The World Health Organization recommends HIV-PrEP for all people at risk for HIV infection, which includes men who have sex with men (MSM). Substantial part of new HIV diagnoses in the Netherlands are in non-western born MSM. This study evaluated new HIV diagnoses and reported PrEP use among non-western born MSM and compared it to western-born MSM. To inform public health efforts in the context of equitable PrEP access, we further assessed sociodemographic factors related to higher HIV risk and lower PrEP use among non-western born MSM.Surveillance data of consultations among MSM in all Dutch STI-clinics (2016–2021) were analyzed. STI-clinics provide PrEP via the national pilot-program since August 2019. In non-western born MSM (born in Eastern-Europe/Latin-America/Asia/Africa/Dutch-Antilles/Suriname), sociodemographic factors were evaluated for association with HIV  and reported PrEP use in the past 3 months .New HIV infections were diagnosed among 1.1%  of non-western born MSM-consultations . Low education  and age under 25 years  were associated with new HIV diagnoses. PrEP use in the past 3 months was 40.7% in non-western born MSM . PrEP use was lower among non-western born MSM aged under 25 years , living in less urban areas , and having low education level .Our study confirmed that non-western born MSM are an important key population in HIV prevention. Access to HIV prevention, including HIV-PrEP, should be further optimized to all non-western born MSM at risk for HIV, and specifically to those who are younger, live in less urban areas, and have a low education level. Therefore, the World Health Organization has recommended PrEP for all people at substantial risk for HIV infection . Many hiIn accessing PrEP, key are organizational, and social and personal factors. Several barriers have been identified for PrEP uptake among migrants in high-income countries, including HIV-related stigma, barriers to openly discuss sexual health, and non-equitable access . In the Here, we evaluated new HIV diagnoses and reported PrEP use in non-western born MSM who attended a Dutch STI clinic, and compared it with western-born MSM. To inform public health efforts in the context of equitable PrEP access, we further assessed sociodemographic factors related to higher HIV risk and lower PrEP use among non-western born MSM.2.2.1.In this retrospective cohort study, coded surveillance consultations of MSM were included from all outpatient STI clinics in the Netherlands  which were submitted between 1 January 2016 and 31 December 31 2021 via an electronic patient registry using a consultation code to the National Institute of Public Health and the Environment. From 2016, individual-level data (with a patient identifying number) was available. Reporting to this national institute is standardized and mandatory for all STI clinics. For the current study, consultation-level and individual-level data in MSM was extracted on sociodemographic characteristics, sexual behavior in the past 6 months, STI and HIV diagnoses, and PrEP use in the past 3 months.2.2.Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), HIV, hepatitis B and syphilis as part of routine sexual healthcare. MSM are generally advised to test every half year for STIs and HIV; and MSM using PrEP are advised to test every 3 months for STIs and HIV. Urine, self-collected anorectal swabs and nurse-collected oropharyngeal swabs were tested for CT and NG. Venepuncture nurse-collected blood samples were tested for HIV, hepatitis B and syphilis by screening and confirmatory tests. Specimens were tested in regional laboratories using different commercially available diagnostic assays. All tests were performed according to the manufacturers’ protocol. Further, STI clinics have been providing PrEP care via the national PrEP pilot program since August 2019 to MSM with a high risk of acquiring HIV  positive HIV test. Recent PrEP use was defined as reporting PrEP use in the past 3 months at the time of the consultation. Non-western born migrant was defined as a person born in Eastern Europe, Latin America, Asia, Africa, Netherlands Antilles or Suriname. Western-born was defined as MSM born themselves and of whom parents were born in Europe, Oceania or North America. Age was grouped into <25, 25–35, >35 (based on tertile distribution). Urbanicity was based on postal codes and categorized into high urban  and low urban (<15.00 addresses/ m2) according to Statistics Netherlands.2.4.Proportion of new HIV diagnosis was compared between non-western born and western-born MSM consultations using descriptive statistics and chi-square tests. The proportion of new HIV diagnoses among western-born MSM was used as a reference proportion. Descriptive statistics and chi-square tests were used to assess differences in proportions of new HIV diagnoses by different continents of birth among non-western born MSM. For the outcome new HIV diagnoses, univariable and multivariable generalized estimating equations (GEE) analyses were used to assess independent sociodemographic factors related to new HIV diagnoses in all consultations in non-western born MSM. Assessed factors were age groups, urbanicity and educational level, and continent of birth. In multivariable analyses, all factors were entered and associations were adjusted for time calendar period based on the start of the PrEP pilot (before and after August 2019). GEE analyses were used to control for repeated measurements of patients that visited the STI clinic multiple times during the study period, using a non-identifiable patient identifier.p-values < 0.05 were considered statistically significant. All analyses were performed using SPSS V27 IBM Corp., Armonk, NY, United States.For the outcome PrEP use, analyses were performed on a subset of the data to reflect only PrEP-eligible persons. Therefore, we included the most recent consultations of MSM, who reported at least three sex partners in the past 6 months without consistent condom use during anogenital sex, in the period between 1 August 2019 and 31 December 2021. Proportion of PrEP use was compared between non-western born and western-born MSM using descriptive statistics and chi-square tests. The proportion of PrEP use among western-born MSM was used as a reference proportion. Descriptive statistics and chi-square tests were used to assess differences in proportions of PrEP use by different continents of birth among non-western born MSM. Univariable and multivariable logistic regression analyses were used to assess independent sociodemographic factors related to recent PrEP use among non-western born MSM. Heterogeneity of associations with continent of birth were tested for various sociodemographic groups  by including interactions terms into the models. In a sensitivity analysis, associations between new HIV and sociodemographic factors were assessed by multivariable logistic regression analyses on the person-level high-risk data subset from 2019. 2.5.The Medical Ethics Committee of Maastricht University waived the requirement for ethical approval and written informed consent because the data were coded, originated from standard care, and were analyzed anonymously (METC 2017-0251).3.3.1.After exclusion of consultations in which a known HIV-infection was reported and exclusion of consultations without a HIV test, the study population included 44,887 consultations among non-western born MSM and 210,450 consultations among western-born MSM . Median 3.2.New HIV was diagnosed among 1.1%  of non-western born MSM consultations . HIV positivity rate ranged from 0.6% in MSM born in Asia to 1.8% in MSM born in Latin America .3.3.p = 0.012). Being aged < 25 years , and being aged between 25 and 35 years  were only significantly associated with new HIV diagnoses in MSM born in Latin America.Proportion of new HIV diagnoses was higher among non-western born MSM aged under 25 years, having a low education level, MSM from Latin America, Suriname/Dutch Antilles, Eastern Europe (compared to Asia), and in consultations with missing postal codes (unknown urbanicity). All these factors were independently associated with new HIV diagnoses . The ass3.4.Exclusion of known HIV positive MSM and MSM reporting 2 or less sex partners in the past 6 months and consistent condom use during anogenital sex since they were ineligible to receive PrEP, resulted in 4,207 non-western born MSM and 17,458 western-born MSM who visited a Dutch STI clinic between August 2019 till 2021 . Median 3.5.PrEP use in the past 3 months was reported by 40.7%  of non-western born MSM  of MSM born in Europe) during the most recent consultation . PrEP us3.6.Current PrEP use was lower in non-western born MSM aged 35 years or younger, who lived in low urban areas, had a low educational level, or were born in Suriname/Dutch Antilles, Eastern Europe or Sub-Saharan Africa. All these factors were independently associated with PrEP use .4.This study includes one of the first large scale evaluations of PrEP use among non-western born MSM who live in a high-income country with an available PrEP-program. We assessed that non-western born