ObjectiveAnxiety sensitivity (AS) is an issue that has gained importance in obsessive-compulsive disorder (OCD) in recent years. Family accommodation (FA) is the participation of family members in compulsions and rituals. The objectives of this study were to (1) investigate the relationship between FA and AS in OCD and (2) determine the frequency and types of FA in a Turkish OCD sample.MethodsThis cross-sectional study was conducted with 81 OCD patients. The Yale-Brown Obsession Compulsion Scale (YBOCS), Family Accommodation Scale-Patient Form (FAS-PF), Anxiety Sensitivity Index-3 (ASI-3), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) were administered to the patients.ResultsFamily accommodation was extremely prevalent among family members of OCD patients. There were significant relationships between FA and ASI-3 total, ASI-3 cognitive subscale, ASI-3 psychical subscale, YBOCS, and BAI scores. In addition, ASI-3 total, ASI-3 cognitive subscale, and ASI-3 psychical subscale were significant predictors for family accommodation above and beyond the OCD severity.ConclusionsThe present study identified a significant association between anxiety sensitivity and family accommodation in OCD. Anxiety sensitivity is a relievable psychological trait. Alleviating anxiety sensitivity can decrease accommodating behaviors and may be beneficial in OCD treatment. Anxiety sensitivity may be a novel potential treatment target for OCD. Obsessive-compulsive disorder (OCD) is a chronic mental illness characterized by obsessions and compulsions that are common all over the world. Obsessive-compulsive disorder is time-consuming and causes clinically significant distress and impairment in social, occupational, or other important areas of functioning . There aObsessions cause intense anxiety and distress, and the patients perform compulsions or avoidance behaviors to reduce this distress. Relatives of the patient who witness the intense distress and anxiety felt by the patient may facilitate, allow, or sometimes participate in compulsions, rituals, or avoidance behaviors in order to alleviate the negative experiences and distress of the patient related to the disorder. This phenomenon seen in OCD is called family accommodation (FA). Family accommodation can occur in several ways. Family members may actively participate in compulsions, for example, by cleaning unpolluted surfaces together with the patient. They can prevent the triggering stimuli that elicit obsessions by taking the clothes to a specific place requested by the patient without touching anything when they come from outside. They do not interfere with the compulsions by ignoring the patient washing his or her hands for a long time.Family accommodation is highly prevalent among the relatives of patients with OCD, with rates ranging from 62% to 100% . AlthougAnxiety sensitivity (AS) is conceptualized as a feature that reflects an individual's propensity to fear the consequences of anxiety or anxious arousal. Because the person believes that anxiety or anxious arousal can lead to physical, psychological, or socially harmful results , a persoAnxiety sensitivity has historically been examined within the context of anxiety disorders. There are persuasive results indicating that AS plays a crucial role in the onset and persistence of several anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress disorder. There has been a growing body of literature on the importance of AS in OCD in recent years after studies related to anxiety disorders. Several studies have demonstrated that OCD patients have greater levels of AS compared to healthy individuals and that greater AS is significantly associated with severe OCD symptoms and poor treatment outcomes ,9. In adThe aim of this study was to (1) examine the relationship between FA and AS in OCD and (2) determine the frequency and types of FA in a Turkish OCD sample. We hypothesize that there would be a significant relationship between family accommodation and anxiety sensitivity in obsessive-compulsive disorder. We also hypothesize that family accommodation would be very prevalent among the family members of OCD patients.Participants and proceduresThe present study was conducted with patients diagnosed with OCD admitted to the psychiatry outpatient clinic of Balıkesir Atatürk City Hospital, a tertiary care hospital in Balıkesir, Turkey. Ninety-four patients aged 18-65 who volunteered to participate in the study and who had been living with a relative older than 18 years old for at least six months were enrolled in the study. The exclusion criteria were as follows: schizophrenia/psychotic disorders; bipolar disorder; active alcohol and substance use disorder; mental retardation; a severe neurological disorder that may interfere with the scale results ; and the diagnosis of any mental illness in the family member evaluated for FA. Thirteen patients were excluded from the study . Finally, the study was carried out with 81 patients.A psychiatrist with expertise in OCD administered the clinician version of the Structured Clinical Interview for The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Disorders (SCID-5-CV)  to patieInformed consent was obtained from all participants. Ethics committee approval was obtained from the Ethics Committee of Balıkesir Atatürk City Hospital (date and number: 2023/4/35).MeasuresThe Yale-Brown Obsession Compulsion Scale (YBOCS)The Yale-Brown Obsession Compulsion Scale is a semi-structured instrument measuring the severity of OCD. Five items measure the severity of obsessions, and five items measure the severity of compulsions. Each item is scored between 0 and four. The sum of 10 items indicates the severity of the disorder. Higher scores indicate severe OCD symptoms . TurkishFamily Accommodation Scale for Obsessive-Compulsive Disorder, Patient Version (FAS-PV)It is a self-report scale that assesses the nature and frequency of family accommodation behaviors in OCD. It consists of two parts. The first part is a symptom checklist that provides information about OCD symptoms. Part two consists of 19 items that assess the type and frequency of accommodating behaviors of family members in the last week. Items are rated by the patient in terms of frequency on a scale of 0-four . The total score is obtained by summing the 19 items in Part Two. High scores indicate severe accommodating behaviors . The TurAnxiety Sensitivity Index-3 (ASI-3)It is a self-report questionnaire that measures anxiety sensitivity multi-dimensionally. The ASI-3 consists of 18 items with physical, cognitive, and social subdimensions, of which each subdimension has six items. Cognitive concerns are associated with the belief that concentration difficulties or overspeeding of thoughts lead to insanity. Social concerns are associated with the belief that manifestations of anxiety reactions in public  lead to social rejection or derision. Physical concerns are associated with the misinterpretation of anxiety-related bodily sensations as causing catastrophic physical illnesses. Each item is a 5-point Likert-type measure scored between 0 and four. The score that can be obtained from the scale is between 0-72. High scores on the scale indicate increased anxiety sensitivity . A TurkiBeck Depression Inventory (BDI)The BDI is a 21-item self-report scale that measures the severity of depressive symptoms. Each item is scored between 0 and three, and the total score ranges from 0 to 63. A higher total score indicates more severe depression symptoms .Beck Anxiety Inventory (BAI)This is a 21-item self-report scale that measures the level of anxiety symptoms. Each item is scored from 0 to three, and the total score ranges from 0 to 63. Higher total scores indicate more severe anxiety symptoms .Statistical analysisData were analyzed using IBM SPSS Statistics software for Windows, Version 26.0 . Descriptive statistics were expressed as the mean ± standard deviation, number, and percentage. The normal distribution was tested using the Z score, histograms, and normal probability plots (q-q plots). A chi-square test was used to analyze categorical variables. Pearson’s correlation analysis was used to evaluate the correlations between family accommodation and various clinical variables. A multivariate hierarchical regression analysis was performed to determine whether AS was a predictor of FA. Statistical significance was set at p < 0.05.The present study was conducted with 81 patients diagnosed with OCD. The mean age was 34,5 ± 11,7 years, with 53.1% (n = 43) of the participants being female; 55.6% (n = 45) of the patients were married; and the mean period of education was 10.5 ± 3.5 years. The demographic and clinical characteristics of the patients are presented in Table There were 77 (95.1%) family members who engaged in at least one accommodating behavior in the previous week. There were 31 (39.5%) family members who engaged in at least one accommodating behavior every day. The most common family-accommodating behaviors in our sample were providing reassurance, waiting for compulsions, tolerating OCD behaviors, and facilitating compulsions Table .To examine the relationship between FA and variables of interest, Pearson’s correlation analysis was conducted between the FAS-PV score and variables including Y-BOCS, ASI-3 Total, ASI subscales, BDI, and BAI. The FAS-PV score was significantly correlated with ASI-3 total, ASI-3-physical subscale, ASI-3-cognitive subscale, Y-BOCS total, Y-BOCS obsessions, Y-BOCS compulsions, and BAI scores. The FAS-PV did not exhibit a significant correlation with the ASI-3-social subscale. Higher scores on the ASI-3  were related to higher scores on family accommodation , and BAI scores, which were found significant in bivariate analyses, were added to the model as independent variables. Preliminary analyses of regression models indicated no threats to normality, multicollinearity, or homoscedasticity.2): 0.49, p < 0.001). In the second step, adding the ASI-3 total and BAI significantly increased the variance accounted for . The final model accounted for 68% of the variance and was significant . In the final model, ASI-3 total and YBOCS total emerged as significant individual predictors for family accommodation. In addition, ASI-3 total was a significant predictor for family accommodation above and beyond OCD symptom severity . In the second step, adding the ASI-3 cognitive, physical, and social subscale scores and BAI significantly increased the variance accounted for . The final model accounted for 75% of the variance and was statistically significant . In the final model, ASI-3 physical, ASI-3 cognitive subscales, and YBOKS total emerged as significant individual predictors of family accommodation. The ASI-3 physical and ASI-3 cognitive subscales specifically were a predictor of family accommodation after controlling for OCD severity  were independent predictors of FA even after controlling for OCD severity. Anxiety sensitivity is a highly malleable construct and could be a novel potential target for OCD treatment. Alleviating AS can facilitate ERP and decrease accommodating behaviors. Reducing AS may be beneficial for the treatment of OCD symptoms, both directly and indirectly, by attenuating FA.


