Ivor-Lewis esophagectomy (ILE) is the standard surgical care for esophageal cancer patients but postoperative morbidity impairs quality of life and reduces long-term oncological outcome. Two-stage ILE separating the abdominal and thoracic phase into two distinct surgical procedures has proven to enhance microcirculation of the gastric conduit and therefore most likely reduces complications. However, two-stage ILE has not been evaluated systematically in selected groups of patients scheduled for this procedure. This investigation aims to demonstrate the feasibility of two-stage ILE in high-risk patients.In this retrospective analysis of data obtained from a prospective database, a consecutive series of 275 hybrid ILE (hILE) were included. Patients were divided into two groups based on one- or two-stage hILE. Postoperative complications were assessed according to ECCG  criteria and compared using the Clavien–Dindo score. Indication for two-stage esophagectomy was classified as pre- or intraoperative decision.n = 10). The predominant cause for an intraoperative change of strategy was a laparoscopically diagnosed hepatic fibrosis/cirrhosis (n = 5).Overall morbidity and major’ complications (CD > IIIa) were comparable for both groups (11.7% in both groups). The overall anastomotic leak rate was 12.4% and was non-significant lower for the two-stage procedure.34 out of 275 patients (12.7%) underwent two-stage hILE. Patients of the two-stage group were significantly older. In 21 of 34 patients (61.8%) the decision for a two-stage procedure was made prior to esophagectomy, in 13 (38.2%) patients intraoperatively after completion of the laparoscopic gastric mobilization. The most frequent preoperative reason to select the two-stage procedure was a stenosis of the coeliac trunc and superior mesenteric artery (Two-stage hILE is a feasible concept to individualize the surgical treatment of patients with well-defined clinical risk factors for postoperative morbidity. It can also be applied after completion of the abdominal phase of IL esophagectomy without compromising the patient safety. Despite recent improvements of perioperative management including advances of surgical techniques and postoperative care, esophagectomy remains a complex surgical procedure which is associated with a significant rate of morbidity and mortality . HoweverIn an attempt to reduce the surgical trauma, minimally invasive esophagectomy (MIE) has been introduced and developed over the last decade. However, despite its increasing application the scientific evidence supporting superiority of MIE compared to open esophagectomy is limited with only three randomized controlled trials –8 and soTherefore, this study was conducted to investigate whether two-stage IL esophagectomy is a feasible strategy in a selected group of patients with an increased risk for postoperative complications and to compare postoperative outcome with benchmark data.n = 44) and total minimally invasive esophagectomy (n = 23) were excluded. Furthermore, patients with a benign or malignant tumor other than squamous cell or adenocarcinoma of the esophagus or gastroesophageal junction were excluded (n = 6). The final study cohort consisted of 275 patients undergoing a hybrid IL esophagectomy. Patients were stratified in two groups according to application of one- or two-stage IL esophagectomy.From 01.05.2016 to 30.04.2018, a total of 348 patients underwent an IL esophagectomy at the Department of General, Visceral and Cancer Surgery, University of Cologne. Patients undergoing open gastric mobilization . The dissected tissue remained attached to the lesser curvature. The gastroesophageal junction was completely mobilized at the level of the diaphragmatic hiatus. Devascularisation also included dissection of the short gastric arteries along the gastric fundus. Finally, the greater curvature was completely mobilized with visualization and preservation of the right gastroepiploic vessels. After an interval of 3–5 days right-sided open transthoracic esophagectomy was performed with dissection of the mediastinal lymph nodes (2-field lymphadenectomy). For patients with squamous cell carcinoma, lymphadenectomy was extended to compartments on left side of the trachea (extended 2-field lymphadenectomy). After pull-up of the stomach, the gastric tube was fashioned with a width of 4 cm using several magazines of a longitudinal stapler  stapling devices). After placing a purse string suture, esophagogastrostomy was done as end-to-site anastomosis with a 25 or 28 mm circular stapler  above the level of the dissected transverse azygos vein. The anastomosis was located at the anterior wall of the gastric corpus closely to the greater curvature. After placing several tension-release sutures, the circular anastomosis was covered by an omental flap.One-stage hybrid IL esophagectomy comprised the same surgical procedure except for the step that during the abdominal phase the fatty tissue on the lesser curvature was dissected at the level of incisura angularis and gastric tube formation was initiated laparoscopically  stapling devices).All patients were extubated in the operating theater and transferred to the ICU for further recovery.Prospectively collected data included basic demographics, American Society of Anesthesiologists (ASA) and World Health Organization (WHO)/Eastern Cooperative Oncology Group (ECOG) scores, body mass index (BMI) as well as comorbidities, tumor-specific parameters  and technical details of the operation. In addition, all patients were preoperatively screened for atherosclerotic stenosis of the celiac trunk (TC) and