MSM generally have a higher proportion of new HIV diagnoses (1.1% vs. 0.4% in western-born MSM), and also use PrEP (41% vs. 35%) more often than MSM born in western countries (among those who are PrEP-eligible). However, several subgroups within non-western born MSM who have a higher or equal proportion of new HIV are less likely to use PrEP. These groups include younger people, people living in less urban areas and people with a low educational level. This indicates that efforts are needed to target both organizational and personal/social factors to promote access to PrEP care in these subgroups.People born in all assessed non-western continents had a higher proportion of new HIV diagnoses than people born in western countries; highest proportions were noted in MSM born in Latin America, Suriname/Dutch Antilles and Eastern Europe. This is consistent with previous reports on HIV incidence among migrants living in Europe from non-western countries , 4. Our 4.1.This large study provides insight in PrEP use among non-western migrant MSM with a higher HIV risk and hereby underpins the importance of efforts to increase accessibility of PrEP to less reached groups. A limitation of this study was that the study population included only MSM visiting the STI clinics, which limits the generalizability to MSM who do not attend sexual health care. As PrEP care is mostly organized by STI clinics and less by general practitioners in the Netherlands, this study gives a good estimation of the absolute number of PrEP users, but likely overestimates the proportion of PrEP use among all non-western migrant MSM. Non-western born MSM are demonstrated to have less access to health care . Other sampling methods, and inclusion of general practitioner data, are needed to estimate PrEP uptake among a wider group of non-western born MSM in the Netherlands. Another limitation of this study is that the PrEP care provider is unknown from the used registry data. Furthermore, we used a proxy for PrEP eligibility , as the PrEP eligibility criteria were unavailable from the standard registry data used in this study. Although this proxy ensured that we assessed PrEP use among MSM at risk for HIV, it is unclear whether this proxy would underestimate or overestimate people eligible for PrEP (per routine triage and practice). Finally, on the sociodemographic factor educational level, more missing values (categorized in unknown) were registered than among MSM born in the Netherlands. One explanation could be that the question about education in the current demographic/sexual history questionnaire used at Dutch STI clinics is not applicable to people who have followed education in non-western countries.4.2.Non-western born MSM have a higher proportion of new HIV diagnoses, and also more often have used HIV-PrEP in the past 3 months than western-born MSM. Still, PrEP use in non-western born MSM who already attend sexual health care is not optimal. Efforts to increase accessibility to PrEP are needed, with specific attention to non-western born MSM who are younger, live in less urban areas and are lower educated.soap@rivm.nl.The data analyzed in this study is subject to the following licenses/restrictions: the data used were explicitly made available for this study by the National Institute for Public Health and Environment. Any data sharing requests should be directed to the National Institute for Public Health and Environment. Requests to access these datasets should be directed to Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.YE, CG, CH, and ND-M contributed to the conception and design of the study. YE drafted the report and performed the statistical analyses. CG and ND-M contributed to statistical analysis. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Supplemental Digital Content is Available in the Text.We report attenuated subjective pain ratings and neurophysiological responses to electrical pain in both chronic pain and control participants while exposed to conditioned pain modulation. Conditioned pain modulation (CPM) is an experimental procedure that consists of an ongoing noxious stimulus attenuating the pain perception caused by another noxious stimulus. A combination of the CPM paradigm with concurrent electrophysiological recordings can establish whether an association exists between experimentally modified pain perception and modulations of neural oscillations.We aimed to characterize how CPM modifies pain perception and underlying neural oscillations. We also interrogated whether these perceptual and/or neurophysiological effects are distinct in patients affected by chronic pain.We presented noxious electrical stimuli to the right ankle before, during, and after CPM induced by an ice pack placed on the left forearm. Seventeen patients with chronic pain and 17 control participants rated the electrical pain in each experimental condition. We used magnetoencephalography to examine the anatomy-specific effects of CPM on the neural oscillatory responses to the electrical pain.Regardless of the participant groups, CPM induced a reduction in subjective pain ratings and neural responses (beta-band [15–35 Hz] oscillations in the sensorimotor cortex) to electrical pain.Our findings of pain-induced beta-band activity may be associated with top-down modulations of pain, as reported in other perceptual modalities. Therefore, the reduced beta-band responses during CPM may indicate changes in top-down pain modulations. In humans, CPM likely involves both DNIC and top-down modulation  from higher-order brain systems.73 Although the CPM effect is maximal during the application of CS, several studies have found that the effect persists after the removal of CS.44 Therefore, sequential CPM protocols  can be used to account for potential biases from distraction.83Neurophysiological responses to nociceptive inputs are inhibited or enhanced by pain modulatory descending pathways, from the cerebrum to the dorsal horns of the spinal cord, in part via the brainstem.44 Its efficacy is typically reduced in populations experiencing chronic pain, suggesting a disturbance of their pain inhibitory signaling.69 However, chronic pain encompasses a considerable variety of phenotypes, and evidence is still missing that CPM has decreased efficacy in patients with chronic low back pain.50 There is also a growing interest in using the predictive value of preoperative CPM on the likelihood of developing postoperative chronic pain.82 For all these reasons, advancing the understanding of the neurophysiological mechanisms of CPM is likely to promote its evidence-based adoption for the clinical management of pain.A growing body of research shows clinical relevance of CPM.58 Conditioned pain modulation reduces pain-induced brain activations in a distributed set of brain regions, including the primary and secondary somatosensory cortices (S1 and S2), anterior cingulate cortex (ACC), insula, and amygdala.58 Conditioned pain modulation also reduces pain-evoked potentials (EPs) measured at the vertex (Cz) in scalp electrophysiology.35 However, if and how event-related spectral perturbations (ERSPs) of ongoing brain oscillations are modulated under CPM remains unknown. Event-related spectral perturbations are typically defined as transient increases (event-related synchronization [ERS]) or decreases (event-related desynchronization [ERD]) of the magnitude of brain electrophysiological activity in a frequency band.55 The literature reports that painful stimuli induce (1) a transient suppression of alpha (8–13 Hz) frequency activity  across central and posterior brain regions ,55 (2) a transient suppression of beta-band (15–30 Hz) activity (beta-ERD) over the sensorimotor cortex,61 followed by (3) a transient enhancement of beta-band activity (beta-ERS), also over the sensorimotor cortex.30 The functional relevance of these ERSPs remains speculative, with alpha-ERD and beta-ERD possibly reflecting large-scale changes in cortical excitability, and therefore contributing to the alerting function of pain,59 and beta-ERS possibly signaling top-down components of pain processing.14The modulation of pain-induced neural responses by CPM has been shown with functional magnetic resonance imaging (fMRI) and electrophysiology.45 to report the spatiotemporal characteristics of pain-induced ERSPs  and describe their changes under CPM, in patients with chronic pain in their lower body and in pain-free control participants.Here, we used magnetoencephalography (MEG) source imaging11), 3 with diabetic neuropathy, and 1 with neuropathic pain. Exclusion criteria were severe pain in other body parts or any other form of serious decline in general health. HC had no history or current experience of chronic pain. Participants with moderate, nonpainful medical conditions  were not excluded.Seventeen pain-free control participants (HC) and 17 patients (CP) with chronic pain in their low back and/or lower extremity (inclusion criteria) participated. The patients had chronic pain of one or more etiology, with 15 presenting persistent spinal pain syndrome type 2  and the Donders Institute