LED light is used for many medical and cosmetic applications such as phototherapy and skin rejuvenation. Such physical methods can be combined with drug therapy, such as LED-responsive drug delivery system, the subject of present investigation.8,9PC, was prepared as LED-sensitive systems. Calcein was loaded in the liposomes as a fluorescent probe for drug release studies. Different LED wavelengths  were used for triggering release of calcein from nanoliposome. Indoor daylight, darkness, and sunlight were applied as controls.To perform this investigation, a nanoliposome composed of DPPC, DSPE-PEG2000, and DCResults showed that liposomes do not release their cargo in darkness, but they released it in response to indoor daylight, sunlight and LEDs, with the blue light showing the highest effect. Results also showed that release of calcein was sensitive to wavelength.Our results reveal potential of LED-sensitive liposomes for medical and cosmetic applications and that such system can be combined with phototherapy. Such concomitant therapies can increase medical/cosmetic effects and decrease adverse reactions to phototherapy. Liposomal drug delivery has been studied for decades and in spite of wide application and advantages -3, theiret al., studied the healing effects of blue and red LED lights on different type of cells in an in-vitro scratch-wound model and showed that these effects depend on the wavelength , UV, near –infrared (NIR), and fluorescent lamps -30. Amonvelength . et al., showed that blue LED is able to trigger the release of cargo from Bis-Azo PC coating liposomes that works through photo-isomerization . DC8,9PC is a diacetylene lipid -sn-glycero-3-phosphocholine  were purchased from Avanti Polar (USA), calcein and HEPES were purchased from Sigma (Germany), cobalt chloride (CoCl2 . 6H2O), methanol and chloroform were purchased from Merck (Germany). All other materials were of pharmaceutical grade.1,2-dipalmitoyl-sn-glycero-3-phosphocholine , and 1,2-distearoyl -sn-glycero-3-phosphoethanolamine-N-[methoxy(polyethylene glycol)-2000  were purchased from Lipoid GmbH (USA), -sn-glycero-3-phosphocholine , and DSPE-PEG2000 (4 mol%) reported by Yavlovich and coworkers , DCoworkers , was choin-vitro . Increas8,9PC/DSPE-PEG-2000) were diss-olved in chloroform:methanol mixture (2:1) in an amber vial. The organic solvent was then evaporated at room temperature under nitrogen gas flow while the vial was rotated. To remove trace amount of solvent, the vial was kept under vacuum desiccator overnight. 1ml of HEPES buffer  containing 1 mM calcein was then added to the lipid film and the mixture was sonicated by probe sonicator  for 5 min .Nanoliposomes were prepared by a lipid film hydration method. Probe sonication was used to reduce their size and increase their uniformity. To perform this method, lipids  and Cytation Imaging Reader as described below.Size and zeta potentialZetasizer Nano ZS ZEN3600  was used to evaluate the zeta potential, particle size and polydispersity index (PDI) of the prepared nanoliposomes at room temperature. Sizing technique is by dynamic light scattering (DLS) and zeta potential uses laser doppler velocimetry (LDV). Nanoliposomes were diluted in distilled water (1:9), then poured in quartz cell and their size and zeta potential were evaluated.Quenching of free calcein2.6H2O was added to the prepared liposomes to quench the free calcein (2 was added to the prepared nanoliposomes in HEPES buffer (5:95) and vortexed for 30 seconds.To discriminate between free and entrapped calcein, CoCl calcein . Cobalt  calcein , therefoImagingTo evaluate the morphology of liposomes, the system was studied by imaging using AFM and cytation imaging reader. AFM images were taken with the Nanowizard II AFM, with the intermittent mode manufactured by JPK Company (Germany). 50-100 µL of the prepared nanoliposomes were spread on a microscope slide, dried at room temperature and AFM images were then obtained at the same temperature.Em and λEx of the probe, which were adjusted to be 511 and 485 nm, respectively for calcein. λEm and λEx at experimental conditions were measured here using f-2500 Fluorescence Spectrophotometer .The fluorescence images of the nanoliposomes were taken using the Cytation Imaging Reader (Cytation III) with the GEM5 software . This technique showed calcein loaded nanoliposomes as green spots. This technique uses λRelease studies at different light conditions were performed using blue, green, red and white (blue+green+red) LEDs , as descRelease of calcein from liposomes under different LED light wavelengths was investigated at room temperature. The quenched nanoliposome mixture split into several vials and each vial was exposed to a specific condition. The conditions included amber vial in darkness and transparent vial exposed to sunlight, daylight in laboratory, white LED light, blue LED light, green LED light and red LED light as shown in Calcein measurement-9 to 10-7 mM calcein in HEPES buffer using λEm and λEx of 511 and 485 nm, respectively. All points were measured in triplicates, and the experiment was performed at room temperature.The amount of calcein in the sample was measured by a fluorescence method. Calibration curve of calcein dissolved in HEPES buffer was obtained by plotting fluorescence intensity vs. calcein concentration using cytation imaging reader. A 0.1 M stock solution of calcein in HEPES buffer  was prepared and calibration curve was drawn up over 10LED sourceLight emitting diode (LED) is a semiconductor light source that emits light when current flows through it. The LED used in the present study was manufactured and validated in our laboratory at Shahid Beheshti University of Medical Sciences. Wavelengths and intensities were validate using UV-Vis spectrometer (190-850 nm) EPP2000 StellarNet Co. (USA) and luxmeter MS6610 MASTECH Co. (USA).Characterization of liposomesCalcein calibration curve-9 to 10-7 mM calcein using 11 concentrations at pH 7.5 (2 = 0.995) over the studied range  also did not show any calcein release. Statistical analysis showed that the difference between sunlight and indoor daylight  and white LED and sunlight  are significant. These results show that the DC8,9PC liposomes release their cargo only in the presence of light and that the effect of light is not a thermal effect. These results indicate that liposomes should be kept in darkness to prevent any possible release due to light from other sources such as daylight. Therefore, such systems require special packaging. However, heating by sunlight did not result in release of the cargo and no protection is required in this regard.According to the results shown in 8,9PC is a lipidic monomer which will be polymerized when exposed to the light as demonstrated by Yavlovich, et al. . Intensity of sunlight is about 2000 times of that of indoor daylight. Considering our results  and lighet al. investigated the effect of wavelength on proliferation of cultured murine cells and concluded that both wavelength and cell type influence the cell proliferation response to low intensity laser irradiation  in the present investigation. These wavelengths are used for clinical and cosmetic applications. For instances, red range of wavelengths is used in wrinkles, scars, and persistent wounds treatments, green range of wavelengths is used for skin calming, anti-aging and increasing the collagen in the skin and blue range of wavelengths is used for treatment of acne vulgaris, combination therapy and seasonal affective disorders . P-value < 0.003). Their effects on release are different and red LED with the lowest intensity was more effective than green light, by about 2.5 times. These data are in good agreement with Leung and Romanowski who have suggested that wavelength is the most affecting factor on cargo release from light-sensitive liposomes  dependent. Such a property allows adjustment of the treatment through controlling the release of the cargo by using proper light. Our results also show that such liposomes should be kept in darkness to prevent any possible release due to light from other sources such as daylight. Therefore, such systems require special packaging. However, heating by daylight does not result in release of the cargo. Further studies are required to fully explain this area of drug delivery.