the superior mesenteric artery (SMA) using computed tomography (CT) scans.The indications for performing a two-stage esophagectomy were classified as preoperative  and intraoperative . In addition, the time interval between the two operations was recorded.Postoperative complications were assessed according to ECCG  definitions  and weret test. P values less than 0.05 were considered statistically significant.Data analysis was done retrospectively using IBM SPSS statistics software . Statistical analysis was primarily based on descriptive means. Categorical data were summarized as frequencies and percentages. Continuous variables were analyzed using medians with corresponding interquartile range (IQR) and means with corresponding standard deviation. Statistical differences between the one- and two-stage esophagectomy groups were assessed using Pearson’s chi-square test, Fisher’s exact test or the Independent sample p < 0.001). The BMI, ASA and ECOG scores of the two groups were also comparable. There were no significant differences regarding the distribution of the histology. If administered, the predominant neoadjuvant therapy was radiochemotherapy (CROSS protocol) in both groups . Patients of the two-stage group demonstrated a lower rate of preoperative chemo- or chemoradiotherapy  and had a significant more advanced tumor stage at final pathological assessment .Two hundred and forty one patients (87.3%) underwent a one-stage IL esophagectomy and 34 patients 12.7%) a two-stage IL esophagectomy. The demographic and baseline characteristics of the two groups were similar (Table 2.7% a twIn 21 of 34 patients (61.8%), the decision for a two-stage procedure was made prior to esophagectomy (Table In 13 patients 38.2%), a one-stage IL esophagectomy was intended but changed to a two-stage procedure during the laparoscopic phase of IL esophagectomy . The distribution of ECCG type II and type III leakages were comparable for one-stage and two-stage esophagectomy . The majority of leakages (24 of 34 patients) were treated successfully by endoscopy using an Eso-sponge or a metal stent (ECCG type II leakage) and 9 of 34 patients underwent re-operation (ECCG type III leakage).The rate of anastomotic leaks was lower in the two-stage esophagectomy group without reaching statistical significance  without any significant differences in both cohorts (p = 0.058), though it occurred more frequently in the two-stage group (2/32 patients (5.9%)) than in the one-stage group (3/238 patients (1.2%)).p = 0.403), and the median overall hospital stay .There were neither any major intraoperative and postoperative bleedings nor major conduit ischemia observed as well as the readmission rate to ICU  part of the two-stage approach, whereas it usually initiated at the end of the laparoscopic gastric mobilization. The postponement of the reconstructive phase appears necessary since the diversion of the lesser curvature with a longitudinal stapler inevitably results in a partial necrosis of the stapled and devascularized short lesser curvature segment with subsequent risk of gastric perforation. During laparoscopy, dissection of the fatty tissue on the lesser curvature with separation of the vascular supply between right and left gastric artery is an optional but not necessary step of devascularisation because its contribution to overall gastric perfusion is minor.In this large consecutive series of esophageal cancer patients treated in a high volume center, one-stage hybrid IL esophagectomy presents the standard of surgical care. However, one out of ten patients underwent a two-stage procedure. The novelty of this concept comprises the expansion from the preoperative to the intraoperative indication depending on the intraoperative morphological findings as well as the patient condition under general anaesthesia. Summarizing the indications, the pre- and intraoperative decision making for two-stage esophagectomy can be classified into two main groups.The first group consists of those patients having an increased risk of inadequate perfusion to the gastric conduit due to changes of micro- or macrocirculation. There is mounting evidence that atherosclerotic changes of the celiac trunk and/or superior mesenteric artery are associated with an increased risk of anastomotic leakage. In a consecutive series of 145 patients scheduled for Ivor-Lewis esophagectomy the overall incidence of coeliac trunc stenosis defined as any atherosclerotic narrowing on CT scan was 40% . The incThe second group 29.4%) of indications for two-stage esophagectomy comprised patients with multiple concomitant comorbidities as expressed by advanced age. All of these scores proved to have an inversely proportional correlation with early postoperative outcome measured by the overall morbidity and mortality rate or the Clavien–Dindo score % of indi, 22.Two-stage esophagectomy is a feasible concept to individualize the surgical treatment of patients with a high risk for postoperative complications. Based on these results, two-stage esophagectomy does not compromise patient safety. The two-stage procedure seems to be particularly beneficial in patients with risk factors of an impaired vascular gastric perfusion or patients with borderline functional operability due to single or multiple organ dysfunctions. The decision to follow a two-stage strategy can be made before esophagectomy or after completion of the laparoscopic gastric mobilization and therefore increases the flexibility and individualization of the surgical treatment. This study provides evidence to further evaluate the two-stage approach in a prospective study.