for Brain, Cognition and Behavior . Ethics approval was obtained from the Institutional Review Boards of the MNI and the CMO region Arnhem-Nijmegen. All participants provided informed written consent.The TS was delivered via transcutaneous electrical stimulations to the right ankle with Ag–AgCl electrodes. One TS trial consisted of five 1-millisecond electrical pulses with 4 milliseconds between 2 consecutive pulses. The stimuli were delivered at randomized intertrial intervals of 6 to 10 seconds to minimize stimulus predictability. Before the experiment, we presented a short series of TS stimuli with ascending and descending intensity to identify the intensity that induced a pain score of 5 on a 0 to 10 scale  in each participant.We delivered the conditioning stimulus with a commercial ice pack  placed on the participant's left forearm, wrapped in thin fabric to prevent skin damage. The temperature was approximately −10°C, and participants reported moderate pain.Before CPM (TS only), During CPM (concurrent TS and CS), and After CPM (TS only). Each block lasted 3 minutes, with 2-minute breaks in-between. Participants sat still, with eyes open, and focused on a fixation cross presented on a back projection screen. The participants rated average TS intensity on the 0 to 10 scale after each block and rated average CS intensity on the same scale following the During CPM block.The experiment consisted of 3 consecutive blocks Fig. A: Before59 and thus, we defined a scalp ROI containing central and posterior MEG sensors ,84 and maladaptive response to pain .70Before the experiment, all participants completed questionnaires related to pain evaluation (Brief Pain Inventory [BPI]),The brain signals were recorded in a passive magnetically shielded room with identical 275-channel CTF MEG systems  at each study site. The sampling rate was set to 2400 Hz and third-order gradient compensation was applied for noise reduction. Eye blinks and cardiac activity were recorded from electro-oculograms and electrocardiograms, respectively.22 Poor-quality MEG sensors were excluded from the analysis (0–14 sensors across participants). The TS stimulus artifact (maximum duration 70 ms after stimulus onset) was cropped from the MEG time series and replaced with linear interpolation. The data were then bandpass filtered (1–200 Hz) and notch filtered to remove power line contamination . Signal-space projections73 were used to attenuate MEG contamination from eye blinks, cardiac activity, movement (1–7 Hz), and muscle activity (40–240 Hz).Magnetoencephalography data were preprocessed and analyzed using Brainstorm.29Individual anatomical T1-weighted MRI volumes were co-registered to MEG data when available (in 7 of 34 participants). In other participants, the ICBM152 template was warped to fit the individual's head shape digitized at the time of their MEG visit using a 3D digitizer system , via affine transformations. The cortical surfaces were tessellated using Freesurfer and reduced to 15,000 vertices. Individual MEG forward models were derived using the overlapping-sphere approach, and source time series were reconstructed using unconstrained minimum-norm estimation.To characterize the ERSPs induced by the TS, we derived time–frequency representations (TFRs) of the signals extracted from the sensor and brain ROIs in every participant. Time–frequency representations in the time range of −2, 6] seconds (0 second marking TS onset) and the frequency range of  Hz were computed with Morlet wavelets . Time–frequency representation coefficients were then z-scored with respect to prestimulus baseline  seconds, and averaged across all trials, conditions, and participants, yielding sensor and brain ROI average spectrograms  to the respective ROI average spectrograms  with a window length of 500 milliseconds. We then measured the duration of the ERSP in each individual after applying a threshold of ≥2 z-score on the resulting data transforms. Furthermore, the magnitude of an ERSP was extracted at each of the 15,000 brain locations to map the spatial pattern of the ERSP.The magnitude of alpha- and beta-band ERSPs was computed by averaging the We also computed phase-locked EPs in response to the TS. In each participant, MEG time series were averaged across all trials for each study condition and then corrected to the prestimulus baseline interval of  seconds.We examined baseline signal power before each TS stimulus delivery. To compare frequency-specific baseline differences between participant groups and experimental conditions, we derived the power spectral density (PSD) of data time series over the prestimulus baseline  of each trial . Power spectral densities were obtained in the  Hz frequency range in each participant's brain ROI and standardized across individuals by dividing the PSD magnitude at each frequency bin by the total signal power across the entire frequency range.60 and Brainstorm71 with a significance level of 0.05. The 2 study groups were compared for demographics and clinical characteristics using Wilcoxon rank sum tests. We used 2 × 3 nonparametric analysis of variance (ANOVA)-type statistics (ATS) to compare TS pain ratings as well as ERSPs across study groups and conditions, using the nparLD package.53 The associations between neurophysiological  and behavioral  measures were analyzed with Spearman rho correlation coefficients. Cluster-based permutation tests  were used to compare the TFRs of the ERSPs across study groups and conditions. We also performed nonparametric permutation Student t tests  for the following analyses: computing the spatial patterns of the ERSP changes induced by CPM and chronic pain, comparing the prestimulus baseline PSDs across the experimental conditions, and comparing the prestimulus baseline characteristics  between the 2 study groups.Statistical analyses were performed using RP = 0.97). However, the CP group featured significantly higher scores in anxiety , depression , and pain catastrophizing . At the time of their MEG visit, 12 patients had pain in the lower back and additional areas , 1 patient had lower back pain only, and 4 patients had pain in legs and/or feet.Participant characteristics are summarized in Table P = 0.99) or pain ratings to CS (P = 0.45). The experimental condition affected pain ratings of TS , but there was neither an effect of participant group  nor an interaction effect  of TS pain ratings  and After CPM (P adjusted = 0.023) conditions with respect to the Before CPM condition.Pain intensity and ratings in the 2 study groups are summarized in Table  TS  across participants and conditions Fig. A over th31 However, such reduction during CPM was not found in our data on visual inspection of the EPs . We did not further analyze EPs due to the potential confounding influence of stimulus artifacts (maximum duration of 70 ms poststimulus) on the extraction of early peak amplitudes and latencies.Previous EEG studies have found a reduction in the pain-evoked N1–P1 peak-to-peak amplitude at the vertex (Cz) during CPM.P = 0.0001; ATS [1.99] = 8.46, P = 0.0002, respectively). The study group, however, did not have a significant effect on beta-ERS . There was no significant interaction between the effects of condition and group on beta-ERS . Post hoc tests showed that beta-ERS magnitude and duration were reduced in the During CPM  and After CPM  conditions with respect to the Before CPM condition. Lastly, cluster-based permutation tests further revealed a significant reduction in beta-band magnitude (1–3 seconds poststimulus) during CPM (P adjusted = 0.006) . Therefore, the reduced beta-ERS during CPM could not be attributed to changes in baseline beta-band activity but rather to changes in beta-band responses to TS.We then studied whether the observed changes in beta-ERS could be explained by changes in ongoing levels of beta-band activity during the application of CPM as a consequence of CS. Paired nonparametric permutation Student http://links.lww.com/PR9/A206), consistent with previous resting-state studies in chronic pain populations.81 Despite this observation, independent nonparametric permutation Student t tests did not find significant differences in baseline signal power between the HC and CP groups. Additionally, there were no significant differences in peak frequencies nor total signal power in the alpha and beta frequency bands between the 2 groups.Moreover, we visually observed a shift in the alpha and beta band peaks towards lower frequencies in patients with chronic pain  and the supplementary motor area (SMA) . This indication of a group difference remains to be replicated and validated with a larger participant sample size.Beta-ERS was reduced during CPM in the sensorimotor cortex in both study groups Fig. A. The HCMA) Fig. B. Withours = 0.10, P = 0.559, N = 34) .The previous analyses demonstrate that CPM induces attenuations in both behavioral  and neural  measures caused by the TS. However, based on Spearman rho, there was no significant correlation between behavioral and neural measures in response to CPM  over the bilateral sensorimotor cortex in both