To examine the utility of the peripheral blood neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) as biomarkers of prognosis in seropositive autoimmune encephalitis (AE).In this multicenter study, we retrospectively analyzed 57 cases of seropositive AE with hospital admissions between January 2008 and June 2019. The initial full blood examination was used to determine each patients’ NLR and MLR. The modified Rankin Scale (mRS) was utilized to assess the patients’ follow-up disability at 12 months and then at final follow-up. Primary outcomes were mortality and mRS, while secondary outcomes were failure of first line treatment, ICU admission, and clinical relapse. Univariate and multivariable regression analysis was performed.During initial hospital admission 44.7% of patients had unsuccessful first line treatment. After a median follow-up of 700 days, 82.7% had good functional outcome (mRS ≤2) while five patients had died. On multivariable analysis, high NLR was associated with higher odds of first line treatment failure . Increased MLR was not associated with any short or long-term outcome.NLR on initial hospital admission blood tests may be provide important prognostic information for cases of seropositive AE. This study demonstrates the potential use of NLR as a prognostic marker in the clinical evaluation of patients with seropositive AE. The interaction between the immune cells of the periphery and the “immune-privileged” CNS in autoimmune disorders has drawn significant attention. Many of the immunopathological models of CNS autoimmunity are based on multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE) in animals. In the last decade, the increased recognition of autoimmune encephalitis (AE) as a clinical entity has resulted in subsequent pathological studies in humans and animal models suggesting potential roles for innate and adaptive immune cell subsets, as well as their associated cytokines and chemokines, in disease pathogenesis .Routine full blood examination is easily performed and provides a detailed snapshot of the circulating innate and adaptive immune cells. The neutrophil-to-lymphocyte ratio (NLR) is an increasingly recognized biomarker of systemic inflammation across a broad variety of different disease states including ulcerative colitis, rheumatoid arthritis, and systemic lupus erythematosus –6. In MSHere we performed a large multicenter retrospective study to examine for the presence of correlation between acute peripheral blood immune cell ratios, and morbidity and mortality in seropositive AE. We hypothesized that increased NLR and MLR would be associated with worse outcomes.via direct immunofluorescence. Cases with autoantibodies to the voltage-gated potassium channel (VGKC) complex with negative or no specific testing for anti-LGI1 or anti-CASPR2 antibodies were excluded from the study.Ethics for this multicenter study was obtained through the Melbourne Health Human Research Ethics Committee. Patients were included from six secondary and tertiary referral centers in metropolitan hospitals in Victoria, Australia: Melbourne Health, Alfred Health, Monash Health, Eastern Health, Barwon Health, St Vincent’s Health. De-identified study data was collected and managed using REDCap (Research Electronic Data Capture) , 13. PotWe obtained data on demographics, antibody profile, clinical features, paraclinical findings , follow-up MRI findings, treatment types and duration, and data on hospital stay . For this study, an abnormal MRI was defined as having findings that were in keeping with neuroinflammation . PatientWe recorded the total white blood cell count and immune cell subset counts from the first full blood analysis within 24 h of admission . We exclImmunotherapies were classified as first line  or second line  as previously described . SteroidThe primary endpoints were functional outcome [as assessed by the mRS ] at 12 mBaseline demographic, clinical, and paraclinical data were compared using summary statistics. A composite group containing all non-NMDAR patients was generated to compare against the NMDAR group. Outcomes were compared between these groups using Fischer’s exact test. Mann Whitney U test was used to compare the length of follow-up between the groups. The MLR values of the cohort were heavily right-skewed, so we performed a Box-Cox transformation using a λ of 0.5 to normalize the data (Shapiro-Wilk test 0.163). This variable was named “MLR transformed.”Univariate logistic regression analyses were performed to determine correlations between selected covariates (including NLR and MLR) and the time-independent outcomes . Univariate Cox regression analyses were performed to similarly examine the time-dependent outcomes . For the purpose of the Cox regression analyses, patients that died during their initial inpatient admission were defined as having follow-up of 0 days. Clinically or statistically relevant variables from univariate analyses were used in the relevant multivariable logistic and Cox regression models, depending on the outcome of interest. Acknowledging the differences between the NMDAR group and all others 2, NMDARThere were 57 patients that met our inclusion criteria. Cases with antibodies to the NMDAR were the largest overall constituent with 29 subjects. There were no patients with both LGI1 and CASPR2 antibodies, and there were only single cases with either γ-Aminobutyric Acid Receptor B (GABAb) or IgLON5 antibodies. We replicated prior data that adult anti-NMDAR antibody-mediated encephalitis is typically a disease of young females. Baseline demographic, clinical, paraclinical, and treatment data is shown in vs 4.02, There were 12 cases that did not have an adequate full blood examination for our analysis, either because the result was unavailable or they had immunotherapy treatment prior . No patients had concomitant illness at the time of sampling, and therefore none were excluded on these grounds. The immune cell counts were similar between the NMDAR and Non-NMDAR patients Table 2.Five patients were lost to follow-up after hospital discharge . The median duration of follow-up for the remaining 52 patients was 700 days (1.92 years), which was not different between the subgroups. Morbidity, follow-up, and outcome data were notable for significantly higher rates of ICU admission and mechanical ventilation amongst anti-NMDAR antibody-mediated encephalitis patients compared to those in the Non-NMDAR group Table 3.On univariate analysis, younger age, female sex, and failure of first line treatment were associated with ICU admission Table 4.Accounting for patients with inadequate blood samples (12 patients) and those lost to follow-up , the final multivariable regression model was performed in 45 patients for in-hospital outcomes (treatment failure and ICU admission) and 41 patients for long-term outcomes . The multivariable regression analysis showed that age was associated with worse 12-month functional outcomes, but not long-term mRS 6. FirstOur study examines the role of peripheral blood immune cell counts and ratios as a prognostic biomarker in AE. High NLR at the time of hospital admission may predict an increased chance of first line treatment failure. MLR was not associated with any outcome.vs 2.39) and after (4.14 vs 2.62) treatment . TO’B receives research funding from Biogen, UCB Pharma, Eisai Pharma, Anavex Pharmaceuticals, Zynerba Pharmaceuticals, and serves on the scientific advisory boards for UCB Pharma, Eisai Pharmaceuticals, Zynerba Pharmaceuticals, ES Therapeutics, Seqirus Pharmaceuticals. MM’s institution receives funding from Merck.WD’S’s salary is part-funded by The University of Melbourne. He has received travel, investigator-initiated, scientific advisory board and speaker honoraria from UCB Pharma Australia & Global; investigator-initiated, scientific advisory board, travel and speaker honoraria from Eisai Australia & Global; advisory board honoraria from Liva Nova; educational grants from Novartis Pharmaceuticals, Pfizer Pharmaceuticals and Sanofi-Synthelabo; educational, travel and fellowship grants from GSK Neurology Australia, and honoraria from SciGen Pharmaceuticals. AB is on the editorial boards for The remaining 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.


By mapping the clinical pathophysiology of the novel coronavirus disease 2019 (COVID-19) against insights from virology, immunology, genomics, epidemiology and pharmacology, it is here proposed that the pathogen recognition receptor called toll like receptor 9 (TLR9) might have a pivotal role in the pathogenesis of COVID-19. Severe Acute Respiratory Syndrome Coronavirus 2, is causing the greatest global social and economic disruption since world war II. Lack of a vaccine, lack of successful treatment and limitations of the healthcare workforce and resources needed to safeguard patients with severe COVID-19 on the edge of life, demands radical preventive measures. It is urgently needed to identify biomarkers and drug candidates so that vulnerable individuals can be recognized early and severe multi-organ complications can be prevented or dampened. The TLR9 COVID-19 hypothesis describes a mechanism of action that could explain a wide spectrum of manifestations observed in patients with severe COVID-19. The introduced hypothesis proposes biomarkers for identification of vulnerable individuals and positions TLR9 as a promising multifaceted intervention target for prevention and/or treatment of COVID-19. TLR9 agonists might have value as prophylactic vaccine adjuvants and therapeutic immune stimulators at the early onset of disease. Additionally, in this current manuscript it is proposed for the first time that TLR9 could be considered as a target of “inhibition” aimed to dampen hyperinflammation and thrombotic complications in vulnerable patients that are at risk of developing late stages of COVID-19. The readily availability of TLR9 modulating drug candidates that have reached clinical testing for other disorders could favor a fast track development scenario, an important advantage under the current high unmet medical need circumstances regarding COVID-19. The COVID-19 (Coronavirus disease 2019) pandemic, caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has been declared a public health emergency of international concern by the WHO Director General . The virus, first identified in Wuhan City, China, has spread worldwide, resulting in more than 65M confirmed cases and over 1,5M cases . At the time of this writing there are no validated specific therapies with proven effectiveness available for prevention of mortality from COVID-19. Remdesivir has been shown superior to placebo in shortening the time to recovery in adults who were hospitalized with Covid-19 but no significant benefit on mortality could be found . Remdesiin vitro and thrombosis in vivo (Toll-like receptors (TLRs) are a family of 13 conserved transmembrane receptors that are at the forefront of directing innate and adaptive immune responses against invading bacteria, fungi, viruses and parasites . When TL in vivo . It is i in vivo . This TLIn 2004, TLR9 has been linked to SARS coronavirus induced disease because of the relatively high numbers of CpG motifs in corona viral sequences . A paperp-value of 0.016)  . The arrn levels . Life stn levels  FEB. Expn levels  NOV 9. Un levels  AUG. Incn levels .et al. analyzed immune factors influencing racial disparity in Covid-19 mortality rates, which revealed presence of inherent differences in the immune system, which may increase the predisposition of black Americans to a severe cytokine storm (There are many examples of genetic predisposition leading to TLR9 gain of function. One example is the single nucleotide polymorphism (SNP) of the C allele of rs5743836 (T-1237C), which is associated with immune-mediated disease and with a higher incidence of ICU acquired infection . T-1237Cne storm . The autThe airways as principal site of entry and target of SARS-CoV-2 can become severely affected in patients with COVID-19. In vulnerable patients, COVID-19 leads to the development of severe pneumonia with enhanced neutrophilia and complications including ARDS requiring mechanical ventilation . Postmorp < 0.05) association with cardiovascular disease measure and TLR9 gene expression was observed in patients that receive lipid treatment  (Mycobacterium w (Mw), resulted in successful management, not causing adverse events  . Mw is am w (Mw) . Mw recem w (Mw) . A smalle events . A previe events . A randoe events .During the first wave of Covid-19, low Vitamin D levels have been found in the vulnerable aging population in Spain, Italy and Switzerland which pointed towards the potential of vitamin D in prevention of COVID-19 infection and mortality . VitaminThe novel hypothesis that TLR9 could be associated with COVID-19 pathology in vulnerable patients, positions TLR9 as a multifaceted drug target worth considering for preventing and/or treatment of critical conditions of SARS-CoV-2 infected patients. Both TLR9 activation- and inhibition could be relevant to produce opposing therapeutic effects at the different stages of disease . ProphylViral load and viral RNA levels are relevant predictive parameters for disease. Viral load of SARS-CoV-2 detected from the respiratory tract of COVID-19 patients seems positively linked to biochemical indexes and disease severity . Studiesin vitro model system such as used by Ng et al. for investigating genome-wide host response to SARS coronavirus (The TLR9 COVID-19 hypothesis is testable within the framework of current knowledge. TLR9 expression levels in response to SARS-CoV-2 can be analyzed in an onavirus . Anotheronavirus . Prior aThe original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.GB formulated the TLR9 COVID-19 hypothesis, drafted the manuscript and figures, and revised the final form. JG provided key insights for manuscript revision. Both authors contributed to the article and approved the submitted version.GB filed a patent entitled “A TLR9 inhibitor for use in treatment of COVID-19,” reference number 1043690.The remaining author declares that there are no commercial or financial relationships that could be construed as a potential conflict of interest to this work.