The SARS-CoV-2 Omicron variant has replaced the previously dominant Delta variant because of high transmissibility. However, studies on the impact of the Omicron variant on the severity of COVID-19 are still limited in developing countries. Our study aimed to determine the prognostic factors for the outcomes of patients infected with SARS-CoV-2 Omicron and Delta variants, including age, sex, comorbidities, and smoking.In this retrospective cross-sectional study, we involved 352 patients with COVID-19 from Yogyakarta and Central Java provinces, Indonesia, from May 2021 to February 2022, consisting of 164 males and 188 females. We included all patients with the PCR’s Ct value of less than 30 for further whole-genome sequencing.p = 0.146 and 0.273, respectively). Patients infected with Omicron (n = 139) and Delta (n = 213) variants showed similar hospitalization (p = 0.396) and mortality rates (p = 0.565). Multivariate analysis of both groups showed that older age (≥ 65 years) had a higher risk for hospitalization  and fatalities . In both groups, patients with cardiovascular disease had a higher risk for hospitalization , whereas patients with diabetes revealed a higher risk for fatalities .Ct value and mean age of COVID-19 patients were not significantly different between both groups (Our study shows that patients infected with Omicron and Delta variants reveal similar clinical outcomes, including hospitalization and mortality. Our findings further confirm that older age, cardiovascular disease, and diabetes are substantial prognostic factors for the outcomes of COVID-19 patients. Our findings imply that COVID-19 patients with older age, cardiovascular disease, or diabetes should be treated comprehensively and cautiously to prevent further morbidity and mortality. Furthermore, incomplete data on vaccination status hampered us from analyzing further its impact on hospitalization and mortality in our patients.The online version contains supplementary material available at 10.1186/s12920-023-01637-1. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the ongoing global pandemic of Coronavirus disease 2019 (COVID-19) . TherefoThe Omicron variant B.1.1.529) was first identified in a sample collected in Botswana on November 11, 2021. However, South Africa first reported it on November 24, 2021. Only within two days, the World Health Organization classified Omicron as a variant of concern (VOC) on November 26, 2021 , single-stranded cDNA was synthesized from total RNA extracted from the samples of COVID-19 patients by SuperScript™ III First-Strand Synthesis System . Subsequently, the second strand was synthesized by COVID-19 ARTIC v3 primer pool design by SARS-CoV-2 ARTIC Network using Phusion™ High-Fidelity DNA Polymerase . The library preparations were performed using the Illumina DNA Prep . The Illumina MiSeq next-generation sequencer was used to perform the WGS of SARS-CoV-2. The genomes of our samples were assembled and mapped into the reference genome from Wuhan, China  using Burrow-Wheeler Aligner (BWA) algorithm embedded in UGENE v. 1.30 .https://mafft.cbrc.jp/alignment/server/). The neighbor-joining statistical method with 1,000 bootstrap replications  was used to construct a phylogenetic tree from 29.409 nucleotide length of the open reading frame (ORF) of SARS-CoV-2, followed by computation of the evolutionary distances and model of the rate variation among sites by the Kimura 2-parameter method and the gamma distribution with estimated shape parameter (α) for the dataset, respectively ; Here, we show that the outcomes of patients infected with the Omicron variant might be similar to patients infected with Delta variant regarding the hospitalization and mortality rates. Our findings were different from previous reports –12. NybePrevious studies showed that older age and comorbidities are significant prognostic factors for hospitalization and mortality ,, 31, 32Children were hospitalized more during the Omicron surge than during another variant surge . The risA previous study showed that the Ct value of Omicron was significantly higher than Delta, implying that higher transmission of Omicron does not necessarily associate with its viral load . Their fAlthough, according to Lewnard et al., the clinical outcome of Omicron is less severe than Delta, it should be noted that Omicron has higher transmissibility and immune escape from previous COVID-19 infection and vaccination. These findings caused an extraordinary surge of COVID-19 globally and might affect the healthcare systems, including high absolute numbers of hospital admission and mortality rates . Indeed,Several limitations are noted in our study: the design of a retrospective study, incomplete data on vaccination and previous infection of COVID-19, data based on hospital admission but no data from the ICU admission unit and the use of mechanical ventilation, no follow-up data for patients after discharge from hospital, incomparable sample size between Delta and Omicron variants, and selection bias of subject patients. Another possible confounding variable of our findings was time on the central estimates of severity due to hospital pressures and different social mixing restrictions over time.Our study shows that patients infected with Omicron and Delta variants reveal similar outcomes, including hospitalization and mortality. Our findings further confirm that older age, cardiovascular disease, and diabetes are the strong prognostic factors for the outcomes of patients with COVID-19. Our findings imply that COVID-19 patients with older age, cardiovascular disease, or diabetes should be treated comprehensively and cautiously to prevent further morbidity and mortality. Furthermore, incomplete data on vaccination status hampered us from analyzing further its impact on hospitalization and mortality in our patients.Below is the link to the electronic supplementary material.Supplementary Material 1


NCT02835443.Upper-extremity impairment after stroke remains a major therapeutic challenge and a target of neuromodulation treatment efforts. In this open-label, non-randomized phase I trial, we applied deep brain stimulation to the cerebellar dentate nucleus combined with renewed physical rehabilitation to promote functional reorganization of ipsilesional cortex in 12 individuals with persistent (1–3 years), moderate-to-severe upper-extremity impairment. No serious perioperative or stimulation-related adverse events were encountered, with participants demonstrating a seven-point median improvement on the Upper-Extremity Fugl-Meyer Assessment. All individuals who enrolled with partial preservation of distal motor function exceeded minimal clinically important difference regardless of time since stroke, with a median improvement of 15 Upper-Extremity Fugl-Meyer Assessment points. These robust functional gains were directly correlated with cortical reorganization evidenced by increased ipsilesional metabolism. Our findings support the safety and feasibility of deep brain stimulation to the cerebellar dentate nucleus as a promising tool for modulation of late-stage neuroplasticity for functional recovery and the need for larger clinical trials. ClinicalTrials.gov registration:  A phase I trial of cerebellar deep brain stimulation to enhance chronic post-stroke motor rehabilitation supports the safety and feasibility of the approach while providing encouraging evidence of motor improvements. Major advances have been achieved in prevention and treatment of stroke by means of population-health management of risk factors and acute interventions. Innovation and development of new technologies have played a substantial role in improving outcomes in the early hours after insult, including advances in emergency healthcare delivery networks, imaging technologies and medical devices. The same cannot be said, however, for the post-acute phase where, despite substantial effort and investment, technological leaps have been slower. Even with contemporary techniques, up to 50% of survivors experience chronic disability2, the timing of acute and post-acute interventions4, age5, genetic factors6 and preexisting comorbidities8. Harnessing the potential of neuroplasticity and modulating its extent and timing remains a major frontier in medicine with vast upside and has been the focus of our group. A wide range of neurostimulation-based treatment approaches aimed at modulating neuroplasticity and improving outcomes are currently under exploration at preclinical and clinical phases. These include targeting ipsilesional cortex directly using noninvasive techniques or surgically implanted electrode grids10 as well as efforts aimed at the peripheral nervous system that include the recently approved use of vagal nerve stimulation (VNS)11.Neuroplasticity is a well-documented phenomenon that is associated with gradual spontaneous or therapy-driven improvements in post-stroke motor function. The extent of recovery varies considerably across individuals and is known to depend largely on lesion location and size12. This central hypothesis is supported by extensive invasive and noninvasive electrophysiological investigation of the cerebellothalamocortical pathway over the past decades in the feline16, rodent17 and nonhuman primate18 models as well as in humans21. The crossed, reciprocal cerebello-cortical pathways have been shown to be highly relevant to motor function and post-stroke rehabilitation22, as originally evidenced by crossed-cerebellar diaschisis phenomenology and its influence on recovery of motor function23. Our prior work in preclinical rodent models of ischemia27, corroborated by subsequent, independent work28, supports our central hypothesis that DN deep