the study groups . We found that both behavioral (subjective pain ratings) and neural (sensorimotor beta-ERS) responses to test pain significantly decreased during CPM, although we did not find a linear association between them. We also found the reduction in beta-ERS to persist after the removal of conditioning pain. There was no main group or interaction effect from the ANOVA-type tests and cluster-based permutation tests, and thus, we cannot draw a conclusion on the difference between HC and CP in their response to CPM.The reduction of subjective TS pain ratings induced by CS may result from a combination of DNIC and top-down processes. Such putative neurophysiological supraspinal components of cortical activity related to the CPM effect remain to be characterized.64 in various tasks such as visual,6 auditory,20 working memory,4 and decision-making80 tasks. Therefore, our findings of pain-induced beta-ERS may be associated with top-down cortical modulations in pain processing. Supporting this idea, a study reported that pain-induced beta-ERS in contralateral S1 was increased when participants attended to the pain rather than visual stimuli.14 Attention can influence pain perception: attending to a painful stimulus increases the sensation of pain,77 and directing attention towards another task or object reduces pain.76 Currently, there is mixed evidence of the contribution of attention to the CPM effect. Some studies reported minimal effects of attention,46 whereas others reported that instructing participants to focus their attention on the CS (vs. the TS) induced a stronger CPM effect.37 Therefore, one possible interpretation of our findings is that beta-ERS marks attentional modulation involved in pain processing, and their reduction could mark reduced attention toward TS during CPM. Although the participants were not instructed to pay attention to the stimuli, painful stimuli tend to grab attention involuntarily.42 Hence, the noxious CS during CPM may have induced an involuntary allocation of attentional resources, potentially leading to lower levels of beta-ERS in response to TS due to competing attentional demands. This interpretation may also explain the partial recovery of beta-ERS after CPM termination, as the removal of the CS may have allowed more attentional resources to be allocated towards the TS.Beta-ERS has been suggested to be involved in top-down signaling68 Consistent with this notion, our finding of pain-induced beta-ERD followed by beta-ERS may reflect motor processing upon nociceptive stimulation. Although the participants were instructed to avoid voluntary movement, the transcutaneous electrical stimulation may have elicited a nociceptive withdrawal reflex (NWR).2 This reflex, which results in rapid withdrawal from painful stimuli, may be modulated by top-down input from the sensorimotor cortex.5 In fact, some studies have found that CPM can reduce NWR amplitude or threshold,72 complicating the interpretation of CPM-induced cortical activity.Furthermore, ERSPs in beta frequencies are commonly observed in motor studies, with movement execution inducing sensorimotor beta-ERD and movement termination inducing sensorimotor beta-ERS.65 and is commonly induced by transcutaneous electrical stimulation.62 Therefore, future studies using tonic thermal pain as the TS and electromyography to identify any motor involvement could provide a clearer interpretation of pain-induced beta-ERS.In conclusion, the pain-induced beta-ERS observed in the present study may reflect top-down modulation involved in pain processing, potentially associated with attentional influences. However, we cannot exclude the possibility of beta-ERS reflecting cortical modulation involved in motor processing, particularly related to NWR. Nociceptive withdrawal reflex is believed to primarily involve the thinly myelinated Aδ fibersOur exploratory analysis showed a trend towards lower beta-ERS in patients with chronic pain than in control participants. Cluster-based comparison of sensorimotor cortex TFRs and whole-brain exploratory analyses revealed that the CP group expressed lower levels of beta-ERS in the medial and inferior lateral sensorimotor cortex. We emphasize that these results are tentative and not supported by the main group effects or interactions reported herein. Our interpretation of potentially lower beta-ERS in chronic pain patients is that they are in a continued CPM state at baseline due to their ongoing experience of chronic pain. Under such circumstances, patients with chronic pain would experience a ceiling effect on CPM whereby experimentally-induced CPM via an external CS does not further reduce the TS-related pain sensation and the associated beta-ERS neurophysiological marker. Therefore, these observations encourage further replication studies to advance our understanding of the potential effect of chronic pain on beta-ERS. Additionally, the selected ROIs for beta-ERS included a broad swath of the medial and superior lateral sensorimotor cortex, which may not be anatomically specific enough and further challenge statistical sensitivity. Another possibility may be that beta-ERS effects occur within a narrower sub-band of the beta frequency range that may also be participant specific.57 Ploner et al.59 proposed that their pain-induced suppression across broad regions may be related to the alerting function of pain and its disruption of ongoing behavior. Relating to the possible interpretation that beta-ERS reflects attentional influences on pain processing, alpha-ERD and beta-ERD may initially alert about the presence of TS, with beta-ERS subsequently signaling the redirection of attentional resources towards that stimulus.We observed global alpha-ERD and broad sensorimotor beta-ERD upon delivering TS, consistent with previous studies. We did not find significant differences between study groups or conditions in terms of these desynchronization effects. Considering that attenuations in alpha and beta oscillations may be related to the relatively higher excitability of neural circuits,82 However, some studies have reported that the application of TS to painful neuropathic sites may enhance79 or reduce CPM efficacy.75 In the present study, most CP participants experienced chronic pain in their lower extremities, and thus, delivering TS to the painful body sites potentially influenced their CPM response.There are several limitations with the present data and analyses. Firstly, individual anatomical MRI volumes were not available for most participants, and their individual head shapes were used to warp a standard MRI template. Therefore, we could not account for fully-informed anatomical variability in these participants, which introduced approximations in MEG source mapping. Also, we delivered the TS and CS to the ankle and the forearm, respectively, to maximize the heterotopic effects of CPM.54 A few participants in the HC group also used pain medications  for nonpainful medical conditions . Participants were not instructed to make changes to their medication use before the experimental session and continued with their usual medication(s). However, there was no group difference in behavioral/neural indicators of CPM between individuals under medication and controls. Additionally, comorbid mental health disorders are common in chronic pain populations,19 which may bias group comparison analyses. The inclusion and exclusion criteria in this study aimed to provide a representative sample of the study populations. Although our study groups were not balanced regarding medication use and comorbid medical conditions, we did not solely include HC participants without medical conditions or CP participants without medication use in an attempt to minimize confounding effects. Nevertheless, these confounding factors may still have biased our analyses, which is a limitation of our study.Additionally, several patients with chronic pain were on pain medications including opioids (n = 7) and nonsteroidal anti-inflammatory drugs (NSAIDs) (n = 5), which may have affected their endogenous pain inhibitory systems.During CPM block could be an effect of CPM hypoalgesia and/or habituation is unclear. However, we emphasize the partial recovery of beta-ERS in the After CPM condition in the HC group, where the experienced CPM effect was substantial. Therefore, the reduction in the magnitude and duration of beta-ERS in the During CPM condition cannot be explained by habituation alone.Also, habituation might play a role in the current study design as it involved 3 consecutive experimental blocks with repeated test stimulus delivery. Whether the reduction in pain ratings and beta-ERS in the The present study aimed to characterize pain-induced neurophysiological responses to CPM. Amongst the 3 event-related spectral perturbations that we investigated, only beta-ERS was reduced during CPM. Based on previous findings on the involvement of beta synchronization in top-down brain processes, we discuss the finding of reduced beta-ERS as a manifestation of altered top-down modulation of pain during CPM.The authors have no conflict of interest to declare.http://links.lww.com/PR9/A206.Supplemental digital content associated with this article can be found online at