Conclusion: Although the current study demonstrated similar results in patients who underwent GKRS with and without embolization, the embolized group included more AVMs with larger nidus volume, higher SM grade, Pollock-Flickinger score, and aneurysm, which have a lower chance of obliteration and a higher probability of repeat hemorrhage. GKRS followed by embolization appears to be a beneficial approach for the treatment of ruptured AVMs that are at risk for obliteration failure and repeat hemorrhage during the latency period after single-session GKRS alone. Further studies involving a larger number of cases and continuous follow-up are necessary to confirm our conclusions.Background: Aggressive treatment to achieve complete obliteration of brain arteriovenous malformation (AVM) is necessary in patients with a recent history of hemorrhage. The major drawback of Gamma knife radiosurgery (GKRS) alone for AVM is risk of bleeding during the latent period until the AVM occludes. At our center, patients who present with ruptured AVMs are frequently offered GKRS followed by embolization. The goal of this study was to compare outcomes of embolization for patients who have previously undergone GKRS for ruptured AVMs. Methods: A database including 150 GKRS for ruptured AVMs between November 2008 and October 2017 was reviewed. The embolized group was selected by including AVMs with post-GKRS embolization. The non-embolized group was defined as AVMs treated by GKRS alone. Outcomes including obliteration rate, incidence of repeat hemorrhage, and delayed cyst formation were compared between two groups. The predictive factors related to AVM obliteration and complications were analyzed. Results: The study consisted of 81 patients in the non-embolized group and 17 patients in the embolized group. Statistically significant differences were detected between the two groups with respect to age, Pollock-Flickinger score, Spetzler-Martin (SM) grade, eloquence of adjacent brain, and presence of aneurysms. The embolized group included more AVMs with larger median nidus volume. The predictive factors for the obliteration of ruptured AVMs were nidus volume, SM grade, Virginia Radiosurgery AVM Scale (VRAS), and Pollock-Flickinger score and for the subsequent hemorrhage were marginal dose, nidus volume, SM grade, VRAS, and Pollock-Flickinger score. The obliteration rates and complication rates after GKRS between groups were not significantly different. However, this study demonstrated statistically significant difference in the cumulative incidence of obliteration in AVMs with SM grade III and IV ( Intracranial hemorrhage is the most devastating complication of intracranial arteriovenous malformations (AVM). Without treatment, the overall risk of a spontaneous hemorrhage from a brain AVM has been reported to range from 2% to 5% per year ,2,3. TheAt our facility, patients who present with an intracranial hemorrhage requiring hematoma evacuation and decompression are candidates for surgical resection. Patients who have been ruled out as surgical candidates are offered GKRS followed by embolization, instead of GKRS after embolization due to the several disadvantages described above. After a short interval, following endovascular embolization can be used to treat the remaining AVM. During the post-GKRS period, the risk of AVM repeat rupture has been reduced by endovascular embolization. In this study, we report the results of a retrospective analysis of outcomes for all patients who presented to our institution with ruptured AVMs. All included patients were treated with GKRS before endovascular embolization or with GKRS alone. A database including 150 cases of patients with ruptured AVMs who underwent GKRS between November 2008 and October 2017 at our hospital was retrospectively reviewed. The embolized group comprised of AVMs with post-GKRS embolization. The non-embolized group was defined as AVMs treated by GKRS alone. All patients presented with hemorrhage confirmed by non-contrast enhanced computed tomography (CT) imaging. This study excluded patients who had follow-up for less than 2 years or who had been previously treated by resection or embolization in our hospital or at another institution. All patients had at least one post-GKRS magnetic resonance imaging (MRI) or cerebral angiography follow-up study at our hospital available for analysis. Patient clinical data, including demographic characteristics, imaging findings before embolization and GKRS, radiosurgical parameters, and follow-up images, were reviewed. Spetzler-Martin (SM) grade, Virginia Radiosurgery AVM Scale (VRAS), and Pollock-Flickinger score were used to classify AVMs. This study obtained full ethical approval from the institutional review board. The procedure for GKRS has been previously described ,20. In bPlanning of endovascular treatment was based on consensus by a multidisciplinary stroke team meeting after the careful evaluation of 3-dimentional angiograms. Endovascular embolization was performed for the purpose of reducing nidus flow and decreasing the risk of subsequent hemorrhage during the latent period. The embolized group underwent transarterial embolization using N-butyl cyanoacrylate (NBCA) or non-adhesive copolymer ethylene vinyl alcohol  at our institution. Post-GKRS embolization was scheduled for the earliest possible date after GKRS, considering the patients’ medical and neurologic conditions. After GKRS, all patients underwent clinical evaluation and MRI/MR angiography (MRA) including time-of-flight (TOF) studies at 6-month intervals for the first 2 years and then annually thereafter. Once the nidus was considered obliterated on MRI/MRA, a cerebral angiogram was recommended. Total obliteration of the AVM was defined as complete absence of nidus filling on angiogram . If the p value less than 0.05. All analyses were performed using statistical software .The Chi-square test, Fisher exact test, and Mann-Whitney U-test were used to examine differences between the embolized and non-embolized groups. Descriptive statistics are presented as the median and range for continuous variables and as frequency and percentage for categorical variables. Since all continuous variables did not satisfy normality, they were analyzed by the Mann-Whitney U-test. Descriptive statistics were presented as medians . The rates of obliteration, repeat hemorrhage, and delayed cyst formation after treatment were assessed in both groups. Obliteration and complication rates were compared between the two groups using Chi-square test or Fisher’s exact test, as appropriate. The Kaplan-Meier method was used to investigate different groups in association with the obliteration and complication rates after stratification with the log-rank test. Univariate analyses were performed using the Cox proportional hazards regression model to analyze the predictive factors of AVM obliteration and complications. The hazard ratio (HR) and 95% confidence interval (CI) were calculated. Statistical significance was indicated by a Among 150 GKRS for ruptured AVMs, 14 cases of repetitive GKRS were identified, therefore a total of 136 patients underwent GKRS for ruptured AVMs. Fourteen patients were excluded because their follow-up periods were less than 2 years and they did not undergo follow-up imaging studies. Twenty-four patients who underwent embolization or surgical resection before GKRS were also excluded. In total, 98 patients were enrolled in this study. The non-embolized group consisted of 81 patients and the embolized group consisted of 17 patients.The median interval between embolization and GKRS was 6.3 days (range 0–21 days). The embolic agents were Onyx, used in 12/17 procedures (70.6%), and NBCA, used in 5/17 procedures (29.4%). (p = 0.2232). The Kaplan-Meier curves for obliteration are shown in p = 0.4281, Log rank test). The Cox regression model for factors regarding time to obliteration is shown in In the embolized group, MRI/MRA or angiographic obliteration after GKRS was achieved in eight patients (47.1%). In the non-embolized group, MRI/MRA or angiographic obliteration after GKRS was achieved in 51 patients (63.0%). The difference was not significant according to the Chi-square test p = 0.3439). The Kaplan-Meier curves for repeat hemorrhage are shown in p = 0.2099, Log rank test). The Cox regression model for factors regarding time to repeat hemorrhage is shown in Post-GKRS complications included repeat hemorrhage and cyst formation. In the embolized group, none of the 17 patients experienced repeat hemorrhage at the last follow-up. In the non-embolized group, eight repeat hemorrhage episodes were noted after GKRS. The difference was not significant according to the Chi-square test (p = 0.9999). The Kaplan-Meier curves for delayed cyst formation are shown in p = 0.8341, Log rank test). The Cox regression model for factors regarding time to cyst is shown in In the embolized group, there was one patient with radiation-induced delayed cyst formation. In the non-embolized group, six patients showed delayed cyst formations after GKRS. The difference did not achieve statistical significance in the Chi-square test . The cumulative incidence of repeat hemorrhage and delayed cyst formation were not significantly different between the two groups . However, statistical significance was observed in the cumulative incidence of obliteration   D. 3, 18 Gy to 50% of the isodense line; A 28-year old patient was admitted to the emergency department with sudden onset of headache and nausea. The non-contrast enhanced CT scan revealed an acute intraventricular hemorrhage in the left lateral ventricle A. A subs3, 16 Gy to 50% of the isodense line; A 20-year old patient had presented with sudden onset of left homonymous hemianopsia. The non-contrast enhanced CT scan revealed an acute intracerebral hemorrhage in the right parieto-occipital lobe A. The DSWe started this study to compare the outcomes of ruptured AVMs at a higher risk of subsequent hemorrhage treated with and without post-GKRS embolization and to investigate the potential benefits of post-GKRS embolization. We hypothesized that the potential benefits of post-GKRS embolization would lower the risk of subsequent hemorrhage and increase the rate of obliteration of previously ruptured AVMs.p = 0.003, 0.004, <0.001, and <0.001, respectively)  . AVM volctively) . The preUsing univariate analysis, the marginal dose, nidus volume, SM grade, VRAS, and Pollock-Flickinger score were identified as predictive factors for subsequent hemorrhage in the present study . Our finp = 0.0372, Log rank test)  D.In the present study, it was unusual to demonstrate six (7.4%) delayed cyst formation in the non-embolized group after GKRS with the short latency period. In the systematic review by Ilyas et al., the overall rate of post-SRS cyst formation was 3.0%, which is half the percentage in our report, and the mean latency period to post-SRS cyst formation was 78 months (6.5 years) . HoweverThe major limitation of the present study includes the retrospective review at a single institution with a small number of patients (17 patients with embolization). Regarding the subgroup analysis performed on AVMs with SM grade III and IV, this consisted of 11 patients in the non-embolized group and 4 patients in the embolized group. Although statistical significance was observed in cumulative incidence of obliteration between the two groups, it may not be considered to prove the clinical significance because of the small sample size. The selection bias may play a critical role in patient selection and the decision to choose treatment because larger AVMs with more complex angioarchitecture are usually selected for combined management. In addition, the treatment bias associated with endovascular embolization being decided by “accessibility” was unavoidable. Lastly, our institution started to treat larger AVMs with staged-GKRS rather than single-session GKRS. In this study, only first single-session GKRS data of patients were used for analysis. In the present study, predictive factors for the obliteration of ruptured AVMs were nidus volume, SM grade, VRAS, and Pollock-Flickinger score. In addition, our study showed that marginal dose, nidus volume, SM grade, VRAS, and Pollock-Flickinger score significantly affected subsequent hemorrhage after GKRS. Although the current study demonstrated similar results in patients who underwent GKRS with and without embolization, the embolized group included more AVMs with larger nidus volume, higher SM grade, Pollock-Flickinger score, and aneurysm, which have a lower chance of obliteration and a higher probability of repeat hemorrhage. GKRS followed by embolization appears to be a beneficial approach for the treatment of ruptured AVMs that are at risk for obliteration failure and repeat hemorrhage during the latency period after single-session GKRS alone. Further studies involving a larger number of cases and continuous follow-up are necessary to confirm our conclusions.