brain stimulation (DBS) can promote recovery of function and ipsilesional cortical reorganization. Behavioral improvements were further associated with increments in ipsilesional cortical excitability, synaptogenesis, reorganization of motor representation of the affected limb, and greater expression of markers of long-term potentiation.We have proposed and investigated a new, invasive surgical approach for extending the degree and temporal window of neuroplasticity after ischemic and traumatic insults to the brain. Specifically, the approach involves continuous stimulation of the cerebellar dentate nucleus (DN) to modulate neural activity and ipsilesional cortical excitability through activation of the robust, endogenous dentatothalamocortical pathway Fig. 12. This Here we report a first-in-human translation of this research in a group of 12 stroke survivors with persistent, moderate-to-severe upper-extremity impairment. In this open-label, phase I clinical trial, we evaluated the safety and feasibility of surgical implantation and chronic DBS of the cerebellar DN. Overall, we found that our surgical approach and chronic stimulation was feasible and well tolerated in the target population, with no study-related serious adverse events encountered across the trial. Additionally, participants underwent a battery of secondary assessments to begin to characterize and understand the effect of therapy on upper-extremity motor impairment and function. We report significant improvements in motor function across all individuals who, at the time of enrollment, had even minimal residual distal motor function in the affected upper extremity and correlated effects on cortical metabolism. Of particular interest to stroke survivors, the magnitude of benefit was not found to depend on time after stroke, with robust improvements observed in participants who enrolled as late as 3 years after their index event. These early findings support that this new neuromodulation-based approach is safe and feasible in a moderately-to-severely impaired post-stroke population and shows promise for promoting recovery of function and influencing neuroplastic processes after cerebral ischemia, even in the later stages of disability.Electronic medical record screening was used to identify individuals with a first-time, unilateral, ischemic stroke affecting the middle cerebral artery territory, sparing the diencephalon and basal ganglia, 12–36 months before surgery. Each candidate had to show persistent moderate-to-severe upper-extremity hemiparesis and sufficient upper-extremity motor ability to engage in rehabilitation  and meetThe study accumulated 168 participant-months of DBS implant experience and 72 months of DN stimulation experience, with no device failures and no study-related, serious adverse events throughout the trial. A total of 51 adverse events were recorded during the trial, including 21 deemed related to study participation. Table P = 0.004) median improvement across the pre-stimulation, rehab-only phase followed by an additional seven-point improvement when rehabilitation was combined with DN-DBS . During the 2-month, rehab-carryover phase, which consisted of continued physical rehabilitation as DBS was weaned (weekly 25% amplitude reductions over the first month) and then OFF (second month), no further change in FM-UE was observed . Finally, the median FM-UE score for the full cohort again remained unchanged at the end of the long-term follow-up phase, supporting the durability of the previously realized, treatment-related gains.Our evaluation of changes in motor impairment and function during the trial focused primarily on differences observed across five key intervals Fig. : (1) preP = 0.0010) and QoM  subscales. The FA change was within the previously reported clinically important difference (CID) range (0.29 to 0.40) based upon patient perception29 and exceeded the 0.21 threshold used in a prior neurostimulation-based trial focused on upper-extremity rehabilitation9. A further modest, but significant, gain within the FA subscale was also noted following cessation of DBS during the rehab-carryover phase .To learn if reductions in impairment would be associated with gains in function, given that both are important indicators of recovery, we also evaluated surgical and treatment-related changes using the Arm Motor Ability Test (AMAT). Individual scores for each study participant during the trial are presented for the functional ability (FA) subscale in Extended Data Fig. No significant treatment-related effects were observed across any of the remaining secondary metrics, including the Nine-Hole Peg Test, the Bilateral Box and Block Test, the Short Form Health Survey SF-12), the EuroQol (EQ-5D), the Beck Depression Inventory or the Beck Anxiety Inventory. Detailed pretreatment/posttreatment scores are provided for the motor outcome metrics in Extended Data Table , the Eur30. For the DBS + rehab phase, participants who entered the study with at least some distal preservation of motor function  displayed a median gain of 15 points on the FM-UE over the DBS + rehab phase. This contrasted with a three-point gain for those who entered the study with no distal preservation (non-preserved) of motor function . A similar separation was observed on the AMAT, where participants in the preserved subgroup showed a change in AMAT (ΔAMAT)-FA of 0.46, while those in the non-preserved subgroup showed a ΔAMAT-FA of 0.21  and exceeded the patient perception-based 0.29 to 0.40 CID range previously published29. A similar pattern was observed for the AMAT-QoM, with change scores of 0.46 (P = 0.03) and 0.36 (P = 0.06) observed for the preserved and non-preserved sub-cohorts, respectively  positron-emission tomography/computed tomography (PET/CT) was used to characterize metabolic changes across ipsilateral perilesional cortex before and after the DBS + rehab phase, with comparisons made between data acquired toward the end of the rehab-only phase and again during the latter half of the DBS carryover phase. In both cases, data were collected with DBS turned OFF as our interest was in characterizing treatment-related metabolic effects in the absence of any potential confounding effect of ongoing stimulation delivery. As illustrated in Fig. P = 0.007) and in five of the six ipsilesional motor-associated cortical areas . These changes were associated with a change in AMAT after adjusting for uptake time in the ventral pre-motor cortical region . No other ipsilesional motor-associated brain region showed a statistically significant association with a change in AMAT. None of the contralesional control occipital regions showed a significant change in metabolism over the treatment interval or change associated with change in AMAT after adjusting for uptake time. None of the ipsilesional motor-associated cortical regions or contralesional control occipital regions showed a significant association between change in metabolism over the treatment interval and change in FM-UE after adjusting for uptake time.32 and distal motor function29. This cohort with chronic, upper-extremity motor deficits was enrolled 1 to 3 years following their index middle cerebral artery infarction and underwent unilateral DBS targeting the contralesional cerebellar DN area without any major perioperative complications . Although open-label, DN-DBS-related improvements on the FM-UE and AMAT met or exceeded established minimal CID thresholds. Finally, a post hoc analysis revealed that participants with preservation of some degree of distal motor function at enrollment showed significantly larger effects than those without such preservation.Data from this phase I trial of 12 individuals with chronic, moderate-to-severe post-stroke motor impairment support the safety and feasibility of chronic stimulation of the ascending cerebellothalamocortical pathway. Furthermore, it provides an in-human demonstration of significant and clinically meaningful effects of DN-DBS combined with rehabilitation on motor impairment1. As most survivors are left with substantial residual impairment despite contemporary rehabilitation efforts, there is growing interest in developing adjuvant, neurostimulation-based treatments to synergistically influence mechanisms underlying rehabilitation and improve long-term outcomes. While noninvasive approaches continue to be investigated, more recent efforts have begun to explore invasive, surgical alternatives, including direct cortical9 and VNS11. In contrast to current noninvasive technologies, these surgically implanted options can provide more continuous, at-home or demand-based, modulatory effects. One of the earliest efforts in this realm sought to enhance chronic post-stroke upper-extremity function through direct, epidural, electrical stimulation of perilesional cortex. Despite promising preclinical rodent and nonhuman primate as well as early clinical trial data, data from the phase III trial failed to meet its intended primary end point9. Reasons for this translational failure remain unclear but may in part be attributable to the overall integrity of the corticospinal pathways across participants9 or the limited capability of cortical surface stimulation to fully penetrate the gyrencephalic human brain33. Finally, and more recently, a randomized-controlled trial has shown that VNS was associated with improved outcomes compared to surgical controls, albeit with modest treatment effects11.Stroke remains the leading cause of physical disability in the industrialized world, with post-acute care costs exceeding those of acute hospital care34, severity appeared to play a role in the degree of individual benefit achieved, as participants with at