Pregnancy-associated malaria is preventable and curable with intermittent preventive treatment with Sulfodoxine-Pyrimethamine (IPTp-SP). However, despite the effectiveness of IPTp-SP against malaria in pregnancy, the uptake among pregnant women in Nigeria remains very low. Thus, this study aimed to establish the factors associated with the uptake of at least one dose and optimal doses of IPTp-SP among pregnant women aged 15 to 49 years living in Nigeria in 2018. The study included 12,742 women aged 15 to 49 years with live births two years before or during the 2018 Nigeria Demographic Health Survey (NDHS) in the analysis. Descriptive analysis was carried out to determine the prevalence of IPTp-SP uptake. Multivariable logistic regression was used to establish the factors associated with receiving IPTp-SP during pregnancy, adjusting for possible confounding factors. Given the complex survey design, all analyses are adjusted for sampling weight, stratification, and clustering. The p-value of <0.05 was considered significant. In 2018, the prevalence of at least one dose of IPTp-SP was 63.6% (95% CI:62.0–65.1), and optimal doses of IPTp-SP were 16.8% (95% CI:15.8–17.8) during pregnancy. After the multivariable analysis, age group, region, frequency of ANC visits, belief in IPTp-SP effectiveness, and morbidity caused by malaria predicted the uptake of at least one IPTp-SP dose. Similar maternal characteristics, including household wealth index, spouse’s educational level, and media exposure were significantly associated with taking optimal IPTp-SP doses. For instance, women in the wealthiest households whose husbands had secondary education predicted a four-fold increase in uptake of at least one IPTp-SP dose . The low prevalence and regional variations of IPTp-SP uptake in the study area imply that most pregnant women in Nigeria are at substantial risk of pregnancy-associated malaria. Therefore, stakeholders should explore context-specific strategies to improve the IPTp-SP coverage across the regions in Nigeria. Globally, about 1.7 billion malaria cases and 10.6 million malaria-related deaths were averted in the past two decades . EquallyIn addition, approximately 50 million pregnant women remain at significant risk of pregnancy-associated malaria and possible malaria-related death annually . The risDespite the efforts by the WHO to increase the coverage of IPTp-SP in sub-Saharan African countries, several maternal characteristics have been established as barriers to IPTp-SP uptake during pregnancy. Studies have reported that pregnant women’s attitudes and motivation to receive IPTp-SP were related to their levels of knowledge of malaria-related factors such as morbidities caused by malaria , 9. SimiThe prevalence of at least one SP dose in Nigeria has increased from 27% in 2013 to 51% in 2015 and about 64% in 2018 . HoweverThe primary study: the Nigeria Demographic Health Survey women’s data was a cross-sectional study conducted to provide estimates of the Nigerian populace’s basic demographic and health indicators. The survey included samples from 36 States, including the Federal Capital Territory (FCT). The sampling frame of the NDHS relied on the National Population and Housing Census (NPHC) carried out in 2006. Two sampling stages were carried out, and each of the 36 states and the Federal Capital Territory (FCT) were grouped into urban and rural areas to form 74 strata . First, The study population was all women aged 15 to 49 years who had live births during or two years before the survey resident in Nigeria between 2016 and 2018. This study involved the secondary data analysis of the data obtained from the NDHS Women dataset collected between August to December 2018.From the survey sampling frame, 41,821 women of childbearing ages (15 to 49 years) were interviewed. Among these women, 12,935 had live births during or two years preceding the 2018 NDHS. Of these, data from 12,742 women were extracted, who reported to have received and known the exact number of IPTp-SP doses they took during their last pregnancy. These 12,742 women served as the analysis sample for this study after the survey weighting was applied .The extraction and coding of variables from the 2018 NDHS women dataset for the analysis were guided by previous literature , and pre“Did you take SP/Fansidar to prevent you from getting malaria during pregnancy?” and “How many times did you receive SP/Fansidar during this pregnancy?” For statistical analysis, the uptake of at least one dose of IPTp-SP was categorized and coded into 0 = no dose of IPTp-SP and 1 = at least one dose of IPTp-SP (≥1 dose). The uptake of optimal doses of IPTp-SP was categorised and coded into 0 = two or fewer doses (≤ 2 doses) and 1 = at least three doses of IPTp-SP (≥ 3 doses) [The outcome variables are the uptake of at least one dose of IPTp-SP and optimal doses of IPTp-SP during pregnancy. The outcomes were created using responses from the following NDHS survey questions : “Did yo3 doses) , 20.The extracted exposure variables were either sub-grouped into the following factors empirically or associated with the uptake of IPTp-SP theoretically: sociodemographic, pregnancy-related, and knowledge of malaria-related factors. Sociodemographic factors include residential areas, age in years, household wealth index, the highest level of education, region, religion, employment, and spouse’s educational attainment. Pregnancy-related factors include frequency of ANC visits, the timing of first ANC initiation, and parity. In addition, knowledge of malaria-related factors include belief in the effectiveness of IPTp-SP, belief about malaria morbidity, subscription to health insurance, and media exposure. The household wealth index was derived in the primary study (NDHS 2018) by scoring each number and asset owned by the selected households using principal component analysis (PCA). The assets ranged from a television to a bicycle or car, and housing characteristics such as the source of drinking water, toilet facilities, and flooring materials. Then, the National wealth quintile or index was compiled by allocating the household score to each usual (de jure) household resident. Subsequently, the household population was divided into five equal categories from poorest to richest .“Does malaria preventive medicine keep the mother healthy?” and “Does malaria preventive medicine keep the baby healthy?” Also, the level of belief score about malaria morbidity was derived from the following four survey questions [“Can malaria lead to death?” “Can malaria make people dangerously sick?” “Only weak children die of malaria?” “Do you worry about malaria can be cured?” The women’s responses to the abovementioned questions asked in the Nigeria DHS were scored using a three-point Likert scale such that 1 = Disagree, 2 = Do not know, and 3 = Agree [The score for the level of belief in the effectiveness of IPTp-SP and malaria morbidity was generated using a three-point Likert scale . The levuestions : “Can ma = Agree . After t = Agree , 23, theet al., 2017 [Data extraction, cleaning, re-coding, and analysis were done using Stata version 16. The extracted data were restricted to only women with live births during or two years before the 2018 NDHS. However, in creating the outcome variable, women who did not know if they took SP/Fansidar and the number of doses of SP/Fansidar taken were dropped, that is, 171 and 127 women, respectively. All selected exposure variables were categorical, and the missing observations across the exposure variables were reported as missing responses. Finally, the cleaned dataset was saved independently and converted into a survey dataset by applying the weighting, stratification, and clustering. Proportions and frequencies were used to summarise all categorical variables for the descriptive analysis. At the same time, bivariate and multivariable logistic regression were used in the analytical analysis. The bivariate and multivariable logistic regression models were fitted using a four-step approach for modelling survey data as Heeringa l., 2017  and Hosml., 2017  recommenFirst, we fitted a bivariate logistic regression model to estimate the association of the outcome variables  to each exposure variable. Second, all exposure variables with a p-value of <0.10 from the bivariate models were selected as candidates for main effects in the multivariable logistic regression model. Building the final multivariable logistic regression model involved an iterative process—the exposure variables of importance identified by previous studies were arranged from highest to the least importance. Third, we fitted different model specifications by manually adding or dropping each exposure variable and performing the adjusted Wald test to assess each exposure variable’s contribution to the model. Lastly, scientifically plausible interactions among the exposure variables were checked. The interaction term was assessed by specifying factorial interaction using binary operators (##). The selection of the variables to interact was based on epidemiological notions or from previous literature. However, the selected multivariable logistic regression model accounted for only interaction terms with a p-value <5%. Then, the fit of the final model was assessed using the Hosmer-Lemeshow goodness-of-fit test. The final models estimated the adjusted odds ratios (aORs). The significance level used was less than 5% (<0.05), two-tailed at 95% confidence intervals.M2011103.The Nigeria DHS 2018 was conducted by the Nigerian Population Commission in collaboration with the National Malaria Elimination Programme (NMEP) of the Federal Ministry of Health, Nigeria. Before each interview during the 2018 NDHS survey, all respondents above 18 years provided written informed consent, and for those under 18 years of age, written informed consent was obtained from the parent/guardian. The fieldworker ensured confidentiality throughout the survey process, and the respondents’ records were coded and de-identified . For thiThe study included 12,742 pregnant women between 15 and 49 years with live births from the 2018 NDHS whose mean age was 28.3 ± 6.7 years old. The study participants were selected from all the six regions  in varying proportions, however, majority of them were living in Northwest Nigeria. 