Native nanostructured lipoproteins such as low- and high-density lipoproteins (LDL and HDL) are powerful tools for the targeted delivery of drugs and imaging agents. While the cellular recognition of well-known HDL-based carriers occurs via interactions with an HDL receptor, the selective delivery and uptake of LDL particles by target cells are more complex. The most well-known mode of LDL-based delivery is via the interaction between apolipoprotein B (Apo-B) – the main protein of LDL – and the low-density lipoprotein receptor (LDLR). LDLR is expressed in the liver, adipocytes, and macrophages, and thus selectively delivers LDL carriers to these cells and tissues. Moreover, the elevated expression of LDLR in tumor cells indicates a role for LDL in the targeted delivery of chemotherapy drugs. In addition, chronic inflammation associated with hypercholesterolemia  can be abated by LDL carriers, which outcompete the deleterious oxidized LDL for uptake by macrophages. In this case, synthetic LDL nanocarriers act as ‘eat-me’ signals and exploit mechanisms of native LDL uptake for targeted drug delivery and imaging. Lastly, recent studies have shown that the delivery of LDL-based nanocarriers to macrophages via fluid-phase pinocytosis is a promising tool for atherosclerosis imaging. Hence, the present review summarizes the use of natural and synthetic LDL-based carriers for drug delivery and imaging and discusses various mechanisms of targeting. Lipoproteins are naturally-occurring supramolecular particles comprised of various lipids that form complexes with specific apolipoproteins. Lipoproteins consist of a non-polar core – composed primarily of cholesteryl esters and triacylglycerides – and an amphiphilic outer shell of phospholipids and embedded cholesterols and apolipoproteins, held together by noncovalent forces , disease state, nutrition, and genetics . LDL – which accounts for 80–90% of all circulating cholesterol – mainly serves to transport cholesterol from the blood to peripheral tissues, and is ultimately removed from the blood by binding to LDL receptors that are expressed in peripheral tissue cells in a process known as forward cholesterol transport Tall, . In contLipoprotein mimetics is a burgeoning field in which lipoproteins can be modified in a variety of ways to be used as nanocarriers in targeted drug delivery as well as in imaging , very-low density lipoprotein (vLDL) receptor, and apolipoprotein E receptor-2 (ApoER2) . In this section, we focus on native LDL nanoparticles, usually isolated from blood plasma by ultracentrifugation and subsequent modification of the surface (shell) of this lipoprotein with MRI contrast agents. We discuss the most prominent examples while providing additional references in 3+)-based imaging contrast agents are usually incorporated into LDL particles via intercalation of Gd-chelating lipids. For instance, Lowell et al. have developed MRI-visible LDL nanoparticles via intercalation of a long alkanoyl moiety anchoring within native LDL lipid shell, while chelating Gd3+ through DO3A , the biodistribution studies showed 50% lower liver uptake vs. wild type mice. This study also showed that when Au-HDL was administered in B16-F10 tumor-bearing mice and imaged by CT, Au-HDL accumulated in tumor-associated macrophages (TAMs), highly expressing LDLR. The results from this study and the work of others indicate that loading of LDL with organic dyes, metals (Au), or inorganic molecules (quantum dots) do alter the physicochemical nature and targeting of LDL. This is particularly exciting as such an approach paves the way for the development of targeted CT contrast agents as well as for studying LDL interactions in atherosclerotic plaques in vivo. Additional examples of LDL-based CT contrast agents and their properties are presented in Targeted molecular probes enhance specificity and binding to tissue enabling contrast enhancement for cancer/cardiovascular imaging. LDL-based nanoparticles offer key advantages of biocompatibility and receptor-mediated targeting mechanism via LDLR that was explored in multiple studies using computed tomography (CT) imaging . In one In addition to the aforementioned advantages of LDL-based nanoparticles in their ease of synthesis using a reconstitution , their intrinsic targeting ability is of great potential . Native mdr1 siRNA while chitosan nanoparticles were conjugated with doxorubicin (Dox). The goal of the study was to deliver siRNA to silence the multidrug-resistant gene in tumors simultaneously with chemotherapy  docosahexaenoic acid (DHA) as an anticancer agent against hepatocellular carcinoma in a murine model  2 h post-injection. Additional experiments showed that the targeting was through the LDLR endocytic pathway  nanotherapy uses a photosensitizer molecule that absorbs the irradiated light and converts it to vibrational energy (heat) that causes toxicity to the cancer cells. Although research has advanced on the preclinical side, safety issues in the clinic still remain a concern and thus are under active investigation. Thus, Li and Song et al. examined the delivery of (Nc) naphthalocyanine-reconstituted and phthalocyanine-reconstituted LDL nanoparticles as PDT payloads to humans hepatoblastoma G2 (HepG2) tumor cells , aspartate transaminase (AST), total bilirubin (TBIL), and total albumin (ALB). Serum cytokines  and CTGF levels themselves (by western blot) were reduced as compared to CLSN without targeting siRNA. Immunohistochemistry for liver fibrosis showed no signs of collagen deposition.In contrast to reconstituted LDL that retains the native structure of LDL with intact ApoB-100 protein, synthetic LDL particles are assembled from commercial phospholipids but lack ApoB-100 protein . For exaIn a series of very intriguing studies, Nikanjam et al. developed a synthetic LDL mimic as a drug delivery vehicle for glioblastoma multiforme , Zhou et al. examined the potential for drug delivery to CML progenitor cells via a synthetic LDL nanoparticle (sLDL) , while simultaneously administering a statin (mevastatin or simvastatin) to upregulate the expression of the LDLR in cells in an in vitro and their uptake was inhibited by blocking LDLR  proteins that accumulate in the arterial walls and undergo various modifications. One of the most important modifications is the oxidation of accumulated LDL resulting in the formation of oxLDL . AMs mimic the charge and hydrophobicity of oxLDL and are able to bind scavenger receptors with high affinity. The initial discovery by Uhrich et al. reported sugar-based amphiphilic polymers that were composed of short hydrophobic segment  on mucic acid conjugated to hydrophilic PEG segment that spontaneously can assemble into oxLDL-mimicking micelles   feature of LDL carriers is their ability to cross BBB and target LDLR-positive tumors as well as sub-population of neurons. This seemed like an underdeveloped area, especially given the immense importance of potential biomedical applications. Indeed, brain tumors are the most difficult to treat and neurological diseases are the world's largest cause of disability – both are likely to be addressed by LDL carriers’ LDLR-targeting mechanism. Such studies are urgently warranted in the settings of translational research.