least minimally preserved distal motor function showed a robust, 15-point median improvement during the DBS + rehab phase. Lastly, we did not observe a correlation between time after stroke and motor improvements associated with DBS + rehab. As such, participants who were enrolled at 3 years after stroke still demonstrated effects of large magnitude, which counters the expectation that time after stroke might limit treatment-related benefit. These findings are important as they support the potential of DN-DBS to widen the therapeutic window of opportunity for stroke survivors. Overall, these observations provide encouragement for further investigation and valuable insight for refining the target population in the next, randomized-controlled, trial.We observed significant and meaningful benefits in the form of both a reduction of motor impairment and gains in motor function in this cohort. It is noteworthy that these improvements were achieved: (1) in patients with overall poor function at enrollment, evidenced by a mean FM-UE of 22.9 points, and deemed to have poor natural prognosis and (2) after participants underwent a 3-month period of supervised rehabilitation aimed at minimizing the impact of renewed rehabilitation alone on impairment and function. In line with prior reports27, we applied PET as an exploratory approach to characterize treatment-related changes in cerebello-cortical physiology. In comparing pre-DBS + rehab versus post-DBS + rehab data, we observed significant group-level changes in perilesional metabolism, with subregional changes in metabolism in the majority of motor-associated cortices. In particular, changes in pre-DBS + rehab versus post-DBS + rehab PET data in ventral pre-motor cortex were found to be correlated with gains on the AMAT. Unlike FM-UE, which is a measure of gross motor impairment, AMAT is a measure of distal motor function and coordination and is therefore more physiologically dependent on the evolutionary specialization of motor cortices on distal control and finger movement35. Other ipsilesional motor-associated brain regions showed significant gains in pre-DBS + rehab versus post-DBS + rehab PET data that were not statistically significantly associated with functional changes. The lack of significant association between functional changes and metabolic changes in other motor areas may be consequent to effect variances in a small sample due to variabilities in stroke location or in damage along the dentatothalamocortical pathway. Overall, these findings are in line with our preclinical data and corroborate the effects of DN-DBS on ipsilesional cortical reorganization in late stages after stroke.Given our prior animal model evidence that potentiation of corticomotor excitability and ipsilesional reorganization mediates the therapeutic effects of DN-DBS36. Thus, while the magnitude of effects observed during the rehab+DBS phase are encouraging, only a subsequent, randomized-controlled trial will truly measure the contribution of DN-DBS to chronic recovery. To that end, all analyses of secondary measures should be considered exploratory, with the primary purpose of informing subsequent trials. The duration of treatment and improvement in function are intrinsically linked in our sample, as continued improvement was a prerequisite for additional time on treatment. Notably, no patients in the non-preserved group demonstrated a level of improvement to have treatment time extended. Finally, interpretation of the PET data presented were similarly limited by the small sample size, variability in stroke lesion location, and the lack of a control group.The study has limitations inherent to an early stage, Phase 1 investigation. Overall interpretation of the data presented is limited by the open-label nature of the design, the heterogeneity in baseline impairment level across the sample population, and, finally, the limited size of that same sample that are typical of a phase I neurological device trial. The latter two issues likely contributed to the lack of observed effects on several of the additional secondary measures applied, including the Nine-Hole Peg Test, the Bilateral Box and Block Test and the EQ-5D. Next, although we made some effort to overcome confounds related to chronic physical deconditioning before initiating DBS by including a rehabilitation-only phase, we are not able to distinguish, with certainty, the effects of rehabilitation from the effects of DBS. This is particularly the case given that structured rehabilitation has been shown to result in meaningful improvements even in chronic post-stroke stagesIn summary, this phase I study presents the first evidence of safety and feasibility of DN-DBS in individuals with chronic post-stroke hemiparesis with encouraging rehabilitative effects and associated neurophysiological gains observed across the DBS + rehab phase. This emerging intervention has shown translational potential to modulate the magnitude of neuroplastic reorganization toward recovery of function and to extend its time window to late phases of disability.Eligible individuals suffered a first-time, unilateral, ischemic stroke in the middle cerebral artery territory that spared the diencephalon and basal ganglia 12–36 months before surgery. Individuals with persistent moderate-to-severe upper-extremity hemiparesis as defined by an FM-UE score of ≤42 and sufficient upper-extremity motor ability to engage in rehabilitation  were included. Exclusion criteria included excessive spasticity or contracture of the upper-extremity muscles , severe cognitive impairment , as well as surgical, imaging or transcranial magnetic stimulation-related contraindications as detailed in the Candidates were enrolled in an open-label, non-randomized, single-arm trial with a target enrollment of 12 individuals. Participation spanned 20–24 months, with monthly assessments performed to record safety data and secondary metrics Fig. . FollowiThe study protocol and subsequent amendments were approved by the Food and Drug Administration  with local approval established by the Institutional Review Board (IRB) of the Cleveland Clinic. Written informed consent was obtained before study-specific testing and re-consent to protocol changes was obtained when applicable. The informed consent process was actively monitored by two neuroethicists (P.F. and L.S.) and an independent Data Monitoring Committee (DMC). The DMC was composed of two neurosurgeons experienced in DBS and one physical medicine and rehabilitation physician. The DMC had the authority to halt the study in case of an unanticipated event or terminate the study in case of a second unanticipated event that did not have an acceptable etiology or resolution.37. Sessions consisted of adaptive task practice, where the difficulty of the task was segmentally graded based on individual performance, and repetitive task practice, where a functional task was repeated continuously to reinforce successful performance30. The ratio of repetitive task practice to adaptive task practice alternated from 1:1 to 1:2 approximately every 4 weeks to maximize motor learning and standardize the rehabilitation dose between participants38. Tasks within the specified ratio were selected based on the level of motor impairment and collaborative goal setting between the participant and the therapist. Each session lasted 1–1.5 h, twice weekly and was supplemented with a targeted home exercise program of 3–5 exercises to be performed on days when formal therapy was not conducted. The number of sessions was reduced to one per week during the programming phase  with electrode arrays up to 15.5 mm in length. Additional surgical details are provided in the Participants underwent stereotactic implantation of a single DBS lead in the area of the cerebellar DN contralateral to the lesioned cerebral hemisphere using a frame-based technique similar to that used in DBS for movement disorders  in participants, users or other persons whether or not related to the investigational medical device. Adverse events included all hospitalizations and events related to the investigational device or the comparator. This included events related to the procedures involved . For users or other persons, this was restricted to events related to the investigational medical device. Adverse events did not include conditions preexisting to the participant’s enrollment. Preexisting conditions were not reported as adverse events unless the condition had an increased occurrence or intensity. Serious adverse events were defined as adverse events that (a) led to a death; (b) led to a serious deterioration in health that resulted in a life-threatening illness or injury, resulted in a permanent impairment of a body structure or a body function, required in-patient hospitalization or prolongation of existing hospitalization, resulted in medical or surgical intervention to prevent life-threatening illness or injury or permanent impairment to a body structure or a body function, or resulted in a substantial disruption in ability to conduct normal life functions; (c) led to fetal distress, fetal death or a congenital abnormality or birth defect; (d) when the event did not fit the above outcomes, but the event may have jeopardized the patient and may have required medical or surgical intervention (treatment) to prevent one of the other outcomes. It did not include in-patient hospitalization for a planned study procedure. Serious adverse events included device deficiencies that might have led to a serious adverse event if (a) suitable action had not been taken or (b) intervention had not been made. A planned hospitalization for preexisting conditions, or a procedure required by