12,180 (95.6%) were married or living with a man, while 561 (4.4%) were single, divorced or widows. Of these women, 6692 (52.7%) had less than four children, whereas 6049 (47.5%) had four or more children. Also, more than half of the women, 7888 (61.9%), resided in the rural areas of Nigeria. In addition, the distribution of study participants varied depending on maternal characteristics; 5,766 (45.3%) of study participants had no formal education, and 4568 (35.9%) of them had husbands/spouses with no formal education. Although 8827 (69.3%) of the study participants were gainfully employed, only 2.0% subscribed to health insurance coverage. Furthermore, 75.8% of them attended ANC services during pregnancy, of which 56.1% visited the ANC clinic more than four times in 2018. In the same year, almost half (47.1%) of the study participants commenced ANC services in their second trimester. Details of the characteristics of the study participants are presented in The estimated prevalence of at least one IPTp-SP dose was 63.6% (95% CI: 62.0–65.1), and three or more IPTp-SP doses were 16.8% (95% CI:15.9–17.8) among pregnant women in Nigeria . Yet, thThe results indicated that all selected maternal characteristics were independently associated with receiving at least one IPTp-SP dose during pregnancy . Yet, afAll included maternal characteristics in the study were independently associated with the uptake of at least three IPTp-SP doses . HoweverThis study established the pattern of IPTp-SP usage and the factors associated with the uptake of at least one dose and at least three doses of IPTp-SP among pregnant women in Nigeria. The study found regional disparities and a low IPTp-SP uptake during pregnancy. Several maternal characteristics such as, age group, education, antenatal care attendance, household wealth index and spouse’s educational attainment were found to contribute to the low IPTp-SP uptake during pregnancy in Nigeria.et al., 2013, differences in maternal characteristics across and within countries in sub-Saharan Africa contributed to low coverage of IPTp-SP uptake during pregnancy [et al., 2020 reported that the prevalence of taking optimal IPTp-SP doses was significantly below 25% in DR Congo, Madagascar and Nigeria [In this study, compared with at least one SP dose at 63.6%, the prevalence of three or more SP doses was much lower at 16.8% among pregnant women in Nigeria. These findings fall significantly below the National Malaria Elimination Programme’s stipulated target for 100% of pregnant women attending ANC in Nigeria to receive at least three IPTp-SP doses by 2020 . A simil Nigeria , Ghana [ Nigeria , respectet al., 2019 in Nigeria [et al., 2015 in Tanzania [et al., 2013 [Several sociodemographic characteristics were established as factors associated with the uptake of at least one IPTp-SP dose. In terms of age group, women aged 35 years and above had higher odds of receiving at least one IPTp-SP dose during pregnancy. This finding was consistent with Olugbade  Nigeria  and KibuTanzania . The higTanzania . In contl., 2013 . Women rl., 2013 . This rel., 2013 . This evl., 2013 .et al., 2018, who established a similar relationship in malaria-endemic countries [et al., 2020 found that pregnant women from the wealthiest households have increased IPTp-SP uptake than those from the poorest households in Nigeria [This current study indicated that pregnant women’s educational status negatively predicted optimal IPTp-SP uptake during pregnancy in Nigeria. This finding agrees with Yaya ountries . The resountries . The finountries . Utilisiountries , 11. How Nigeria et al., 2013, a study conducted in SSA countries, including Nigeria [Early commencement of ANC services (timing of ANC initiation) implied an increased likelihood of initiating the first dose and completing at least three IPTp-SP doses during pregnancy. This finding aligns with the new IPTp-SP policy, which recommends the uptake of the first IPTp-SP dose after the first trimester during pregnancy and then successive IPTp-SP doses received in each scheduled ANC visit at a one-month interval . Studies Nigeria . Among t Nigeria , a short Nigeria , occasio Nigeria , 36 and  Nigeria .et al., 2020, that knowledge about the efficacy of SP predicts the receipt of the first SP dose, and ultimately, the subsequent IPTp-SP doses during pregnancy [et al., 2019 found that a lack of awareness of malaria-associated morbidity reduced the odds of taking SP by pregnant women in Mozambique [et al., 2020 found an increased IPTp-SP uptake among women with health insurance coverage in Ghana [The finding suggests that exposure to malaria-related messages via media at least once a week may increase the odds of being aware of the benefits of IPTp-SP during pregnancy. This increased awareness may translate to higher chances of taking three or more IPTp-SP doses by pregnant women. Similar results have been found in Ghana , Uganda regnancy . Also, pzambique . These fin Ghana . The difin Ghana .The major strength of this study was using a nationally representative sample to establish the factors related to IPTp-SP uptake. Next, the sample used was considerably large . Therefore, the findings may be generalizable to Nigerian women with live births on the factors that may influence the effective delivery of IPTp-SP during pregnancy. However, it is essential to note the following limitations in considering the factors associated with IPTp-SP use among women with live births in Nigeria: first, the established factors associated with IPTp-SP use do not imply causality because of the cross-sectional nature of the study design. Secondly, this study could not assess pregnant women’s attitudes and healthcare-related constraints concerning IPTp-SP use because the analysis was limited to the variables in the 2018 NDHS questionnaire. Therefore, there is a likelihood that women who attended at least four ANC visits during pregnancy did not receive IPTp-SP because the drug was out of stock. Third, excluding women who had stillbirths may have resulted in selection bias. The exclusion might have reduced the estimated effect of each possible factor on the uptake of IPTp-SP . Fourth,There is low uptake of at least one IPTp-SP dose and an even lower uptake of three or more doses by pregnant women in Nigeria. This low uptake of IPTp-SP was associated with several maternal characteristics, age group, education, antenatal care attendance, household wealth index, and trust in the efficacy and safety of SP. Therefore, there is a need for context-specific strategies such as targeted mass sensitisation and community awareness to increase the coverage of IPTp-SP uptake among vulnerable women. In addition, future research should explore the drivers of region-specific low uptake of optimal doses among pregnant women, especially in South-West Nigeria. IPTp-SP uptake remains suboptimal despite a relatively high antenatal care attendance among pregnant women in Nigeria. This situation calls for urgent action to deploy region-specific strategies to mitigate the bottlenecks (such as drug stock-out and non-compliance to the guidelines) at the healthcare facilities that hinder the delivery of IPTp-SP via ANC clinics in Nigeria. Also, pregnant women’s belief in the effectiveness of IPTp-SP influences their decision to initiate antimalarial treatment. Therefore, future research should examine the effectiveness of social-behavioural change communication strategies in driving the uptake of three or more IPTp-SP doses during pregnancy in Nigeria.S1 TableThis is the extension of (DOCX)Click here for additional data file.S2 TableThis is the initial model without the interaction term for the uptake of at least one SP dose.(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.