We sought to contain a healthcare-associated coronavirus disease 2019 (COVID-19) outbreak, to evaluate contributory factors, and to prevent future outbreaks.Quasi-experimental cluster-control outbreak evaluation.All patients and staff on the outbreak ward (case cluster), and randomly selected patients and staff on COVID-19 wards (positive control cluster) and a non-COVID-19 wards (negative control cluster) underwent reverse-transcriptase polymerase chain reaction (RT-PCR) testing. Hand hygiene and personal protective equipment (PPE) compliance, detection of environmental SARS-COV-2 RNA, patient behavior, and SARS-CoV-2 IgG antibody prevalence were assessed.P < .001). RNA levels on the COVID-19 ward (where there were no outbreaks) and the outbreak ward were similar . Mean monthly hand hygiene compliance, based on 20,146 observations (over preceding year), was lower on the outbreak ward (P < .006). Compared to both control wards, the proportion of staff with detectable antibodies was higher on the outbreak ward .In total, 145 staff and 26 patients were exposed, resulting in 24 secondary cases. Also, 4 of 14 (29%) staff and 7 of 10 (70%) patients were asymptomatic or presymptomatic. There was no difference in mean cycle threshold between asymptomatic or presymptomatic versus symptomatic individuals. None of 32 randomly selected staff from the control wards tested positive. Environmental RNA detection levels were higher on the COVID-19 ward than on the negative control ward (OR, 19.98; 95% CI, 2.63–906.38; Staff seroconversion was more likely during a short-term outbreak than from sustained duty on a COVID-19 ward. Environmental contamination and PPE use were similar on the outbreak and control wards. Patient noncompliance, decreased hand hygiene, and asymptomatic or presymptomatic transmission were more frequent on the outbreak ward. These reports should be accompanied by an analysis of the specific infection control measures implemented.1 However, none of the major case series of COVID-19 patients from US hospitals, Italy, or China discuss infection control measures.8 Similarly, reports from skilled nursing facilities in the United States and London did not detail infection control measures beyond “restricting visitors, canceling communal events, and implementing COVID-19 transmission-based precautions.”11 Those reports did not explain those transmission-based precautions or evaluate other related factors such as compliance with personal protective equipment (PPE) and hand hygiene (HH), or the role of the environment in the outbreak.11An outbreak on a pediatric dialysis ward in Germany has also been described, but the details of the exposure are not provided. Other than saying that exposed staff were quarantined, specific infection control measures were not described.12Detailed descriptions of hospital-acquired coronavirus disease 2019 (COVID-19) and workplace transmission patterns are crucial to preventing outbreaks and improving patient safety.17 until most recently, most COVID-19 testing in the United States has been performed on symptomatic individuals. This situation complicates nosocomial outbreak investigations because the prevalence of asymptomatic infections and the baseline seroprevalence are not fully known. However, this information is important for differentiating nosocomial transmission from background positivity rates and assessing the degree of spread throughout the ward.Although presymptomatic and asymptomatic transmission is increasingly recognized,After the first nosocomial transmission of SARS-CoV-2 at our facility, we sought to contain the outbreak, to assess contributory factors, and to prevent future outbreaks using the information gained. In addition to those efforts, we describe the control measures implemented and their short-term impact.1 (online). Due to neurologic impairments in the patients, close physical contact with nursing and physical and occupational therapists occurs more frequently on this ward than on te general medical–surgical wards. Historically, nosocomial respiratory syncytial virus cases are more frequent on the ward compared to other wards. On average, 80% of the patients have intravenous catheters and 40% have indwelling or external urinary catheters.The outbreak occurred on a 39-bed acute-care stroke ward in a 528-bed teaching hospital. The layout of the ward and the sequence of secondary patient cases are illustrated in Supplementary Fig. The index case was a patient who had been on the stroke ward for 22 days before becoming acutely symptomatic with fever and lower respiratory tract symptoms. Her SARS-CoV-2 test was positive 20 hours later, and she required transfer to the intensive care unit (ICU) for endotracheal intubation. Prior to becoming symptomatic, the patient wandered throughout the ward visiting other patients and the nurse’s station without adhering to directions to wear a mask. To ameliorate nocturnal agitation that the patient suffered from, it was often necessary to place the patient in a geriatric chair at the nursing station. She was initially admitted for delirium and medication toxicity. During the admission, the patient also required continuous positive airway pressure and occasional bilevel positive airway pressure for chronic obstructive pulmonary disease.2 online). Both patients had a history of mental illness and were not compliant with requests to remain in their rooms or to use masks, despite repeated redirections from nursing staff. Subsequently, a second patient care technician became symptomatic and tested positive for SARS-CoV-2 .One day after the index case became ill, a patient care technologist also became symptomatic and tested positive for SARS-CoV-2 the following day. All staff with exposure to the index case in the 14 days prior to her symptom onset, were offered SARS-CoV-2 screening. Three days after the index case was identified, a second patient on the ward, who was a frequent visitor of the index patient, also tested positive for SARS-CoV-2  , or BD SARS-CoV-2 Reagents for BD MAX, . A hospital-acquired COVID-19 case was defined as a patient who had their first positive specimen collected after day 14 of their hospitalization.Prior to the outbreak, several COVID-19–specific infection control measures had already been adjusted to account for possible presymptomatic transmission. These included visitor restrictions, that is, no visitors allowed except in special circumstances, such as imminent death of the patient, and 1 birthing partner allowed. All such special circumstance visitors were interviewed in and questioned regarding symptoms and exposures, and their temperatures were measured. All healthcare workers were required to wear ASTM -Level 1 surgical masks. ASTM International, formerly known as American Society for Testing and Materials, is an international standards organization that develops and publishes technical standards. Staff who were positive for SARS-CoV-2 testing or symptomatic were restricted from working. SARS-CoV-2–positive patients were placed in cohorts on dedicated COVID-19 wards, and patients were required to wear masks when leaving their rooms. In addition to masks, all staff were provided face shields to wear when caring for COVID-19 or suspected COVID-19 patients. Face shields were required for COVID-19 patient care but were only recommended for non–COVID-19 patient care. Any patient having an aerosol-generating procedure was treated as a possible person under investigation. These aerosol-generating procedures required the use of N-95 filtering respirators and were performed in an airborne-infection isolation room whenever such a room was available.Historically and currently, all wards were and are required to report monthly HH compliance to infection control and leadership committees. Clandestine observations are performed by specially trained staff . The same procedures apply to PPE observations.Following the discovery of the index case, the entire outbreak ward was placed on quarantine precautions. As a result, gloves, face shield, and face mask were required for all patient contact on the ward (regardless of SARS-CoV-2 status) until 14 days after the last exposure. Patient assignments and work locations of staff were determined by interview and review of shift assignments. Quarantine information was given to the nurse manager and attending physicians from the ward to share with patients. Directly exposed patients (meaning patients who were visited by the index case or cared for by an employee who tested positive) were notified of their exposure and were placed in quarantine. Discharged COVID-19–exposed patients and their primary care physicians were notified by an ambulatory results nursing call center and were instructed to remain in home quarantine for the remainder of the 14 days following their last exposure. The list of exposed patients and staff was also reported to the local health department. New admissions to the stroke ward were restricted to patients with acute neurologic conditions.Staff break-room capacity was limited through staggering and distanced seating. In addition to the routine regular monthly assessments, additional PPE and cleaning assessments were conducted clandestinely . For an observation to be counted as compliant, the proper equipment had to be worn and worn correctly. For example, a cloth face mask covering the nose and mouth would not be considered compliant because staff were required to wear approved surgical masks. A surgical face mask covering the mouth but not the nose would also be considered noncompliant.The same authors also observed patient behaviors regarding mask use on the outbreak and control wards. Additionally, safety and incident reports that involved behavior deviations by inpatients, and patient exposures, were reviewed.Any employee who had spent time on the outbreak ward or had multiple interactions with patients and/or staff on that ward from 2 days before the index case became symptomatic to 7 days afterward was offered voluntary PCR testing for SARS-CoV-2. Staff were able to continue to work if asymptomatic while test results were pending . Staff who tested positive for SARS-CoV-2 were restricted from working until they were cleared by the employee health department . Staff who tested negative but had a defined medium- or high-risk exposure to a positive employee or patient were actively monitored for symptoms 14 days from exposure using the Datos Health Application .Before the outbreak occurred, the hospital had predesignated 1 of 4 ICUs and a general medicine floor as a COVID-19 unit in anticipation of the surge of COVID-19 patients. All patients testing positive for SARS-CoV-2 were admitted to this floor or ICU, and these were therefore selected as a positive control comparators. Two wards that had had no SARS-CoV-2–infected admission since the start of the pandemic, and that currently contained no such patients, were selected as the negative control comparators. These control wards and the outbreak ward are located on different floors. Patients and staff on the outbreak ward were considered the outbreak cluster.To assess the background point prevalence of asymptomatic SARS-CoV-2, every other patient across the negative-control comparator wards, and randomly selected staff on those wards were included and tested as ‘negative control clusters.’ Randomization was performed using a random number generator (1–26) corresponding to the first initial of the patient’s last name.In response to the nosocomial case, all patients on the outbreak ward were tested for SARS-CoV-2. All new admissions to the outbreak ward were tested for COVID-19, upon or before arrival to the ward. Patients without typical or atypical COVID-19 symptoms were randomly selected as ‘negative control cluster’ from the non–COVID-19 wards. These wards also acted as the negative controls for serological and environmental assessments.Nasopharyngeal specimens were analyzed on the cobas6800 System, (Roche Diagnostics), the BD MAX BioGX SARS-CoV-2 (Becton Dickinson), or the Simplexa COVID-19 Direct kit .Serology was performed 25–28 days after the index case was identified. Antibody binding to the SARS-CoV-2 spike and N proteins were detected in a standard 2-step enzyme immunosorbent assay using antibody-HRP-conjugate, goat anti-human IgG-antibody in an alkaline phosphatase substrate coated onto 96-well plates . All serum was screened at 1:1,000 dilution, and all samples with an optical density 2-fold higher than the control well were confirmed as positive by 8 2-fold dilutions.2 test surfaces in vacated patient rooms were spotted with 1,250 copies of SARS-CoV-2 genomic RNA (BEI Resources). After 10 minutes of drying time, these surfaces were sampled as positive controls. All such controls tested positive using the commercial assay described below.To ensure that the sampling method could reliably detect environmental RNA before formal sampling began, 100-cm20 Briefly, swabs were streaked over targeted high-touch surfaces for a minimum of 20 seconds in a rolling motion to ensure contact with the entire swab surface. The cobas PCR Media Uni swabs (Roche) were premoistened with the transport media (sterile 40% guanidine hydrochloride tris-HCl buffer) and analyzed on the cobas 6800 System (Roche).Environmental surface sampling was performed as previously described.Eight stationary surfaces were sampled in rooms on the outbreak and control wards: bed rails, call buttons and remote controls, over-bed tray tables, sinks and soap dispensers, chairs, windowsills, and floors. Three shared surfaces were sampled: walking computer workstations, handheld glucometers, and vital-sign machines. Staff break rooms, including microwaves and refrigerators, were also sampled.2 test, the Fisher exact test, and analysis of variance (ANOVA) tests were performed using R software  or Minitab 2020 software .The χ2 online). None of 32 randomly selected staff from the positive and negative control wards tested positive  (Table P < .001). However, there was no difference in the proportion of tested surfaces that were positive between the dedicated COVID-19 ward (where there had been no outbreaks) and the outbreak ward .Of 128 randomly sampled surfaces on the outbreak and control wards, 26 were positive. Floors, call buttons and remote controls, chairs, and shared equipment  were the surfaces most commonly positive for SARS-CoV-2 RNA. The proportion of tested surfaces that were positive for SARS-CoV-2 RNA was higher on the dedicated COVID-19 ward (positive control) than on the non–COVID-19 ward   across all wards at the hospital. The outbreak ward had lower mean monthly HH compliance than most other wards. Of the 20,146 observations, 4,626 were on the outbreak and control wards. Mean monthly HH compliance was significantly lower on the outbreak ward than the positive and negative control wards, averaging 61% on the outbreak ward compared to 79% and 74% on the positive and negative control wards, respectively (P > .05). There were no patient safety or incident reports, and 0 of 72 patients were observed without a mask on the positive and negative control wards.There were 354 clandestine observations for compliance with COVID-19–specific PPE recommendations immediately after the identification of the index case. Overall PPE compliance was 91% on the outbreak ward versus 79% on the positive control ward and 82% on the negative control ward, but the differences were not significant  in this report is lower than those in most available reports.25We found no other cluster control reports of a nosocomial outbreak in a US acute-care hospital that detailed specific control measures and also evaluated compliance with PPE recommendations, environmental surface contamination with SARS-CoV-2, and staff seroconversion. To our knowledge, this report appears to be the first such report. Furthermore, reports from non–university-based locations, such as this one, are underrepresented in research; most studies are carried out in large academic institutions. However, most health care in the United States is provided at non–university-based facilities. Additionally, the factors involved in this outbreak  have been associated with explosive outbreaks and sustained transmission (super-spreading events).17 and nearly all the transmission that occurred in this outbreak was either presymptomatic or asymptomatic .The observation that infection in staff, as measured by seroconversion, was not higher on a dedicated COVID-19 ward compared to wards that had no patients with SARS-CoV-2 infection suggests that the prevailing PPE practices described here were effective. However, unanticipated movements or events are known to be factors in workplace accidents, and those appear to have furthered this outbreak. Similarly, decreased HH compliance likely contributed as well. Presymptomatic and asymptomatic transmission is increasingly recognized,This report has several limitations. Because of its quasi-experimental nature, causality cannot be inferred. It is from a single facility, but the facility is typical of many hospitals and settings in the United States, so the findings are still relatively generalizable. The number of PPE observations was unavoidably small given the limited number of trained observers and competing duties. We did not have the ability to cultivate SARS-CoV-2 virus, so another limitation is that the infectivity of the environmental RNA is unknown.26Our findings raise several unanswered questions that are important considerations for future control efforts. These issues include the legal, ethical, and safety implications of managing noncompliant, infectious, or potentially infectious patients. These challenges and questions have particular implication for neurobehavioral wards where a patient’s understanding and behavior are degraded or risky, and for other vascular wards where symptoms of SARS-CoV-2 infection can overlap with or be mistaken for underlying cardiac and vascular conditions such as stroke, cardiac insufficiency, thromboembolism, or even syncope  remains challenging and merits further research aimed at creative solutions for increasing compliance. Going forward, we are evaluating the effectiveness of highly visible HH and PPE ‘ambassadors’ who roam the wards providing friendly reminders and answering questions. We are also evaluating the feasibility of using whole-genome sequencing at nonuniversity hospitals such as this one to enhance outbreak investigations.


Subjects with ultra-high risk (UHR) states for psychosis show brain structural volume changes similar to first-episode psychosis and also elevated incidence of environmental risk factors like childhood trauma. It is unclear, however, whether early neurodevelopmental trajectories are altered in UHR. We screened a total of 12,779 first-year Chinese students to enroll 36 UHR subjects  and 59 non-UHR healthy controls for a case-control study of markers of early neurodevelopment. Subjects underwent 3T MRI scanning and clinical characterization, including the childhood trauma questionnaire (CTQ). We then used the CAT12 toolbox to analyse structural brain scans for cortical surface complexity, a spherical harmonics-based marker of early neurodevelopmental changes. While we did not find statistically significant differences between the groups, a trend level finding for reduced cortical complexity (CC) in UHR vs. non-UHR subjects emerged in the left superior temporal cortex , and this trend level association was significantly moderated by childhood trauma (CTQ score). Our findings indicate that UHR subjects tend to show abnormal cortical surface morphometry, in line with recent research; more importantly, however, this association seems to be considerably modulated by early environmental impacts. Hence, our results provide an indication of environmental or gene × environment interactions on early neurodevelopment leading up to elevated psychosis risk. Psychotic disorders are often preceded by prodromal symptoms, leading to the construction of clinical criteria defining an “ultra-high risk” (UHR) status, which aims to facilitate early detection and intervention . UHR indPrevious studies have demonstrated that UHR status or risk is associated with environmental exposures such as urbanicity , negativBoth UHR status or risk for psychosis and early environmental stressors like childhood trauma show effects on brain structure, thus mediating genetic and non-genetic impacts on this putative biomarker. Multiple studies have shown the overlap (and differences) of brain structural effects in case-control studies in UHR and first-episode psychosis , includiSurface-based morphometric markers have been used to tap more specifically into the early developmental aspects of brain morphometry. These studies have shown subtle cortical folding abnormalities in neocortical areas overlapping with those seen in VBM studies of schizophrenia –22. Moren = 12,779), and subsequently identifying UHR subjects based on clinical interviews. In particular, the aim of this study was to (1) use cortical complexity to estimate the shape of cortical surfaces in high risk psychosis in college students, and (2) explore the possible interaction and underlying mechanisms between childhood maltreatment and altered folding in high risk for psychosis, in order to evaluate the impact of a prominent environmental risk factor and predictor of subsequent psychopathology.In this study, we propose the use of cortical complexity (CC), a surface-based morphometry (SBM) method , 25 to mn = 12,779 Chinese students from Tongji University in Shanghai, China, we recruited a sample of 95 subjects for MRI analyses, including 36 UHR subjects and 59 non-UHR healthy controls. Subject recruitment and inclusion into the study followed a protocol approved by the ethics committee of the Institutional Review Board at Tongji University.Based on screening Subject recruitment was based on the psychometric screening of large cohorts of undergraduate (1st-year) Tongji University students, who first underwent screening using the prodromal questionnaire (PQ-16 or PQ-B), identifying potential UHR subjects, who then received a clinical interview [Semi-structured Interview for Psychosis risk Syndromes (SIPS)], and upon confirmation were invited to participate as UHR subjects, while otherwise healthy non-UHR subjects from the same population were randomly recruited from that screening cohort.Recruitment was conducted in three waves/study cohorts:In the first wave, the PQ-16 was distributed to 4,040 undergraduate students . The cut-off score of PQ-16 was set at 9, and 71 participants reached the cut-off score (2.3% of the screening population). We invited these participants to our second stage assessment including the SIPS interview, which was conducted by trained psychiatrists. Twenty-nine participants (40.8%) met the criteria as being at ultra-high risk for psychosis based on the SIPS results. One year later, these participants were re-assessed using SIPS (for inclusion in the MRI study). Ten participants still met the UHR criteria while one participant was diagnosed with bipolar disorder. These 10 UHR completed the study including MRI scanning.In a second wave, the PQ-B was given to 4,364 undergraduate students . Applying the PQ-B with a cut-off score of 24, according to a previous study , 27, 1,3In a third wave, the PQ-16 was distributed to 4,675 undergraduate students , of which 100 participants (2.6%) reached the cut-off score of 9. After