the Clinical Investigation Plan, without a serious deterioration in health or to prevent life-threatening illness or injury or permanent impairment to a body structure or a body function, was not considered to be a serious adverse event. Adverse events were reviewed by the principal investigator and DMC, and recorded in accordance with Good Clinical Practice and Food and Drug Administration Code of Federal Regulations for Medical Devices guidelines. Source documentation was provided to the study sponsors. Monthly checks of DBS hardware integrity were established by recording electrical impedance values.42. The total score was derived by summing its four subsections ), with lower scores indicating greater impairment. Initial assessments were performed at screening and presurgical baseline. The threshold for minimal CID was established as five points, consistent with established standards32. The second motor outcome measure examined was the AMAT, which serves as a measure of distal motor function and coordination. Both the functional assessment and QoM subscales were scored. Combined, the FM-UE and AMAT are considered to provide a comprehensive view of motor behavior changes that are relevant to the post-stroke population.All efficacy assessments were performed, unblinded and in person, as secondary measures for this phase 1 trial. Data were collected monthly from the presurgical baseline through 4 months after the DBS + rehab phase Fig. . SecondaSeveral other secondary measures were collected as part of this initial phase I exploration, including the Nine-Hole Peg Test, the Bilateral Box and Block Test, the Bimanual Grip Test, the Modified Ashworth Scale, the Short Form Health Survey (SF-12), the EQ-5D, the Beck Anxiety Inventory and the Beck Depression Inventory. These additional secondary metrics were included to monitor for any possible (then unknown) effects of DN-DBS on non-motor domains, including effects on spasticity, anxiety and depression; however, no significant changes were observed in this limited sample. A complete listing of secondary endpoints is provided in the Supplementary Table 18F-FDG was injected, followed by 30 min of hand physical therapy during the uptake period. PET data were acquired for 15 min, beginning with an average of 38 min (range 29–71 min) after injection. For one participant, the images acquired at the rehab-only phase had excessive motion artifact and were omitted from analyses involving this time point. For each participant, PET images were aligned with the MRI43 and stroke lesions were manually segmented on the MRI. Cortical segmentation was performed using FreeSurfer44. Perilesional cortex was defined as cortical tissue within a 10-mm dilation of the lesion using FSL45. The ipsilesional motor-associated cortical regions were defined using the Human Motor Area Template and consisted of primary motor, primary somatosensory, supplementary motor, pre-SMA, dorsal and ventral pre-motor regions46. Contralesional occipital cortex was not expected to be affected by dentate stimulation; therefore, we defined nine control cortical regions in the occipital lobe from the FreeSurfer segmentation . Mean SUVRs in the perilesional, ipsilesional motor-associated and control occipital cortical regions were calculated relative to the mean radioactivity of contralesional cortex, excluding the Human Motor Area Template regions. As we are reporting mean values for each region, small inaccuracies in the regional borders are not expected to have a meaningful impact on our interpretation.Brain imaging included T1-weighted volumetric MRI of the head  performed before implantation of the DBS lead. FDG PET/CT studies were performed , adding physical therapy to the routine clinical protocol for cerebral metabolic imaging. After fasting at least 4 h, P < 0.05 and carried out using SAS Studio v3.6. Sample size was based on safety. Analyses of secondary outcomes are considered preliminary and to be confirmed in future controlled trials. Thus, correction for multiple comparisons has not been made47.Change scores for each secondary outcome measure were calculated individually across five separate time periods: pre-surgery versus post-surgery (month 1 minus consent), pre-rehab-only versus post-rehab-only (month 3 minus month 1), pre-DBS + rehab versus post-DBS + rehab (month 8–12 minus month 4), pre-rehab carryover versus post-rehab carryover (month +2 minus month 8–12) and post-DBS + rehab to end of long-term follow-up (month ‘+10’ versus month 8–12). Due to skewed distributions, change scores are summarized using medians with interquartile ranges. Wilcoxon signed-rank tests were used to test for a significant change at each time period by comparing change scores for each phase to zero. Descriptive statistics with confidence intervals, for the full sample and for the sample stratified by functional preservation at baseline, are presented in the 48 were used to test for significant change in the mean SUVR of perilesional and ipsilesional, motor-associated and contralesional occipital (control) cortical regions between rehab-only and rehab-carryover phases of the trial, with time point and 18F-FDG uptake time  as fixed effects, participant as the random effect intercept, and applying the default unstructured covariance structure. Normality of model residuals and random effect intercept were evaluated using the Shapiro–Wilk normality test. Model fit was evaluated using Bayes information criterion and visual examination of residuals. Linear models49 using change in 18F-FDG uptake time as a covariate were used to test for a significant association between change in AMAT and change in the mean SUVR of perilesional, and ipsilesional motor-associated, and contralesional occipital cortical regions between rehab-only and rehab-carryover phases of the trial. The F-statistic of each model was calculated, and model performance was evaluated using leave-one-out cross-validation.Statistical analyses of PET data focused on the effect of therapy and its correlation with change in arm function per the AMAT (version 13). Linear mixed-effects modelsFurther information on research design is available in the Any methods, additional references, Nature Portfolio reporting summaries, source data, extended data, supplementary information, acknowledgements, peer review information; details of author contributions and competing interests; and statements of data and code availability are available at 10.1038/s41591-023-02507-0.Supplementary InformationSupplementary Figs. 1–3, Tables 1–4, study protocols 1–2 with summary of changes, DMC charter, summary of screen failures, detailed inclusion/exclusion criteria and surgical procedure details.Reporting Summary


Cardiac resynchronization therapy (CRT) via biventricular pacing (BiVP-CRT) is considered a mainstay treatment for symptomatic heart failure patients with reduced ejection fraction and wide QRS. However, up to one-third of patients receiving BiVP-CRT are considered non-responders to the therapy. Multiple strategies have been proposed to maximize the percentage of CRT responders including two new physiological pacing modalities that have emerged in recent years: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Both pacing techniques aim at restoring the normal electrical activation of the ventricles through the native conduction system in opposition to the cell-to-cell activation of conventional right ventricular myocardial pacing. Conduction system pacing (CSP), including both HBP and LBBAP, appears to be a promising pacing modality for delivering CRT and has proven to be safe and feasible in this particular setting. This article will review the current state of the art of CSP-based CRT, its limitations, and future directions. Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure (HF), wide QRS, and impaired LV systolic function despite optimal medical treatment . It was However, approximately one-third of patients implanted with a BiVP-CRT device show no clinical or echocardiographic improvement and are considered non-responders to the therapy. Moreover, and in spite of the improvement in implant tools and device technology, there is still a small percentage of patients in which either the implant of a CS lead is not successful or, once implanted, optimal resynchronization is hampered by a high pacing threshold or by the presence of phrenic nerve stimulation ,27,28. AConcomitantly, in recent years, a renewed interest in His bundle pacing (HBP) has emerged ,31,32. TThe electromechanical dyssynchrony induced by the presence of LBBB or by conventional right ventricular (RV) myocardial pacing is the cornerstone explaining CRT’s effectiveness from a physiopathology point of view ,41,42,43Preclinical studies have shown that both LBBB and RV myocardial pacing are associated with poorer acute hemodynamic parameters in comparison with the normal activation observed with narrow QRS as a result of the mechanical dis-coordination leading to structural, electrical, and contractile remodeling ,40. At tIn patients with permanent conventional RV myocardial pacing, a specific entity called “pacemaker-induced cardiomyopathy” (PICM) has also been defined to describe the detrimental effects of the asynchronous activation of the LV due to chronic RV pacing ,43,46. PHBP is a physiological pacing modality first described in 1999 by Deshmunk et al. . The objMore recently, a second physiological pacing modality has been described, namely left LBBAP, which includes both left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP). LBBP was first described by Huang et al. in 2017 , and sinUsing non-invasive epicardial electrocardiographic imaging, Arnold et al.  identifiHBP implies