The success of brain-targeted gene therapy and therapeutic genome editing hinges on the efficient delivery of biologics bypassing the blood–brain barrier (BBB), which presents a significant challenge in the development of treatments for central nervous system disorders. This is particularly the case for nucleic acids and genome editors that are naturally excluded by the BBB and have poor chemical stability in the bloodstream and poor cellular uptake capability, thereby requiring judiciously designed nanovectors administered systemically for intracellular delivery to brain cells such as neurons. To overcome this obstacle, various strategies for bypassing the BBB have been developed in recent years to deliver biologics to the brain via intravenous administration using non-viral vectors. This review summarizes various brain targeting strategies and recent representative reports on brain-targeted non-viral delivery systems that allow gene therapy and therapeutic genome editing via intravenous administration, and highlights ongoing challenges and future perspectives for systemic delivery of biologics to the brain via non-viral vectors. Overcoming the blood-brain barrier is key to treating central nervous system disorders with gene therapy.Non-viral delivery systems offer a promising alternative to traditional viral vectors.The review covers various strategies for enhancing brain-targeted gene therapy via non-viral delivery systems and future challenges. Central nervous system (CNS) disorders, including neurodegenerative diseases such as Alzheimer’s disease (AD) and Parkinson’s disease, neurodevelopmental disorders such as autism spectrum disorder and Rett syndrome, brain cancers, and stroke, impact hundreds of millions of people globally , 2. As mThe development of a safe and efficient delivery vector is a critical engineering challenge for gene therapy and therapeutic genome editing . Both viNon-viral vectors offer a promising alternative to address the limitations of viral vectors in brain-targeted gene therapy and therapeutic genome editing through systemic administration , 24–26. In this review, we aim to provide a comprehensive overview of recent advances in the development of non-viral delivery systems for gene therapy and therapeutic genome editing targeting the brain. The importance of this review lies in the fact that effective delivery of biologics to the brain remains a significant challenge due to the presence of the BBB. We start with a brief review on the structure of the BBB. Then, we discuss various brain targeting strategies and representative non-viral brain-targeted delivery systems for gene therapy and therapeutic genome editing via intravenous administration Table . FinallyThe BBB is formed by the tight junctions between the specialized endothelial cells lining the blood vessels of the brain Fig.  2, 26, , 69. TheThere are several ways for molecules to cross the BBB which can be used for brain delivery Fig. d 2, 26], 262, 26Existing strategies for bypassing the BBB to deliver therapeutic agents to the CNS include targeting specific receptors and transporters, as well as using physical and biological mechanisms. In this section, we will discuss these strategies: (1) receptor-mediated transcytosis using ligands targeting transferrin (Tf) receptor, nicotinic acetylcholine receptor (nAChR), low-density lipoprotein receptor-related protein 1 (LRP1), glucose transporter 1 (GLUT1), and neurotransmitter receptors; (2) non-receptor-mediated transport facilitated by cell-penetrating peptide; (3) physical strategies using focused ultrasound; and (4) biological strategies like exosomes. Each of these strategies has unique characteristics that make them promising for delivering therapeutics to the CNS.One strategy to overcome the BBB for nanoparticle delivery to the brain involves targeting the membrane-bound Tf receptor on brain capillary endothelial cells (BCECs) , 73. The. developed Tf-modified nanosystems to deliver nucleic acid therapeutics to the brain , 3230, 3CPPs and CPP-conjugated nanovectors, possess unique capabilities to facilitate the translocation of membrane-impermeable molecules, such as siRNA, mRNA, and pDNA, into cells by crossing cell membranes , 82. RecPlk1 gene decreased the cell viability from 47.2% to 20.7% in U87 cells, and from 41.7% to 19.8% in GS5 cells, compared with LHNP-mediated delivery of pDNA encoding sgRNA targeting Plk1 gene. The LHNP treatment led to a 60.4% decrease in PLK1 expression in the tumor site and significantly inhibited tumor growth and prolonged the median survival time from 29 days  to 40 days in tumor-burdened mice.Zhou et al. designed liposome-templated hydrogel nanoparticles (LHNPs) to deliver the CRISPR-Cas9 genome editor to the brain . The LHNXu et al. reported the integration of neurotransmitter (NT)-derived lipidoids in solid lipid nanoparticles (LNPs) enhanced brain delivery through intravenous injection . NTs areMicrobubble-assisted FUS has gained attention as a promising technique for delivering therapeutic agents to the brain Fig. . By intr. developed a DNA-loaded microbubble for brain delivery via intravenous injection [. reported a folate-conjugated pDNA-loaded cationic microbubble for brain delivery [Early efforts focused on the use of cationic microbubbles for nucleic acid delivery to the brain facilitated by FUS , 85, 86.njection . With thdelivery . With FU. developed a series of strategies using brain-penetrating nanoparticles (BPNs) combined with MRI-guided FUS and microbubbles for gene therapy in the brain through intravenous injection [The major limitations of cationic microbubbles include limited delivery efficiency, the need for high doses of pDNA, and stability issues with the microbubble-pDNA complex in the bloodstream , 85, 87.njection –65. The njection . The tranjection . After a. studied FUS/microbubble-assisted BBB opening for the intravenous delivery of mRNA-loaded LNP to the brain [2, which efficiently opened the BBB without causing harm such as hemorrhage or edema. The mRNA expression, as measured by luciferase, was only observed in the FUS-irradiated side of the brain and the luciferase expression occurred only when FUS and microbubbles were applied. The mRNA-mediated protein expression was faster but shorter-lived compared to pDNA. However, mRNA-mediated protein expression was only observed in the microglia and endothelial cells, but not in astrocytes or neurons.The strategy of combining FUS/microbubbles and nanoparticles was extended to mRNA delivery in the brain using LNP. In a recent study, Kawakami et alhe brain . The opt. developed dendritic cell-derived exosomes that can deliver siRNA to the brain in mice [Exosomes are another emerging and promising nanotechnology for new therapeutics and diagnostics. These cell-derived, small vesicles with a diameter of 40–100 nm are actively secreted by most cell types . Their b in mice . The bra in mice , 89, theThere is a need to further enhance the efficiency and specificity of non-viral vectors for brain targeted delivery. It is known that non-viral vectors often have a lower transfection/genome editing efficiency compared to viral vectors such as AAV , 11, becIt is important to highlight that most published work on in vivo experiments for brain delivery has been conducted in mouse and rat models. There are several major differences between rodents and humans that can impact the effectiveness, safety, and scalability of delivery methods. These differences include (1) differences in brain anatomy, including the BBB, which can impact the effectiveness of the strategies to bypass the BBB and transport vectors within the brain parenchyma –95; (2) Due to the BBB, delivering therapeutic biologics to the CNS is challenging both technically and clinically. There are only a limited number of delivery systems that have progressed to human clinical trials Table . This li


Proteins and RNAs are primary biomolecules that are involved in most biological processes. Coding RNAs are responsible for gene expression and protein synthesis, whereas non-coding RNAs are involved in various biological regulations within cells . ProteinIn recent decades, several experimental techniques have been developed to determine the structures of proteins and RNAs. X-rays incident on crystal interiors and then diffract in different specific directions. X-ray crystallography was the most effective experimental technique to determine the structure from a three-dimensional electron density map in recent decades . NMR anaSeveral computational methods have been developed to predict protein and RNA tertiary structures. For example, Alphafold2 outperforms other traditional methods in the 14th and 15th Critical Assessment of protein Structure Prediction (CASP14 and CASP15) and triggered a revolution in the science community ,8,9. ForThere are many cutting-edge techniques to solve challenging problems in RNA and protein studies ,17. This