the second stage assessment using SIPS, 20 participants met the UHR criteria (20%). One participant dropped out and eight participants refused to participate in MRI scanning. Hence, eleven participants of this population completed the study including MRI scans.All SIPS interviews were conducted within 1 month after finishing first stage assessment. Participants completed MRI scans within two months.Healthy controls were selected randomly out of those with scores below cut-off at first stage assessment at Tongji University.General exclusion criteria included previous psychiatric diseases or treatment, drug-abuse, psychotropic medication and family history of schizophrenia.This community-based two-stage recruitment procedure  resulted in a study sample of a total of 95 subjects: 36 UHR subjects  and 59 healthy non-UHR subjects . All subjects were Chinese.As outlined above, the large-scale recruitment used the prodromal questionnaire (PQ) as a screening tool to identify at-risk subjects from the student community who were subsequently invited for clinical interviews to confirm UHR criteria. Due to a change in the protocol of this large on-going Tongji high-risk study, two slightly different versions of the PQ were used in the different waves of recruitment of undergraduate classes.The 16 items prodromal Questionnaire (PQ-16) is a screening tool for prodromal symptoms of psychosis . It consThe 21-item prodromal questionnaire-brief version (PQ-B) is a self-report assessment to screen the psychosis at-risk state, comprised of positive symptom items plus follow-up questions about related distress/impairment on a scale from 1 to 5. A total score of 24 or more will be considered “positive.” The Chinese version of PQ-B was validated and has high sensitivity (83.8%) and specificity (60.9%) .The semi-structured interview for psychosis risk syndromes (SIPS) was administered in this study by trained psychiatrists to ass ess risk of psychosis/UHR status . The SIPSubjects completed the short form of Childhood Trauma Questionnaire (CTQ-SF), a 28-item self-reported questionnaire measuring the experience of childhood trauma. The scale considers five subscales reflecting basic aspects of childhood traumatic experiences: emotional neglect, physical neglect, emotional abuse, physical abuse, and sexual abuse. Each subscale includes five items and the scores of each item are obtained on a 5-point Likert scale . The Chinese version of CTQ-SF shows good cultural equivalence, good reliability and validity .3, field of view: 192 × 192 mm, 136 slices, TR = 8.168 ms, TE = 3.172 ms, TI = 450 ms, α = 12°).Structural images were acquired with a 3.0 T MR scanner  located at Tongji University, Shanghai, China. Structural data were collected using a 3D FSPGR (fast spoiled gradient-echo) sequence (voxel size: 1 × 1 × 1 mmhttp://www.neuro.uni-jena.de/cat/), a toolbox for SPM , these had been excluded from further analysis.T-tests for both directions . We first corrected for multiple (vertex-level) comparisons using a threshold of p < 0.05 with peak-level family wise error correction (FWE) , we also needed to consider the possibility of regional effects, where the direct association of UHR status and regional CC might not reach statistical significance (on the vertex-level), which might be explicitly explained by a moderation model. Hence, while this uncorrected threshold does not correct for the direct association of UHR status and CC, it considers the possibility of regional associations that are moderated by a third variable  and thus insignificant in direct association. For automated anatomical assignment of identified clusters, we used the Desikan-Killiany-40 atlas  framework of SPM, our first statistical analysis was a group comparison of UHR vs. non-UHR subjects to test for differences in cortical complexity on a vertex-level across the entire brain, equalling on (FWE) ; We then40 atlas , 38–40.Moderation analysis for testing our second hypothesis was then performed on the basis of clusters identified in the first (vertex-level) analysis. To test the assumption that the level of childhood maltreatment modulates the association of UHR-status and cortical complexity, we set up a moderated logistic regression model using the PROCESS macro v3.4 running under SPSS . For that, we extracted eigenvariate values from the significant cluster detected in the SBM analysis and entered that variable as predictor, UHR-status as outcome variable and CTQ sum score as moderator. In the model, age and sex were included as covariates. The moderating effect was tested both for the CTQ sum score and subsequently, for each of its sub scores.Chi2 = 1.427, p = 0.232), the ratio of handedness R/L  and the ratio of ethics Han/other ethnic groups . UHR individuals were younger than healthy controls . As we recruited participants in the same college, we do not expect too many differences concerning education background between the two groups. For the UHR group, the scores of four subscales for SIPS including positive symptoms , negative symptoms , disorganized symptoms  and general symptoms . The demographic information and scores of SIPS are presented in We found that the UHR/non-UHR groups did not differ regarding gender ratio M/F  between the two groups. TFCE analysis also did not show statistically significant group level effects for cortical complexity. However, we observed a trend level finding at p < 0.001 uncorrected levels in a cluster comprising the left superior temporal gyrus (STG) and parts of the left insular and transverse temporal cortex. In addition, uncorrected analyses also identified two smaller clusters of relative increases of CC in UHR vs. non-UHR in the left supramarginal and left rostral middle frontal cortices. Findings are shown in There was no statistically significant (2(5) = 64.19, R2(McFadden) = 0.509, p < 0.001] as are both the main effects of CC values  and CTQ sum  and the interaction of the two . Further, including the interaction improves the model significantly . The positive coefficient of the interaction term indicates the effect of CC becoming more positive  with increasing CTQ sum score.Based on the results of the analysis of cortical complexity, we tested whether the association of CC variation and UHR vs. HC status found for a cluster within the superior temporal gyrus would be moderated by the level of childhood maltreatment reported by the participants. We first tested this assumption in a model including CTQ sum score as moderating variable. This model is overall significantly better than a constant-only model , as is the main effect of EN  and its interaction with CC . This model, too, is improved by inclusion of the interaction . It should be noted that multiple testing correction were not performed. Results were presented in We then explored the effect on the level of CTQ dimensions to determine if they contribute differently to the moderating effect. Here, only the model including the emotional neglect (EN) scale is significant [χ(5) = 71.64, This study provides first evidence of a moderating effect of childhood trauma on the emergence of subtle cortical folding abnormalities related to the UHR state for psychosis. In the search of viable biomarkers of risk for psychosis, this provides an important step as it calls for a more detailed consideration of environmental risk factors impacting on early brain development assumed to largely be driven by genetic factors. Three main aspects of this study deserve particular attention in our discussion: first, the identification of subtle cortical folding alterations distinguishing clinically healthy UHR subjects from their non-UHR controls, second, the moderation of these effects by childhood trauma, which implies that different levels of trauma modulate the relationship between UHR status and cortical complexity, and third, a decreasing score of emotional neglect strengthened the effects of cortical complexity in STG, a key area related to risk for schizophrenia.Cortical complexity is an SBM method that could reflect the pathogenic processes in cortical structure changes, and has been used successfully to measure the aberrant cortical folding in schizophrenia , 39, 40 We also found that ultra-high risk individuals showed reduced cortical complexity in the superior temporal gyrus (STG) and insula in the left hemisphere, corresponding with previous studies that found differences of gyrification in UHR . STG andModeration analysis has been used to address that whether and to what degree the effects of one variable on an outcome exists under different levels of an additional condition . The moddecreases with higher childhood trauma. In other words, genetic factors may make individuals more vulnerable to the influences of environmental factors, but this may also depend on the degree of adverse exposures , our sample sizes would be expected to achieve 0.75 power . This would imply that at least medium to larger effects should have been detected with our sample at reasonable power assumptions. However, limited sample size might have precluded detection of more subtle effects. This limitation has to be outweighed against the unique characteristics of the sample: UHR subjects were recruited from a non-help seeking population (hence limiting the bias introduced by subjective distress related to UHR-symptoms) and are more homogeneous for sociodemographic factors (as they stem for a pre-defined student population). Another major limitation of our interpretation linking fugitive genetic effects to our findings is that even though cortical complexity might be related substantially the effects of genes implicated in early brain development, additional environmental factors can impact on the formation of cortical folds, including our findings. Also, the choice of cortical complexity would be expected to focus on the part of brain structural variance related to early development aspects . Yet, even though cortical complexity might be a more sensitive parameter, further replication of our findings is warranted. Since our study only involved cross-sectional data, we cannot infer on the relation of either cortical folding itself or the moderation effect in related to transition rates.We also need to consider some methodological limitations, however. Despite screening a very large cohort of students, our UHR sample was rather limited. While typically with a sample of 50 vs. 50 subjects one would expect to detect effect sizes of In conclusion, this study detected differences of cortical surface folding between individuals at ultra-high risk for psychosis and healthy controls using cortical complexity. Childhood trauma, however, is a significant modulator in this association, suggesting that early brain development leading up to UHR is significantly influenced by  environmental stressors, even for markers of aberrant early neurodevelopment. However, a robust significant association between cortical folding and later UHR status might depend on additional environmental risk factors and thus might be absent in subjects without the latter.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Institutional Review Board at Tongji University. The patients/participants provided their written informed consent to participate in this study.JH: data acquisition, data analysis, original draft preparation, and manuscript writing. SS and TM: data analysis and manuscript writing. IF: manuscript revision and editing. JC: data acquisition and manuscript editing. JW: data analysis and manuscript revision. XZ: manuscript editing. JS: funding acquisition. IN: supervision of data analysis, data interpretation, original draft preparation, manuscript writing, and revision. 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.