the capture of the proximal or distal His bundle resulting in a normal ventricular activation in the presence of a normal conduction through the right and left bundle branches. When no adjacent myocardium is captured, selective HB pacing is defined (S-HBP), while non-selective HBP (NS-HBP) implies the capture of both the HB and part of the surrounding myocardium . Both caOn the other hand, LBBP is defined by the direct capture of the LBB or any of its fascicles together with a variable amount of the surrounding myocardium whereas LVSP is characterized by the capture of the LV septal subendocardium with subsequently rapid engagement of the left conduction system . Both cop = 0.0001) and the NYHA functional class significantly increased from 2.8 ± 0.5 to 1.8 ± 0.6 (p = 0.0001). Other small, observational, single-center studies have shown similar results with significant improvement of LVEF and NYHA class [HBP is theoretically the most physiological pacing modality as it can restore the normal electrical activation pattern of the ventricles. In CRT candidates with a typical LBBB, HBP with bundle branch correction would eliminate the asynchronous activation associated with the intraventricular conduction defect. In 2013, Barba et al.  describeHA class ,60.p = 0.001). After a mean follow-up duration of 12.2 months, the echocardiographic response, defined by an LVEF improvement ≥5%, tended to be higher with HBP-CRT but did not reach statistical significance. Of note, up to 48% of patients allocated to HBP-CRT crossed over to BiVP-CRT while 26% of patients initially randomized to BiVP-CRT were finally implanted with HBP-CRT. The presence of non-specific intraventricular conduction disturbance (IVCD) was the principal reason for crossover from HBP-CRT to BiVP-CRT.To date, only four randomized studies have directly compared conventional BiVP-CRT with HBP-CRT ,61,62,63p < 0.05) and the LV end-systolic volume (LVESV) was lower  in the HBP-CRT group in comparison with the BiVP-CRT group.In the His-Alternative trial, Vinther et al.  randomizHBP-CRT has been also compared to BiV-CRT in patients with atrial fibrillation and LVEF < 40% undergoing AV node ablation . Using aIn summary, HBP has been evaluated in lieu of CRT in small, observational, and mainly single-center studies with limited follow-up data. To date, only 125 patients have been allocated to HBP in randomized controlled trials and compared to BiVP in patients with conventional CRT indications. Two principal concerns arise when observing the currently published data in this particular setting. The first one is that the BBB correction rate with HBP is limited and highly variable, ranging from 52 to 93% in patients included in randomized studies with baseline wide QRS. The second one is that this HBP-BBB correction rate is achieved with high pacing thresholds and a relatively high incidence of lead-related complications (up to 10.3%) including the loss of HB capture or a significant increase in the BBB correction threshold during follow-up. Finally, it should be taken into consideration that all these data come from highly specialized centers with extensive experience in CSP, so the replication of these results may not be possible in other centers.The first description of LBBP by Huang et al. in 2017 was in a patient with dilated cardiomyopathy, HF, and LBBB in which both CS lead implantation and HBP lead implantation failed . PosteriLi and colleagues published the first multicenter observational study evaluating LBBAP as a primary or rescue strategy after failed CS lead implantation in patients with conventional indications for CRT  Table 2Table 2. The first multicenter, randomized controlled study comparing LBBAP-CRT with conventional BiV-CRT was published in 2022 by Wang et al.  A total p < 0.001). The primary outcome of the study was a combined endpoint of time to death from any cause or the first episode of HF hospitalization and was significantly reduced with LBBAP-CRT compared to BiVP-CRT . Secondary outcomes showed that mortality was comparable between the two groups but there was a significant reduction in HF hospitalizations in the LBBAP-CRT group .Data on clinical outcomes comparing BiVP and LBBAP have begun to arise during the last year, principally from observational, non-randomized studies but constantly pointing towards a significant reduction in HF hospitalization with LBBAP-CRT when compared with BiVP-CRT, with no differences in overall mortality ,72,73,74In summary, both HBP-CRT and LBBAP-CRT are currently available techniques for delivering CRT and have been demonstrated to be safe and feasible. When directly compared to BiVP and HBP-CRT, LBBAP-CRT appears to be technically easier, with better electrical parameters and a low rate of lead-related complications ,76,77 T. LBBAP-CThere is a subset of patients in which CSP is not able to completely correct the baseline abnormal electrical activation of the ventricles. This can be explained by the presence of normal His–Purkinje activation even in the presence of a wide QRS, which reflects a primary myocardial disease and not an electrical disease. Upadhyay et al.  showed tp < 0.0001. Moreover, LVEF and NYHA class significantly improved during a mean follow-up of 14 ± 10 months with clinical and echocardiographic responses obtained at 84% and 92%, respectively.Vijayaraman et al.  attemptep < 0.0001. With a mean follow-up of 7.8 ± 2.3 months, there was a significant improvement in LVEF and a significant reduction in NT-proBNP levels. An echocardiographic response was obtained in 62.8% and a clinical response in 76% of patients.LOT-CRT has been also evaluated in 112 CRT candidates in another observational study reporting an implant success rate of 81% . LOT-CRTResults from currently ongoing randomized controlled trials such as the HIS–Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy (HOT-CRT) (NCT04561778) or the Conduction System Pacing Optimized Therapy (CSPOT) study (NCT04905290) are expected to shed additional light on the potential utility of both HOT and LOT-CRT.Current guidelines recommend CRT for patients with symptomatic HF in spite of optimal medical treatment, LVEF ≤ 35%, and non-LBBB morphology wide QRS with a lesser degree of recommendation with respect to patients with baseline LBBB , and a significant improvement in LVEF  and NYHA class  during a mean follow-up of 15 ± 23 months [p = 0.01) and a significant LVEF improvement . Clinical and echocardiographic response was seen in 60% and 61%, respectively. Females and those patients with a greater reduction in QRS duration with pacing (≥10 ms) obtained the maximum benefit from LBBAP-CRT in this particular setting.HBP-CRT has been evaluated in patients with baseline RBBB and CRT indications in a multicenter observational study including 39 patients (implant success rate 95%) showing acceptable bundle branch correction pacing thresholds (1.4 ± 0.7 V at 1 ms), a significant QRS narrowing  Patients with atrial fibrillation, HF, and impaired LVEF are candidates for AV node ablation and CRT ,90,91,92BiVP, HBP, and LBBAP have been latterly compared in an observational, retrospective study including 50 patients with refractory AF, symptomatic HF, impaired LVEF, and narrow QRS who underwent AV node ablation and implantation of a pacing device . HBP (n Both HBP and LBBAP-CRT have been shown to be suitable and effective alternatives for patients with CRT indications and previous CS lead failure implants. But one step forward is to consider the potential utility of CSP-based CRT for conventional BiVP-CRT non-responders. In a multicenter, observational study, Vijayaraman et al.  includedCSP-based CRT is currently a promising alternative for patients with CRT indications and failed CS lead implantation that has been demonstrated to be safe and feasible. Although HBP-CRT is theoretically the most physiological pacing modality, the difficulties in lead fixation, unreliable lead stability, the limited rate of bundle branch correction, and frequently high pacing thresholds are currently hindering the spread of the use of this physiological pacing modality in patients with CRT indications. In contrast, LBBAP-CRT has the advantage of better lead stability, with lower pacing thresholds and a higher implant success rate compared to HBP and, in spite of introducing some amount of RV activation delay, has been consolidated as the preferred CSP modality for patients requiring CRT. There are still important evidence gaps regarding CSP-based CRT including the lack of long-term performance, safety and complications data, and significant concerns about LBBAP lead extractability in the future. The development of a better and wider range of implant tools, with improvements in lead design and batteries and the introduction of specific algorithms for CSP-based CRT by the manufacturers are also critical aspects of the evolution of this technique and will surely result in patient benefits.Meanwhile, current guidelines have prudently introduced CSP-based CRT into their recommendations ,95. The Anyway, the bulk of evidence about CRT benefits still favors conventional BiVP-CRT as shown in HBP and LBBAP are new physiologic pacing modalities that are able to provide effective CRT. Initial observational studies have shown that both techniques are safe and feasible and, in comparison to conventional BiVP-CRT, may be associated with further LVEF improvement and a significant reduction in HF hospitalizations in patients with CRT indications, but these results should be taken cautiously until randomized data become available. Ongoing randomized controlled studies should elucidate if CSP-based CRT is non-inferior or even superior to conventional BiVP-CRT.