Introduction: The ferritin–lymphocyte ratio (FLR) is a novel inflammatory biomarker for the assessment of acute COVID-19 patients. However, the prognostic value of FLR for predicting adverse clinical outcomes in COVID-19 remains unclear, which hinders its clinical translation. Methods: We characterised the prognostic value of FLR in COVID-19 patients, as compared to established inflammatory markers. Results: In 217 study patients , FLR was weakly correlated with CRP  and white cell count . On ROC analysis, an FLR cut-off of 286 achieved a sensitivity of 86% and a specificity of 30% for predicting inpatient mortality . The negative predictive values of FLR for ruling out mortality, non-invasive ventilation requirement and critical illness (intubation and/or ICU admission) were 86%, 85% and 93%, respectively. FLR performed similarly to CRP  for predicting mortality, but worse than CRP for predicting non-fatal outcomes . On Kaplan–Meier analysis, COVID-19 patients with FLR values > 286 had worse inpatient survival than patients with FLR ≤ 286, p = 0.041. Conclusions: FLR has prognostic value in COVID-19 patients, and appears unrelated to other inflammatory markers such as CRP and WCC. FLR exhibits high sensitivity and negative predictive values for adverse clinical outcomes in COVID-19, and may be a good “rule-out” test. Further work is needed to improve the sensitivity of FLR and validate its role in prospective studies for guiding clinical management. In patients with acute coronavirus-19 (COVID-19), clinical risk stratification is important for guiding management decisions ,3,4,5. OSerum ferritin is an inflammatory marker that increases in response to systemic infection and exhibits both host-protective and immuno-modulatory functions . Whilst Lymphopenia is commonly observed in acute COVID-19 . LymphocDespite early promise, the biomarker characteristics and prognostic value of FLR in relation to established inflammatory markers, such as C-reactive protein (CRP) and white cell count (WCC), remain unknown. Furthermore, the prognostic value of FLR has not been re-assessed in another centre or a different COVID-19 patient population, meaning that the potential expansive usefulness of FLR remains largely unknown. These unknown factors significantly limit the clinical applicability of this novel biomarker, and require elucidation.In this study, we set out to characterise FLR as a biomarker in terms of the following: (i) its distribution within an acute COVID-19 population; (ii) its correlation with other inflammatory markers; and (iii) its predictive value for adverse clinical outcomes as compared to established markers of infection. We also sought to further assess the prognostic value of FLR in a different COVID-19 population to the previous report, to assess the replicability of this biomarker. We hypothesised that FLR has good prognostic value in acute COVID-19 patients.n = 1); were transferred to another hospital during their admission and lost to follow-up (n = 1); had been treated at another hospital prior to admission (n = 2); or had ferritin assessed later than 24 h post admission (n = 2). A final total of 217 patients were included in the study.The study population included patients admitted to a UK general hospital  between 3 February 2020 and 9 May 2020. Patients were included if they (i) were 18 years or older, (ii) had been diagnosed with acute COVID-19 using real-time reverse transcriptase polymerase chain reaction (PCR) testing of nasopharyngeal swabs, or (iii) had serum ferritin and lymphocyte assessment on admission to hospital. Patients were excluded if they did not undergo assessment of other inflammatory markers such as CRP on admission  and Health and Care Research Wales (HCRW), UK.9/L), as per conventional units  and 60% of the patients were males . Patientp = 0.026), higher CRP levels (p = 0.001) and lower lymphocyte counts (p = 0.015) compared to survivors  and WCC  and WCC  for predicting mortality.For predicting inpatient mortality in acute COVID-19 patients, FLR achieved an AUC of 0.60  and WCC  for predicting NIV requirement. FLR performed similarly to WCC  for the same purpose.For predicting the non-invasive ventilation (NIV) requirement, FLR achieved an AUC of 0.55 , but not WCC , for predicting critical illness. FLR performed similarly to WCC  for the same purpose. The diagnostic performance of FLR for adverse clinical outcomes in acute COVID-19 patients is summarised in For predicting critical illness (a composite of intubation and/or ICU admission), FLR achieved an AUC of 0.58  had worse inpatient survival compared to patients with other FLR levels,  = 0.041 .This study characterised the use of ferritin–lymphocyte ratio (FLR) for assessing prognosis in patients with acute COVID-19, and its relationship with other established inflammatory markers. The main findings are as follows: (i) on a patient group basis, high FLR values appear to be linked to impaired inpatient survival; (ii) on an individual-patient basis, FLR has relatively high sensitivity and negative predictive values  for predicting adverse clinical outcomes; (iii) FLR has a positively skewed distribution within the study population; (iv) FLR is weakly correlated with other established inflammatory markers; and (v) FLR performed similarly to CRP for predicting adverse clinical outcomes in acute COVID-19 patients.The results suggest that FLR may be a good rule-out test for adverse outcomes in COVID-19, similar to other diagnostic tests previously investigated ,23,24. FAygun et al. showed in 331 COVID-19 patients that FLR demonstrated high sensitivity for predicting inpatient mortality . The curThe prognostic value of FLR was further demonstrated in the current study using Kaplan–Meier analysis. Patients with FLR values below the 286 (Youden point) threshold identified on ROC curves had consistent inpatient survival, which was significantly better than patients with FLR above the 286 threshold. This suggests that using this threshold, there may be a scope for FLR to select low-risk (vs. high-risk) patients, which deserves further investigation.In the study by Aygun et al., FLR achieved an AUC of 0.909 on ROC analysis for predicting inpatient mortality , which iEffective combinations are commonplace in medicine, ranging from clinical risk scores ,26,27 toIn addition to validating the prognostic value of FLR, the current study puts FLR into further context by comparing it to other established inflammatory markers in widespread clinical use, namely WCC and CRP. Whilst FLR was comparable to WCC for predicting adverse outcomes in COVID-19 overall, FLR underperformed compared to CRP in this regard. The results suggest that FLR may be better used in combination with clinical assessment and other biomarkers rather than as a standalone prognostication tool in COVID-19 patients. The combined use of FLR and CRP for risk-stratifying COVID-19 patients deserves further validation.The weakness of FLR appears to lie in its low specificity for adverse outcomes. Although diagnostic cutoffs are arbitrary and changing the FLR threshold would alter the sensitivity and specificity balance, improving the overall specificity of FLR in COVID-19 appears to be an important target of any further work aiming to bring this biomarker into clinical practice.Improving the specificity of FLR for infections requires the fine-tuning of both ferritin and lymphocyte count as prognostic markers. Ferritin, by nature, is a non-specific acute-phase reactant with multiple mechanisms of action in host–pathogen interactions . It may Low lymphocyte counts occur not only in acute COVID-19 but also in other viral infections . TherefoThis was a retrospective analysis, and larger studies are required to improve the specificity of FLR. Given the high sensitivity and negative predictive values of FLR for predicting adverse clinical outcomes in acute COVID-19 and its ability to stratify patients with preserved and impaired survival, FLR is a combination biomarker that deserves further development. One of the important obstacles to overcome in any biomarker introduction lies in standardising the method of its measurement. Thus far, only two studies (Aygun et al.  and thisIron overload can be an important confounder to ferritin and FLR in the assessment of COVID-19 severity. Indeed, iron overload is known to be important in the pathogenesis of COVID-19 . FurtherFLR has prognostic value in COVID-19 patients, and appears unrelated to other inflammatory markers such as CRP and WCC. FLR exhibits high sensitivity and negative predictive values for adverse clinical outcomes in COVID-19 and may be a good “rule-out” test. Further work is needed to improve the sensitivity of FLR and validate its role in prospective studies for guiding clinical management.