Previous systematic reviews evaluating the association between coffee consumption and pancreatic cancer showed inconsistent results. The aim was to conduct a meta-epidemiological study to explore further the association between coffee consumption and the incidence of pancreatic cancer. The selection criteria were defined as a population-based prospective cohort study reporting adjusted relative risk (RR) and their 95% confidence interval (95%CI) of pancreatic cancer occurrence according to coffee consumption. Adjusted RR for the highest versus the lowest level of coffee consumption in each study was extracted. A fixed-effect model was applied to calculate a summary RR (sRR) and its 95%CI. Two-stage random-effects dose-response meta-analysis (DRMA) was performed to estimate the incidence risk per unit dose (cup per day). Twelve cohort studies were selected for meta-analysis. The total number of cohort participants was 3,230,053, and pancreatic cancer incidents were 10,587. The sRR of pancreatic cancer risk for the highest versus the lowest level of coffee consumption indicated no statistical significance . Two-stage random-effect DRMA showed the non-linear relationship between the amount of coffee consumption and pancreatic cancer risk. And the RR for an increment of one cup per day of coffee consumption was 0.97 , without statistically significant. There was no association between coffee consumption habits and pancreatic cancer risk. And there was no statistical significance in the dose-response relationship between the amount of coffee consumption and pancreatic cancer risk. Finding the turning point would be important because it can be critical information for the prevention of pancreatic cancer.  As pancreatic cancer is notorious for having a poor prognosis , finding modifiable risk factors is paramount. While coffee is a popular beverage globally, Zhao et al., (2020) concluded that ‘there is highly suggestive evidence for an inverse association between coffee intake and risk of liver and endometrial cancer.’ But Tsai and Chang (2019) concluded that ‘the association between coffee and pancreatic cancer is unclear.’ Therefore, it needs to conduct a meta-epidemiological study (MES) applying the selection criteria such as ‘a population-based prospective cohort study reporting adjusted RRs and their 95% confidence interval (95%CI) of pancreatic cancer occurrence according to coffee consumption’. The main aim of MES is to evaluate problems associated with potential errors that could occur while performing a systematic review . Thus, this study aimed to conduct an MES to explore further the association between coffee consumption and incidence of pancreatic cancer.The subjects of analysis in MES are original articles selected in systematic reviews . Among the studies selected by seven systematic reviews summarized in After merging the secured study subjects, the authors checked whether the cohort participants were the same among them. If there were duplicates, the cohort study with a more extended follow-up period was adopted.Adjusted RR for the highest versus the lowest level of coffee consumption in each study was extracted. If I-squared value (%) showing the level of heterogeneity was less than 50%, a fixed-effect model was applied to calculate a sRR and its 95%CI . Subgroup analysis by adjustment for diabetes history, adjustment for body mass index, and year of publication, as well as sex was also performed. Egger test for small-study effects was conducted to evaluate a publication bias . In addition, a two-stage random-effects dose-response meta-analysis (DRMA) was performed to calculate the incidence risk per unit dose (a cup per day) considering the P-value of Goodness-of-fit. The non-linear relationship was confirmed by testing the null hypothesis that the coefficients of the second and third spline are all equal to zero . The fixed-effect meta-analysis and two-stage random-effects DRMA were performed using metan and glst command of STATA software , respectively.A total of 11 cohort studies were selected as the primary subjects . From 285 papers by citing these 11 articles, four studies among them were additionally secured as the secondary subjects . And there was not any new cohort study meeting the selection criteria on the reference in the primary and secondary study subjects.Because Genkinger et al., (2012) reported the results of a pooled analysis of 14 cohort studies, three cohort studies duplicated in cohort participants were excluded . Finally, 12 cohort studies were selected for meta-analysis  . The totThe sRR of pancreatic cancer risk for the highest versus the lowest level of coffee consumption indicated no statistical significance . Subgroup analysis by sex, adjustment for diabetes history, and year of publication were the same result, too  Table 2Table 2. Seven cohort studies supplied the information needed to conduct a DRMA , but there was heterogeneity among them . Two-stage random-effect DRMA showed the non-linear relationship between the amount of coffee consumption and pancreatic cancer risk based on the Wald test for linearity (P<0.001) . And theThe findings summarized that there was no association between coffee consumption habits and pancreatic cancer risk. And the non-linear relationship between the amount of coffee consumption and pancreatic cancer risk was shown.The meaningful result of this MES was that there was no heterogeneity among selected cohorts (I-squared=0.0%). It was based on eliminating seven articles following fatal cases and four articles