We explored patterns of COVID-19 vaccination across pediatric visit types using electronic health record data from 7/1/2021 through 7/25/2022 in a pediatric safety-net clinic. We generated frequencies and descriptive statistics for patient demographic and vaccine administration variables. Analyses were stratified into age subgroups of 5-to-11-year-olds and 12- to-17-year-olds. 1,409 children received at least one dose of the COVID-19 vaccine and 2,197 doses were administered in this first year of vaccine delivery. Most vaccines given were first doses in the series (45%), followed by second doses (38%), and then booster doses (17%). First doses tended to be given at well-child (42%) or nurse visits (48%), while second doses were almost entirely given at nurse visits (87%) and booster doses at well-child visits (58%). Efforts to optimize COVID-19 vaccination could leverage clinic workflow systems to provide reminder prompts for vaccination for scheduling future doses and identify strategies to facilitate vaccination at non-well child visits, particularly for booster doses. Across multiple studies, parents have reported their pediatricians' offices as the most desirable location to get their children vaccinated , 5 and rDespite the clear role of pediatric practices in delivering vaccinations, little is known about COVID-19 administration patterns in this setting. Gaining a better understanding of vaccine delivery in the pediatric practice setting could support future vaccine promotion efforts. With other vaccines, for example, successful strategies for increasing uptake include recommending and offering vaccines at all types of visits  (Epic). The clinic began administering COVID-19 vaccines beginning 7/13/2021, and thus our data ranges from 7/13/2021 through 7/25/2022. The clinic exclusively offers the Pfizer-BioNTech vaccine. On an average day the clinic is staffed by 4 FTE  of physician time, 2 FTE nurse practitioners, and 3 FTE nursing staff. Overall, the clinic has approximately 18,000 pediatric visits per year. Most of their patient population is covered by Medicaid (60%), 40% identifies as Hispanic/Latino and 10% prefers a language other than English.χ2 tests to assess differences in demographics across types of visits and to explore differences in types of visits for different doses in the series. All analyses were stratified into age subgroups of 5- to 11-year-olds and 12- to 17-year-olds. Vaccine administration data were aggregated and graphed by month to explore trends over time. Additionally, we used data from the Massachusetts Department of Public Health on monthly COVID-19 case counts to assess trends in vaccine administration during surges of the pandemic. This study received a not human subjects' determination from the University of Massachusetts Chan Medical School Institutional Review Board.EHR data on all patients between ages 5 and 17 who received any COVID-19 vaccination during the time period of interest included: date of vaccine administration, dose in the series , type of visit at which vaccine administration occurred , patient sex, age, race/ethnicity and language. We generated frequencies and descriptive statistics for all variables of interest. We used 3.p < 0.001) and race/ethnicity (p = 0.02) by visit type. In this first year of vaccine administration a total of 2,197 doses were administered to the 1,409 unique patients. In terms of dose in the series, the largest percentage of those administered were first doses (45%), followed by second doses (38%) and booster doses (17%). Of the patients who received a first dose at this clinic, 72% returned for their second dose there (70% in 5- to 11-year-olds and 75% in 12- to 17-year-olds).Overall, 1,409 children were vaccinated in the clinic from July 13, 2021 to July 25, 2022. A little over half (55%) of those vaccinated were in the 5–11 age group. Child demographic characteristics by the visit type of the first COVID-19 vaccine dose that they received in the clinic are shown in χ2 test indicated a statistically significant association between dose and visit type. First doses of the series tended to be given at well-child visits (42.4%) or nurse visits (48.8%), while second doses were almost entirely given at nurse visits (87.9%) and booster doses at well-child visits (58.9%)  . Finally4.Examining trends in COVID-19 vaccine administration at a pediatric practice in the first-year post-approval for 12- to 17-year-olds and 5- to 11-year-olds, we gained important insight into when these vaccines are being administered and how that might be influenced by contextual factors. These findings have implications for COVID-19 vaccine delivery going forward, and also more broadly for other seasonal or multi-dose vaccines . With COVID-19 vaccination rates among pediatric populations lagging and the likelihood that further booster doses may be needed , 11, it In exploring at which visit types COVID-19 vaccines were administered, an interesting pattern arose which gives context to who may be initiating vaccination. We found that first doses were often administered at nurse or well child visits, suggesting that this dose may be parent and provider driven as parents would initiate a nurse visit for the purpose of vaccination and providers would recommend vaccination at well visits. Second doses primarily occurred at nurse visits again implying parent and provider initiation as nurse visits for a second dose could be booked independently by the parent if the first dose was received elsewhere or based on provider's request to return for the second dose. In contrast, our data implied booster doses were mainly provider driven. We found that booster doses were most common at well-child visits but also administered more than the other doses at follow-up and sick visits. The administration of vaccines at these visits may indicate that providers in this clinic are trying to take advantage of all opportunities to vaccinate children, rather than waiting for preventive care or parent-initiated visits. This strategy of reducing missed opportunities by taking better advantage of acute care visits (i.e sick visits or follow up visits) has been shown to increase rates for other vaccines , 13 and We also were able to discern trends in administration based on contextual factors. For example, we saw increases in COVID-19 vaccine doses administered prior to the beginning of the school year and in the weeks during this county's Omicron surge. August is often a popular time to target vaccine promotion efforts due to the influx of children coming into clinics for well child and sports' physicals, going forward COVID-19 vaccination should also be promoted during this time. Moreover, while ideally continued vaccination will prevent future COVID-19 surges like the one experienced due to Omicron, knowing the patterns of the virus allows us to predict optimal timing for vaccination. Similar to influenza and other respiratory viruses, winter surges seem common with COVID-19, therefore messaging should focus on getting vaccinated prior to these potential surges, rather than during. Additionally, pediatric practices can and should prepare to increase capacity for vaccine administration during these times.Beyond understanding these patterns, our results further support the need to focus on pediatric practice clinics as the ideal setting for pediatric COVID-19 vaccination. There is extensive research showing that parents would prefer to get their child vaccinated in their own pediatricians' offices , 5. In o4.1.There are several limitations that should be acknowledged in interpreting our results. First, these results are limited to a single clinic within an academic medical center, and not representative of the experience of all clinics, especially clinics that are community-based, in other geographic areas, or that lack the capacity to offer the COVID-19 vaccines. Moreover, vaccine rollout varied state to state and in Massachusetts, mass vaccination sites were prioritized over individual clinics, which could have affected uptake. Furthermore, we do not have access to these patients' full medical records, therefore it is possible that they received doses outside of this clinic. This would be especially true for patients between ages 12 and 17 as the clinic began offering the vaccine three months after EUA for this age group. Likewise, this makes it impossible in this analysis to estimate prevalence of vaccination receipt within the clinic. Despite these limitations, our results offer insight into challenges of pediatric COVID-19 vaccine delivery and highlight potential strategies for improving vaccination in this age group.4.2.This analysis allowed the exploration of patterns in COVID-19 vaccination and began to identify opportunities to improve vaccine delivery. Other clinical settings may see different vaccination trends and a similar exercise could help them identify opportunities to improve COVID-19 vaccine delivery. Future work in this area could prioritize optimizing COVID-19 vaccine delivery within pediatric practices by leveraging clinic workflow systems to provide reminder prompts for vaccination for scheduling future doses or identifying strategies to facilitate vaccination at non-well child visits. Ultimately, this analysis shed light on the ways in which clinic-level data can be used to understand these trends and the utility in exploring vaccine administration data in this way.


