At present, definitions and diagnostic limitations complicate the accurate identification of patients at high risk for CAPA. Consensus definitions should be more widely developed to help guide appropriate treatment and determine which patients are most likely to benefit from empiric antifungal therapy. Institutions may also consider the use of alternative diagnostics given the limitations associated with