having no adjusted RR-related information. Thus, it can infer that the main reasons for inconsistent results in previous systematic reviews were due to apply selection criteria loosely and/or to have a non-linear dose-response relationship.Based on the current evidence, the established risk factors of pancreatic cancer are cigarette smoking, chronic diabetes, and obesity . All 12 studies finally selected for meta-analysis reported the RRs adjusted for smoking status. In particular, the cohort study of the non-smoking women showed no statistical significance in the dose-response relationship between coffee consumption and pancreatic cancer risk . Subgroup analysis for cohorts adjusted for diabetes history and body mass index showed no statistical significance . Meanwhi The main strength of this MES is that the summary effect size between coffee consumption and pancreatic cancer risk was derived without heterogeneity through including population-based prospective cohort studies having adjusted RRs for potential confounders, strictly. On the other hand, the limitations are the same as those mentioned in the previous systematic review. As Li et al., (2019) pointed out, information about coffee consumption was taken by a self-reported questionnaire, and the possibility of changing the habit did not consider. Also, the standard coffee cup would be different between regions. When additional two-stage random-effects DRMA conducted after changing the dose unit from cup per day into cup per week, there was still no statistical significance .In summary, coffee consumption is not associated with pancreatic cancer risk under a non-linearly relationship. As shown in


The Swan-Ganz catheter plays an important role in gaining understanding of cardiac pathophysiology and in the hemodynamic monitoring of critically ill patients. Difficult removal of the Swan-Ganz catheter is a rare but serious complication.This case presents the difficult removal of a Swan-Ganz catheter in a 28-year-old female patient after cardiac surgery. Fluoroscopy and chest X-ray revealed that a portion of the Swan-Ganz catheter was coiled on the central venous catheter at the level of the superior vena cava. Under X-ray guidance, the central venous catheter was first removed, and then the Swan-Ganz catheter was successfully withdrawn through the percutaneous introducer sheath.This case report provides an unreported reason for difficult removal and describes a successful solution. This report suggests that X-ray examinations may be necessary before removing the Swan-Ganz catheter. Difficult removal of the Swan-Ganz catheter has been reported with an estimated incidence of 0.2–2.5% , due to A 28-year-old woman, weight 55 kg and height 162 cm, initially presented to the emergency department of an outside hospital with a 2-month history of chest distress, cough and dyspnea. The patient’s symptoms did not improve significantly after oxygen therapy or anti-asthma medication combined with aerosol inhalation. The patient was later transferred to the cardiovascular surgery department in the authors’ institution with aggravation of the above symptoms. Echocardiography revealed severe tricuspid regurgitation and congenital heart disease, including a ventricular septal defect and rupture of the right coronary sinus aneurysm. An abdominal computed tomography scan revealed that the inferior vena cava and hepatic veins were widened. The preoperative laboratory examination was unremarkable. For invasive hemodynamic measurement, a Swan-Ganz catheter  was inserted through an 8-F percutaneous introducer sheath placed in the right internal jugular vein, and a central venous catheter was inserted into the right subclavian vein without any difficulties. The pulmonary artery pressure waveform suggested that the catheter was successfully floated into the pulmonary artery. The patient underwent ventricular septal defect repair, aortoplasty and tricuspid valvuloplasty under cardiopulmonary bypass.After obtaining the hemodynamic indexes postoperatively, the Swan-Ganz catheter was found difficult to withdraw when it was pulled out to 35 cm mark. The cardiovascular surgeons and intensive care physicians suggested transporting the patient to interventional radiology. The chest X-ray showed that a portion of the Swan-Ganz catheter coiled on the central venous catheters at the level of the superior vena cava and formed a knot approximately 1 cm in diameter (Fig. The use of a Swan-Ganz catheter with balloon flotation is a feasible and rapid technique for hemodynamic monitoring in critically ill patients . HoweverIn this case report, the authors describe a successful management approach for removing a Swan-Ganz catheter. The key point for addressing loops and knots is to withdraw the central venous catheter with the assistance of radiologic techniques. Then, the Swan-Ganz catheter could be advanced into the right ventricle to provide more space for the catheter to uncoil. Finally, the catheter was withdrawn under X-ray guidance. This case report suggested that the surgeons should place the catheter in a normal coiled state before re-advancing the Swan-Ganz catheter intraoperatively to avoid forming knots and then gently place the catheter in the right ventricle. Additionally, it is important to take a chest X-ray before removing the Swan-Ganz catheter in patients undergoing tricuspid valve surgery. This process may help similar difficult removals of Swan-Ganz catheters, thereby eliminating the need for invasive maneuvers, but cannot be applied for tight knots.