The growing prevalence of Alzheimer's disease (AD) is becoming a global health challenge without effective treatments. Defective mitochondrial function and mitophagy have recently been suggested as etiological factors in AD, in association with abnormalities in components of the autophagic machinery like lysosomes and phagosomes. Several large transcriptomic studies have been performed on different brain regions from AD and healthy patients, and their data represent a vast source of important information that can be utilized to understand this condition. However, large integration analyses of these publicly available data, such as AD RNA-Seq data, are still missing. In addition, large-scale focused analysis on mitophagy, which seems to be relevant for the aetiology of the disease, has not yet been performed.In this study, publicly available raw RNA-Seq data generated from healthy control and sporadic AD post-mortem human samples of the brain frontal lobe were collected and integrated. Sex-specific differential expression analysis was performed on the combined data set after batch effect correction. From the resulting set of differentially expressed genes, candidate mitophagy-related genes were identified based on their known functional roles in mitophagy, the lysosome, or the phagosome, followed by Protein-Protein Interaction (PPI) and microRNA-mRNA network analysis. The expression changes of candidate genes were further validated in human skin fibroblast and induced pluripotent stem cells (iPSCs)-derived cortical neurons from AD patients and matching healthy controls.in vitro models, which confirmed their down-regulation in AD conditions.From a large dataset  based on three different datasets , we identified 299 candidate mitophagy-related differentially expressed genes (DEG) in sporadic AD patients . Among these, the AAA ATPase VCP, the GTPase ARF1, the autophagic vesicle forming protein GABARAPL1 and the cytoskeleton protein actin beta ACTB were selected based on network degrees and existing literature. Changes in their expression were further validated in AD-relevant human in vitro models, primary human fibroblasts and iPSC-derived neurons. Our results provide foundation for further investigation of these genes as potential biomarkers or disease-modifying pharmacological targets.Through the joint analysis of multiple publicly available data sets, we identify four differentially expressed key mitophagy-related genes potentially relevant for the pathogenesis of sporadic AD. Changes in expression of these four genes were validated using two AD-relevant human  Recent years have seen a growing trend in the number of Alzheimer's Disease (AD) patients, which reached 44 million in 2014 and 47 million in 2016   suffer from lack of reproducibility and high variability  networks, a gene whose product interacts with many other gene products  is in general more likely to be a key gene. At the same time, a gene targeted by more microRNAs that are regulated in the opposite direction to this gene, could be regarded to have more reliable differential expression, because a microRNA can bind to the mRNAs of its target gene and degrade the latter. Many unbiased screenings have been published, utilising module detection algorithms to these networks followed by enrichment analysis based on gene sets, or key genes determination for each module  separately for each sex and correcting covariates and batch effects. Gene sets, whose descriptions include one of the three keywords , were collected from different databases . Their member DEGs were extracted for following Protein-Protein Interaction (PPI) network analysis via STRING. Four candidate genes  were selected from highly connected genes in the PPI network from the STRING database  and three AMP-AD datasets from several brain regions.The workflow of this study is shown in https://www.ncbi.nlm.nih.gov/sra/) and converted to fastq format using fasterq-dump in SRAtoolkit (v 2.10.2).For the six GSE datasets   via the Python package synapseclient and synapseutils. Instead of the BAM files stored in each study, fastq files generated by the RNAseq Reprocessing Study carried out by the AMP-AD consortium were used.For the three AMP-AD datasets   utilised bulk RNA-Seq; (2) included at least 5 AD patients and 5 age-matched controls; and (3) examined post-mortem samples of human brain. Eligibility criteria further required patients to be aged above 65 to ensure only late-onset AD patients were considered. The Braak score  Andrews,  and summSalmon .For the three datasets  of Frontal Lobe (FL) shown in To visualise the effectiveness of batch effect correction, PCA was applied before and after batch correction. Variance stabilising transformation was employed using R package DESeq2 (v 1.22.2)    degree ≥ 20 in male or female PPIs; (2) targeted by at least 10 up-regulated microRNAs; (3) the number of down-regulated microRNA targeting the gene should not exceed 1/3 of that of up-regulated microRNA; (4) has at least some implication in AD or mitophagy or mitochondria in literature.TM-II Complete Medium  in 5% CO2 in a humid incubator at 37°C.Primary skin fibroblasts  were obtained from the Coriell Institute for Medical Research . Two fibroblast cell lines from sporadic AD (sAD) patients and two correspondent healthy sex- and age-matched samples have been used  and analyzed with NetPrimer (BioSoft) , using RNeasy MiniKit (Qiagen) following the manufacturer instruction. RNA was analysed both for purity and concentration with an Agilent BioTek spectrometer (CHECK). Samples with OD260/280 ratio around 2.0 were included in the gene expression analysis. cDNA was synthesized using FIREScript RT cDNA synthesis MIX with oligo (dT) primer (Solis BioDyne) according to the manufacturer instructions. Real-time (RT)-PCR was performed using HOT FIREPol EvaGreen qPCR mix from Solis BioDyne following instructions from manufacturer using an Applied Biosystems QuantStudio 6Flex Real-Time PCR system. Three housekeeping genes, HPRT1, RPL13, and TBP were tested for their suitability as control genes.HPRT1 and RPL13a have already been shown to have a stable expression in several brain diseases  .https://www.graphpad.com/scientific-software/prism/). One-way multiple comparisons Student's t-test with Bonferroni's multiple comparison post hoc test was used for mean comparisons between conditions as required. The number of samples used for statistical analyses (n) refers to either the number of different individuals per group or total samples in the study, being always four independent biological replicates. Differences were considered significant when p < 0.05. Data in bar graphs are reported as mean ± SD.Statistical analysis was performed with Prism 6.0  were quantified. The Volcano plots of the combined dataset show that most of the significant DEGs have small absolute values of log2 fold change which may be due to variation in gene expression between samples and datasets . It is nIn total, 4,457 male specific, 3,103 female specific, and 1758 shared AD DEGs were identified in the frontal lobe. Many genes have been previously reported as AD-associated  and defined as candidate new members of these genesets.The size of each node is proportional to its degree (the number of genes that a certain gene interacts with). The direction of gene regulation is indicated by the gene nodes' colour, with down-regulated genes in green while up-regulated genes in red. The depth of a node's colour is in proportion to the absolute value of the log2 fold change of a gene, which ranges from 0 to 0.4 .The PPI network construction began with 195 genes for male and 188 genes for female. After adding candidate new members, the total number of nodes were 311 for male and 298 for female. In total of 3,641 and 3,677 protein interactions for male and female were retrieved from the STRING database respectively, forming the edges of the PPI network.MicroRNAs' suppression of their target mRNAs was regarded as evidence for genes' differential expression at mRNA level. From literature and databases, 559 unique DE-microRNA in FL , and 380,639 microRNA-mRNA pairs were retrieved to create the microRNA-mRNA interaction network. MicroRNAs that were reported in some papers as up-regulated in AD FL but also reported to be down-regulated in the same number of studies were excluded from the analysis.Based on the aforementioned criteria (refer to 2.6) and existing knowledge, four genes were finally selected: VCP, ARF1, GABARAPL1, and ACTB , which aAs expected, a number of known mitophagy genes interact with the selected genes. For example, FUN14 domain containing 1 (FUNDC1), which interacts with GABARAPL1 and is down-regulated in both sexes, assists the phagophore to engulf dysfunctional mitochondria for mitophagy  that were used to complete the sequencing process and did not contain biological information from the original RNA sequence  and sulci (groves or fissures), with specific functions. Since RNA-Seq data from small sub-regions of the cerebral cortex are not abundant, we considered sub-regions belonging to the same lobe as equivalent with regard to how their RNA-Seq data reflect AD pathology, as also previously reported , GABARAPL1 (GABA type A receptor associated protein like 1), VCP , and ACTB (actin beta). Among them, the ACTB product is a cytoskeletal protein with typically housekeeping functions and considered having a stable expression. However, actin and actin-binding proteins have also been recognised as histopathological structures, which may contribute to AD pathogenesis and to primary behavioural symptoms of the disease  here identified by the bioinformatic analysis were further validated in two state-of-the-art models in the field of AD research, and in translational research aimed to target discovery and drug development for this neurodegenerative disease , as promising relevant genes in AD pathology. Although their changes were also further validated here in biological https://adknowledgeportal.org), accession number syn9702085, and the GEO (https://www.ncbi.nlm.nih.gov/gds), accession number GSE110731. All data are previously published and publicly available.The data presented in the study are deposited in the AD Knowledge Portal (LJR, ZL, YL, TM, LB, and RA designed the study. TM and RA collected the datasets and performed the bioinformatic analysis. AO and YL performed the experiments and analysed the results. All authors contributed to writing the manuscript, reviewed the manuscript, and approved the submission for publication.