Genetic susceptibility to depression has been established using polygenic scores, but the underlying mechanisms and the potentially differential effects of polygenic scores on specific types of depressive symptoms remain unknown. This study examined whether systemic low-grade inflammation mediated the association between polygenic scores for depressive symptomatology (DS-PGS) and subsequent somatic versus cognitive-affective depressive symptoms. The sample consisted of 3510 men and women (aged 50+) recruited from the English Longitudinal Study of Ageing. DS-PGS were derived using the results of a recent genome-wide association study. Plasma C-reactive protein (CRP) was measured at wave 6 (2012/13). Depressive symptoms were assessed at wave 8 (2016/17), using the eight-item version of the Centre for Epidemiological Studies Depression Scale. Covariates  included age, sex and ten principal components (PCs) to control for population stratification. Confirmatory factor analysis was performed to corroborate a previously identified two-factor structure of the CES-D, distinguishing between cognitive-affective and somatic symptoms. Longitudinal structural equation modelling was used to investigate the mediating role of CRP in the relationship between DS-PGS and cognitive-affective versus somatic symptoms. Our results showed that participants with a higher polygenic susceptibility to DS were significantly more likely to report cognitive-affective and somatic symptoms at follow-up. Mediation analyses revealed that CRP mediated the relationship between DS-PGS and somatic symptoms, but not the association between DS-PGS and cognitive-affective symptoms. These differential effects highlight the importance of considering individual differences in depression profiles in future studies. Ultimately, this will inform healthcare professionals to design more targeted treatments. It is typically characterised by a number of cognitive, affective and somatic symptoms, including anhedonia, low mood, loss of appetite, and sleep problems3. According to a previous prevalence study, ~18% of adults aged 65 years and older in England experience elevated depressive symptoms4. Research also indicates that depression has substantial public health implications. For example, depression has been linked to an increased risk of morbidity7, cognitive decline8, and mortality10. In the past decades, research has attempted to uncover plausible biopsychosocial pathways contributing to the development of depression. However, the exact biological, psychological and social mechanisms underlying the pathogenesis of depression remain elusive.Depression is a leading cause of disability and a growing public health concern worldwide, particularly among older adults11. GWAS aim to identify individual genetic variants, also known as single nucleotide polymorphisms (SNPs), which are significantly associated with a trait or phenotype of interest12. However, for many complex psychiatric disorders, individual SNPs have been found to exert only modest effects on these conditions, making it difficult to predict disease risk reliably13. Recent evidence suggests that depression is likely to have a substantial polygenic component14. Accordingly, genetic susceptibility to depression cannot be simply explained by the independent contributions of individual genetic variants, but rather by the combined additive effects of multiple SNPs in the human genome15. This has led to the development of polygenic scores (PGS), which summarise genome-wide genotyping data into a single score that measures genetic susceptibility to a particular trait or illness. A number of previous studies have examined the associations between PGS for depression and depressive symptoms18. Interestingly, PGS have been found to significantly correlate with disease status and chronicity of the disorder19. Moreover, they typically explained 0.2–1% of variance in depression, suggesting that other factors contribute to the pathogenesis of depression20.Genetic variation may play an important role in the aetiology of depression. The advent of genome-wide association studies (GWAS) has made it possible to investigate the genetic underpinnings of complex psychiatric disorders, including depression23. Considerable evidence suggests that systemic pro-inflammatory cytokines  are capable of signalling the central nervous system to alter behaviour and mood states24. This is consistent with the cytokine hypothesis of depression, which posits that systemic low-grade inflammation and subsequent neuroendocrine responses can induce depressive-like symptoms in a subset of people25. Systemic low-grade inflammation describes the persistent production of pro-inflammatory factors in response to immune challenge and stress, which may result in a prolonged state of low-grade inflammation26. It is typically measured via serum concentrations of circulating pro-inflammatory markers, including the cytokines interleukin-6 (IL-6) and interleukin-8 (IL-8), the acute phase protein C-reactive protein (CRP), the coagulation protein fibrinogen or the tumour necrosis factor α (TNF-α). Plausible biological pathways exist for the effects of systemic low-grade inflammation on mood. These include the cytokine-induced activation of afferent fibres of the vagus nerve and the transportation of cytokines through the blood-brain barrier, initiating a constellation of depressive-like symptoms, collectively known as ‘sickness behaviour’27. Sickness behaviour usually refers to a set of primarily somatic symptoms, such as fatigue, sleep problems, reduced locomotor activity and loss of appetite27. Notably, most evidence supporting the inflammation hypothesis of depression has been cross-sectional, and prospective studies have found mixed results29. This could be attributed to the possibility of symptom-specific associations between systemic low-grade inflammation and depression, owing to the prevailing use of sum scores rather than factor analytic symptom structures or individual symptoms of depression30. Depression is a multifaceted disorder with varying types of symptom expressions. Previous factor analytic studies suggest a plausible two-factor structure of depression, distinguishing between a cognitive-affective and somatic symptom dimension of depression31.An abundance of studies has indicated a link between peripherally and centrally localised inflammatory activity and the pathogenesis of depressionTaken together, evidence suggests that polygenic susceptibility to depression is associated with an increased risk of developing future depressive symptoms. In addition, inflammatory processes have been identified to be another, potentially aetiological, risk factor for DS. However, it remains unclear whether people with increased genetic susceptibility to depression may also be more likely to show elevated levels of systemic low-grade inflammation. Furthermore, there have been no prospective studies investigating whether systemic low-grade inflammation mediates the relationship between PGS for depressive symptomatology (DS-PGS) and specific symptom dimensions of depression. Therefore, the aim of the present was first, to investigate the association between a GWAS-derived DS-PGS and symptom-specific dimensions of depression  in a sample of English community-dwelling older adults. Second, we examined whether systemic low-grade inflammation acted as a downstream mediator in the association between DS-PGS and self-reported cognitive-affective versus somatic symptoms.32. Participants have been followed up bi-annually from 2002 onwards. So far, there have been 8 waves of data collection. ELSA provides a rich variety of psychosocial data collected via face-to-face computer-assisted personal interviews and self-completion questionnaires. Biological data  was collected during nurse visits at participants’ homes. Genome-wide genotyping was conducted at the University College London Genomics. The follow-up period reported here is wave 8 (2016/17), the latest available wave of data collection in ELSA. A total of 8780 participants attended the core assessment at wave 2. Genotype data on depressive symptoms were available for 7183 participants. Participants aged <50 years (N = 51) and those with missing blood samples (N = 3419) were excluded from the analytical sample. Missing biological data were mainly due to participants’ unwillingness to consent or ineligibility to provide blood samples . Study participants with CRP levels ≥10 mg/L (wave 6) were also excluded from the analysis (N = 212), since these values may reflect acute inflammatory processes rather than systemic low-grade inflammation33. Thus, the final analytical sample consisted of 3510 participants. All participants provided informed consent prior to their participation in the study. Ethical approval was obtained from the London Multi-Centre Research Ethics Committee (https://www.elsa-project.ac.uk).The English Longitudinal Study of Ageing (ELSA) is an ongoing, nationally representative, longitudinal population study of adults aged ≥50 years living in England. ELSA was established in 2002, using a variety of biological, psychological and sociological measures to assess the causes and consequences of health-related outcomes. Further details on ELSA have been described in-depth elsewhere34. Participants were asked to indicate whether they had experienced low energy levels, effort doing things, low mood, enjoyment/happiness in life, sadness, loneliness and/or sleep problems during the past week. The CES-D uses a binary response scale . Scores ranged from 0  to 8, with scores equal to or higher than three corresponding to the CES-D 20 cut-off of 16 points—representing a clinical diagnosis of depression35. The 8-item version of the CES-D is a well-validated screening tool for DS36 and has been used often in previous longitudinal investigations38.Depressive symptoms were measured using the eight-item version of the Centre for Epidemiological Studies Depression Scale (CES-D)https://www.elsa-project.ac.uk/genetics). Briefly, individuals with suspected non-European ancestry and heterozygosity scores >3 standard deviations from the mean were removed. Furthermore, initial quality control measures were conducted to test for duplicates and missingness of more than 2% of the genotype data. SNPs with a call rate of <98%, a minor allele frequency of <0.01%, and Hardy-Weinberg Equilibrium p values of <10−4 were excluded. Non-autosomal markers were also removed, as well as regions known to contain clusters of highly correlated SNPs, as these can bias the analyses40. Principal components analysis was performed to investigate population structure, and ten PCs were retained to account for any ancestry differences in genetic structures41. A total of 7183 samples and 1,372,240 genetic variants remained after quality control. DS-PGS calculation was informed by the GWAS summary statistics from the Social Science Genetic Association Consortium (SSGAC)42. The SSGAC GWAS meta-analysed the results from a mega-analysis conducted by the Psychiatric Genomics Consortium (PGC)19, and the results from two more recent investigations using data from UK Biobank (UKB)43 and the Resource for Genetic Epidemiology Research on Aging (GERA) Cohort (N = 180 866) (https://www.ncbi.nlm.nih.gov/projects/gap/cgi-bin/study.cgi?study_id=phs000674.v1.p1). In UKB, a continuous phenotype measure was derived, based on two questions asking participants about the frequency they experienced feelings of unethusiasm/disinterest and depression/hopelessness. PGC and GERA used case-control data on major depressive disorder. In addition, SSGAC performed a comprehensive replication analysis with data from 23andMe . DS-PGS were computed using methods previously described in the Health and Retirement Study44. Accordingly, DS-PGS were calculated as the sum of SNPs associated with depressive symptoms, weighted by their corresponding effect sizes from the SSGAC summary statistics45. PGS analyses were performed based on a recommended p value threshold of 144, using the statistical software packages PRSice46 and PLINK version 1.947.ELSA participants of European ancestry were genotyped in 2013/14, using the Illumina HumanOmni2.5 BeadChips , with a coverage of ~2.5 million SNPs that capture the genomic variation down to 2.5% minor allele frequency. A full quality control protocol has been described elsewhere  were analysed at the Royal Victoria Infirmary laboratory in Newcastle (UK), using the N Latex CRP mono Immunoassay on the Behring Nephelometer II Analyser49. First, confirmatory factor analysis (CFA) was conducted to examine the validity of a previously suggested two-factor model of depression50. The latent construct cognitive-affective symptom dimension was hypothesised to represent the common variance among five of the eight CES-D items: ‘did you feel depressed?’,‘did you enjoy life?’, ‘did you feel sad?’, ‘did you feel lonely?’ and ‘were you happy?’. The latent construct somatic symptom dimension was hypothesised to be composed of the remaining three items: ‘did you feel everything you did was an effort?’, ‘was your sleep restless’ and ‘were you unable to get going?’. Second, mediation analysis was performed to examine the standardised direct, indirect and total effect of the association between PGS for DS, systemic low-grade inflammation  and the two latent symptom-specific dimensions of the CES-D . Mediation assumes that the relationship between the independent variable and dependent variable is mediated by a third variable. The total effect refers to the effect of DS-PGS on cognitive-affective depressive symptoms and somatic symptoms, respectively. The indirect effect represents the amount of mediation exerted through CRP on the association between the independent and dependent variable. The direct effect describes the effect of the exposure variable on the outcome variable while controlling for the mediator variable51. In the current model, the observed cognitive-affective and somatic symptom scores were treated as ordinal variables. Thus, the model was fitted using the robust weighted least squares estimator (WLSMV). This method has been developed specifically for modelling categorical variables. The WLSMV estimator handles missing data by producing unbiased estimates for the parameters and their standard errors. Model fit indices were compared against Pearson χ2 (Chi-Square) ≤ 0.05, Comparative Fit Index (CFI) ≥ 0.95 and Root Mean Square Error of Approximation (RMSEA) ≤ 0.05. Bootstrapping (1000 replications) was employed as a validated method to estimate the bias-corrected confidence intervals of the indirect effect52. All analyses were adjusted for age, sex and ten PCs to account for any ancestry differences in genetic structures that could potentially bias the results.Following traditional structural equation modelling (SEM) practice, the analyses were performed in two consecutive stepsDescriptive statistics were analysed using the statistical software package STATA version 15. SEM was performed using the Mplus software version 7 .To further explore the temporal precedence in the relationship between PGS, systemic low-grade inflammation and specific types of depressive symptoms, additional analyses were performed to assess the significance of the indirect effect of CRP while adjusting for cognitive-affective and somatic symptoms at wave 6.N = 3 510) are provided in Table Descriptive statistics of the sample N = 3 50 are pro53.CFA of the items included in the CES-D 8 indicated that the two-factor model differentiating between cognitive-affective and somatic symptoms fit the data better than the one-factor model  and somatic  symptoms after controlling for age, sex and 10 PCs (Table DS-PGS were significantly associated with both the cognitive-affective (χ2 < 0.0001). The results indicated that CRP acted as a partial downstream mediator of the relationship between DS-PGS and somatic symptoms , explaining a total of 7.42% of this association. Moreover, a significant direct  and total  effect were found between DS-PGS and the somatic symptom dimension. In contrast, no significant mediating effect of CRP was found for the relationship between DS-PGS and cognitive-affective symptoms . However, DS-PGS had a significant direct  effect on cognitive-affective symptoms. Furthermore, there was a significant total effect  in the association between DS-PGS and cognitive-affective symptoms after adjusting for the mediator variable CRP. Figure Mediation analysis was performed to explore whether CRP  acted as an intermediate mechanism of the relationship between DS-PGS  and cognitive-affective versus somatic symptoms . All analyses were adjusted for age, sex and 10 PCs to control for ancestry differences in genetic structures . Similar to our main results, no significant indirect effect was found for CRP on the relationship PGS and cognitive-affective depressive symptoms The results of the sensitivity analyses Table  revealedThis is the first study to investigate the prospective associations between genetic susceptibility to depressive symptomatology, systemic low-grade inflammation  and specific types of depressive symptoms  in a large nationally representative cohort of older adults. Our findings suggest that increased genetic susceptibility to depressive symptomatology was associated with both subsequent cognitive-affective and somatic depressive symptoms. Moreover, CRP was found to mediate the relationship between DS-PGS and somatic symptoms, but not cognitive-affective symptoms, explaining a total of 7.42% of this association.The present study moved beyond analysing the effects of single genetic variants and instead examined the cumulative effect of multiple SNPs on subsequent depressive symptoms. The use of genetic data in our analyses provided a measure of depressive symptomatology that preceded both the mediator and the outcome. As such, including DS-PGS implied a clear pathway direction—from genetic polymorphisms to systemic low-grade inflammation and subsequent depressive symptoms.20. Importantly, previous studies did not take into account symptom-specific effects of PGS. Hence, our findings provide new evidence highlighting the potentially differential effects of DS-PGS on subsequent depressive symptom profiles.Our results indicate a relatively small overall effect of DS-PGS on both cognitive-affective and somatic depressive symptoms, respectively. This is in agreement with a number of previous prospective cohort studies suggesting that many loci, each with a modest effect, influence DSOur mediation analysis revealed that CRP partially mediated the relationship between DS-PGS and subsequent somatic symptoms, but not cognitive-affective symptoms. These associations were independent of age, sex, and 10 PCs. Although the confidence intervals partially overlapped, our findings indicated that, statistically, the results were significantly different for these symptom domains . Further adjustment for cognitive-affective and somatic depressive symptoms measured at the time of the mediator did not significantly change the results. Taken together, our findings support the notion that systemic inflammation may be an inherent mechanism driving the development of somatic depressive symptoms. Specifically, participants with a higher genetic risk for depressive symptoms were significantly more likely to report elevated levels of CRP, which subsequently increased the risk for developing somatic depressive symptoms, but not cognitive-affective symptoms.28. Another study systematically reviewed the evidence from six prospective cohorts studies investigating the inflammation hypothesis of depressive symptomatology in adults aged 60 years and older and found mixed results22. Five of these studies reported significant associations between interleukin 1 receptor antagonist, IL-6, IL-8 or TNF-α and future depressive symptoms58. However, Stewart et al. found that neither raised levels of fibrinogen nor CRP predicted subsequent depressive symptoms in a sample of American older adults59. This is in line with recent evidence from two large longitudinal cohort studies using data from the ELSA60. Heterogeneity in findings may be due to differences in study designs, population characteristics, and operationalisations of constructs. Another explanation may be the lack of regard for persistent depressive symptoms 31 and the effects of repeated exposure to inflammation61. Furthermore, most studies have not considered plausible differential effects of inflammation on symptom-specific dimensions of depression, potentially masking the effects inflammation exerts on depressive symptoms. Our findings corroborate with the work of a recent study by Iob et al. (2019), which found that systemic low-grade inflammation exhibited stronger associations with somatic symptoms compared with cognitive-affective symptoms of depression31. Likewise, experimental administration of pro-inflammatory cytokines  or cytokine inducers  has been shown to initiate primarily somatic symptoms in both healthy participants65 and animal studies66. Together, these findings suggest that systemic inflammation may be a primary driver of somatic symptoms. Such evidence underlines the importance of considering conceivable symptom-specific profiles of depression in future studies. This may facilitate the development of more targeted treatment approaches.To date, prospective evidence supporting the depressogenic effects of systemic low-grade inflammation has yielded mixed results. For instance, a previous meta-analysis pooling the results of eleven prospective cohort studies reported a significant association between elevated levels of CRP and IL-6 and subsequent depressive symptoms in a sample of 18,527 adults50, there are inconsistencies in the literature regarding the conceptualisation of somatic symptoms67. Last, the generalisability of the present findings is limited to Caucasian older adults only, since the ELSA population is largely comprised of white participants.This study has a number of strengths, including the prospective study design, the large sample size, and the statistical methods employed to investigate the link between PGS for depressive symptoms, systemic low-grade inflammation and specific symptom dimensions of depression. However, our findings need to be interpreted in light of several limitations. First, the measure of systemic low-grade inflammation was based on a single biomarker, which may not be sufficiently precise to understand the complexity of inflammatory processes in depression. Second, although we employed the most suitable factor analytic structure for the CES-D to distinguish between cognitive-affective and somatic symptom dimensionsFuture studies are needed to replicate our findings and further extend the present analyses to symptom-specific clusters of other depression scales, including a wider range of cognitive-affective and somatic items. Moreover, it is worth investigating the potentially mediating effects of multiple inflammatory markers, such as IL-6, fibrinogen, and TNF-α. In addition, further work is required to investigate intermediate mechanisms linking DS-PGS with cognitive-affective symptoms. It is also possible that systemic low-grade inflammation acts as a moderator in the relationship between DS-PGS and depressive symptoms. Therefore, longitudinal mediator-moderator models are needed to shed further light on the role of inflammatory processes. Lastly, research should explore the mediating effect of systemic inflammation through studying the relationship between PGS for systemic inflammation and subsequent depressive symptoms.In conclusion, the current study demonstrated that polygenic susceptibility to depressive symptoms was significantly associated with both cognitive-affective and somatic symptoms of depression in a large population-based cohort of English older adults. Furthermore, systemic low-grade inflammation mediated the relationship between DS-PGS and somatic symptoms, but not the association between DS-PGS and cognitive-affective symptoms. This highlights the importance of investigating the independent effects of both PGS and inflammation on symptom-specific typologies of depression in future studies. Ultimately, this will provide further information about pathophysiological mechanisms of depression and advance the design of more targeted treatment approaches.Supplementary Material