Depressive symptoms and cognitive impairment often concur in older persons. Differentiating the cause of cognitive impairment in older persons with Depressive Disorder (DD) from other diseases such as Alzheimer’s Disease (AD) is challenging. The goal of this study was to characterize cognitive impairment in older persons with DD.Cross-sectional retrospective observational clinical cohort study using patient records from 2014 to 2018.Gerontopsychiatric services of Ulm University at Bezirkskrankenhaus Günzburg serving as primary psychiatric care institution and tertiary referral center for psychiatric care for older persons.18F-fluordesoxyglucose-PET (FDG-PET) or Amyloid-PET (Am-PET) were performed.DD was diagnosed according to ICD-10 criteria. When indicated by the medical history or neuropsychological assessment further diagnostic procedures were initiated. Cerebrospinal fluid (CSF) tap was routinely the first additional procedure. If patients did not consent to CSF tap or contraindications were present, Extensive neuropsychological test battery to assess cognitive profile.457 subjects were diagnosed with DD . Biomarkers were assessed in 176 persons; in 90 of these subjects AD-biomarkers were negative , and in 86 subjects at least one biomarker was compatible with AD . Cognitive performance was below healthy controls  for all groups of patients with DD. With case-control matching of HC and DD-BM- we find that executive functions are impaired in about one out of three and delayed recall in about two out of three patients with DD.Cognitive impairment is frequent in older persons with DD. Cognitive profile in older patients with DD without and with biomarkers of AD is not distinguishable. Therefore, cognitive impairment due to DD should be diagnosed after exclusion of comorbid AD. Cognitive deficits are frequent in patients with Depressive Disorder (DD) . The majUntil now cognitive symptoms are not included in the diagnostic classifications of ICD-10 or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with the same elaborateness as other symptoms of DD. Therefore, hitherto existing literature reports on the frequency and pattern of cognitive impairment in patients with DD are subject to selection bias because patients with cognitive impairment may have been excluded. Likewise, assessment bias cannot be ruled out because cognition may not have been assessed with sensitive methods. Lastly, reporting bias may be present because information on cognitive performance of patients with DD is undervalued and not reported.Organic diseases of the central nervous system are rare in younger persons. Thus, characterization of the pattern of cognitive deficits is sufficient to delineate the profile of cognitive impairment due to DD in younger subjects. Studies in older persons often assume the same procedure and diagnose the cause of cognitive impairment on clinical and neuropsychological grounds –6 despitIn contrast to younger persons, older adults with DD have several co-morbidities affecting cognitive performance  of whichThe course of DD on treatment has been reported to be worse in older subjects than in younger subjects although no association has been found with established risk factors for worse treatment outcome . It has This conundrum is even more complicated since cognitive impairment may occur separately from episodes of low mood . PatientDisentangling the intricate issues of cognition and depression on clinical and neuropsychological grounds is impossible. It cannot be resolved with clinical and neuropsychological methods whether a given cognitive symptom is due to DD or whether DD itself is a consequence of a comorbid condition known to foster cognitive symptoms in older persons. Nevertheless, sophisticated neuropsychological assessment is necessary to objectify cognitive impairment reported by patients. In addition, the most common cause of cognitive impairment in older persons, AD, needs to be ruled out with other methods.A recent consensus paper came to the conclusion that AD is ruled out when CSF-biomarkers of AD are negative . Similar18F-fluordesoxyglucose-PET (FDG-PET), or amyloid-PET (Am-PET)). We hypothesized that cognitive impairment is frequent in older persons with DD even if AD as the most common cause for cognitive impairment in older age is ruled out.The goal of the present study was to tackle the conundrum of cognitive impairment due to DD by analyzing patients with DD in whom comorbid AD has been excluded with use of AD-biomarkers  and was conducted according to the ethical standards of Ulm University and the guidelines outlined in the declaration of Helsinki.Gerontopsychiatric services of Ulm University at Bezirkskrankenhaus Günzburg serve as both a primary gerontopsychiatric service for a rural catchment area of about 650.000 people and a University affiliated tertiary referral center for gerontopsychiatry. As such patients are referred to this unit by general practitioners, neurologists and psychiatrists in private practice, as well as surrounding hospitals. Reflecting this practice and clinical reality these patients often complain about both mood change and memory impairment and many patients lack sufficient introspection to give a clear picture of their primary complaint, which not always accords with the referral diagnosis and report by proxies. Regardless of complaint or referral diagnosis it is our standard practice to assess patients with complaints of both depressed mood and impaired cognition with a detailed neuropsychological assessment if none of the exclusion criteria is fulfilled . We inclPersons were diagnosed as healthy controls (HC) upon unremarkable Medical History without cognitive decline compared to previous capabilities in everyday life and normal performance on neuropsychological assessment. For ethical reasons and considering normality of findings no further diagnostic procedures were initiated. In younger patients with DD, organic diseases of the central nervous system are rarely present, and it is usually possible to determine how many episodes have occurred previously. Similar to an approach reported in the literature  we diagnFurther diagnostic procedures in persons with DD were initiated when on clinical judgment the report on cognitive decline comprised a slowly progressing course of impairment over many months, and when at least a moderate decline of episodic memory was found in the neuropsychological assessment, or when patients remained worried even after clinical and neuropsychological examination and requested further diagnostic measures. The indeterminateness of the decision-making algorithm reflects the hitherto existing vague knowledge on the pattern of cognitive impairment due to DD and due to AD. We performed a cerebrospinal fluid (CSF) tap to rule out organic causes of cognitive impairment. If patients did not consent to CSF tap or contraindications were present (e.g. anticoagulation), FDG-PET or Am-PET was performed. We initiated an additional FDG-PET or Am-PET in some patients when clinical judgment and results of CSF tap differed.The short version of the Geriatric Depression scale  is a 15-The MMSE is a commonly used screening instrument to detect cognitive impairment as well as stage the severity of dementia by assessing a range of cognitive functions. It comprises questions on orientation, registration, short-term memory, language use, comprehension, and basic motor skills. The score ranges from 0–30. Patients are considered to be in mild stages of disease when scoring 20 points or above, to be in moderate stages of disease when scoring between 10 and 19, and severe when scoring 9 or less.The clock-drawing test is most commonly used to assesses the visual-spatial construction; however, successful completion of the task also requires verbal understanding, memory, and abstract reasoning. The patient is encouraged to draw a clock-face with clock-hands indicating the time “ten past eleven”. The clock drawn by a patient falls into one of the six categories, where categories 1 and 2 indicate a normal result and categories 3 to 6 indicate pathology.Educational attainment was categorized in basic, intermediate, and advanced education with 1 for education up to nine years, 2 for education up to 12 years, and 3 for education of 13 and more years.The Digit Span test comprises digit span forward and digit span backward. Forward digit span is a measure of verbal short-term memory, defined as a system allowing temporary storage of the information. In this task participants are asked to repeat a sequence of digits until either the maximum number of eight digits per sequence was reached or until two consecutive incorrectly repeated sequences of same length. Backward digit span represents a measure of verbal working memory. In addition to storing information it also requires ability to manipulate and reproduce the information in an altered form. It employs the same procedure as forward digit span, except this time the numbers need to be repeated in a reversed order. Visual span is a visual-spatial alternative to measure same basic abilities using a different modality. It was measured using a Corsi block tapping test forward and backward. One point is given for each correct answer with scores ranging from 0–12 except for the forward visual span with scores ranging from 0–14.The Trail-Making-Test assesses visual attention and mental flexibility, which is a measure of executive functioning, and requires an examinee to draw pencil lines in ascending order from 1 to 25 (TMT-A) and 25 encircled numbers and corresponding letters in an alternating order (TMT-B) that are randomly dispersed on a DIN-A-4 sheet. The instructions require working as fast as possible while maintaining maximum accuracy. These tests measure the time to completion of the task. As recommended in the manual, we terminated the task at 350 s.animals  as well as words starting with the letters “P” and “S” (phonemic fluency).RWT assesses semantic and phonemic verbal fluency. It is used as a measure of lexical knowledge and lexical access speed as well as test of executive control ability. An examinee is instructed to generate as many words as possible in one minute that belong to the category The CVLT is a verbal memory test, assessing variables such as immediate recall, free and cued recall after short delay, free and cued recall after long delay as well as recognition. Taken together these variables are a good representation of episodic verbal memory and are sensitive to a range of memory deficits, such as problems in memory consolidation or retrieval. A list of 16 words  is read to the participant a total of five times. After each round the participant is encouraged to recall as many words as possible. Immediate recall is followed by a free and cued delayed recall after 5 and 20 min intervals respectively, and a Yes/No recognition task.All statistical data analyses were carried out using the statistics program SPSS . The normality of distribution was tested with the Kolmogorov-Smirnov Test. Since all parameters were not normally distributed, group comparisons were calculated using nonparametric tests, mostly Mann-Whitney-U-test.Overall, performance of HC  is in goThe whole group of patients with depressive disorder cf. ; DD-all 18F-FDG-PET or amyloid-PET were negative. The other group of patients with analysis of biomarkers comprised patients in whom at least one biomarker was compatible with AD , or 18F-FDG-PET suggestive of AD, or amyloid-PET positive). Overall, mean performance of patients from DD-BM+ was not different from patients from DD-BM- (A subgroup of patients was assessed with biomarkers of AD. This subgroup was split further into two groups. One group (DD-BM-) comprised only those patients with biomarker findings excluding AD. To obtain this group we chose conservative criteria including only patients in whom both Abeta1,42 was above diagnostic threshold (> 550 pg/ml) and levels of total-tau-protein were below diagnostic threshold (< 300 pg/ml), or patients in whom m DD-BM- .Biomarker assessments for DD-BM- and DD-BM+ are shown in Lastly, we matched groups of HC and patients with DD-BM- for age (± 3 years), education (± 1), MMSE (± 1), and biological gender (exact). Matching was performed with a 1:1 match. Even in this group, performance of patients with DD was below that of HC .With a criterion of performance being below mean minus 1.5 standard deviations indicating pathology  a percenTo our knowledge, this is the first study to characterize the pattern of cognitive impairment in patients with depressive disorder (DD) in whom the most frequent cause of cognitive impairment in older age, AD, has been ruled out.Subjective memory complaints have been found useful to detect early AD . LikewisHistory-taking in older persons with DD is difficult and duration of previous depressive episodes and age at onset of depressive disorder cannot always be determined reliably even when informants and structured interviews are used . The litWe assessed cognitive performance of three groups of patients with DD. The group DD-all comprises the whole group of patients with the diagnosis of DD regardless of whether biomarker analysis was performed or not. The group DD-BM+ describes a group of patients with DD in whom at least one biomarker was positive , levels of total tau- and phospho-tau-protein), FDG-PET, and amyloid-PET). The group DD-BM- includes only patients with DD in whom all biomarkers were within normal range. Possible AD may be diagnosed when clinical symptoms are consistent with AD and at least one CSF biomarker is positive with others unknown; probable AD may be diagnosed when clinical symptoms are consistent with AD and two CSF biomarkers or imaging biomarkers are positive [Surprisingly, the group of patients with biomarkers within normal range (DD-BM-) and the group with at least one positive biomarker (DD-BM+) were alike in all cognitive domains . This fiIn order to further analyze the cognitive performance of patients with pure depression (DD-BM-) we matched this group with HC. With a criterion of mean minus 1.5 standard deviations and below of HC values indicating impairment , we founPreviously it was argued that the pattern of cognitive deficits in patients with DD is most pronounced for recall tasks but largely intact for consolidation of information over a delay period . The pre18F-FDG-PET or amyloid-PET other than the criterion of medical history being suggestive of cognitive impairment and neuropsychological testing objectifying the impairment. On the other hand, this lack of a precise algorithm reflects the vague knowledge about profiles of cognitive impairment due to DD or due to AD in older patients. The similarity of the cognitive profile in the groups DD-all and DD-BM- support the quality of the clinical diagnosis of DD in our sample.There are some limitations to the present study. The value of using the MMSE to screen for cognitive impairment in patients with DD is questionable . HoweverThe hallmark of deficits in AD is an impairment in total recall and delayed recall . The preIn summary, the present study is the first to demonstrate cognitive impairment due to DD in a large sample of older patients after excluding patients with comorbid AD. The cognitive profile in older patients with DD without and with biomarkers of AD is not distinguishable. Therefore, cognitive impairment due to DD should be diagnosed only after exclusion of AD biomarkers. Cognitive impairment due to DD should receive more attention in psychiatric algorithms and diagnostic criteria.S1 Data(XLSX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.


Catheter ablation is considered as the standard treatment for all patients with symptomatic drug-refractory tachyarrhythmia. The safety and efficacy of the procedure in the adult population is well-established. Due to the small size of the patient and difficulty in attaining venous access, infants are rarely subjected to radiofrequency ablation. Here, we report a case of drug-refractory AV nodal re-entrant tachycardia in a two-year-old child. Radiofrequency ablation was performed with a 5-Fr sized medium-curve ablation catheter deployed at the slow pathway region where a fractionated A-wave with slow-pathway potential was recorded. After ablation, no recurrence of SVT at the end of 12 months of follow-up was observed. Atrioventricular (AV) node reentrant tachycardia (AVNRT) is a less frequent (12%) occurrence.4 Most of these arrhythmias respond to medical management and catheter ablation is reserved for drug-refractory cases only. Cryoablation is the preferred modality for infants and young children as it reduces the risk of AV blockage. Herewith, we report the case of a two-year-old child with drug-refractory AVNRT with repeated hospitalization for the arrhythmia who was subsequently treated by radiofrequency (RF) ablation.Although catheter ablation for cardiac arrhythmia has been performed in adult populations since the early 1980s, ablation for cardiac arrythmias in the pediatric population was not attempted until the early 1990s.. In view of recurrent hospitalization despite maximal medical management, an option of catheter ablation was discussed. Informed consent was obtained in view of the nonavailability of cryoablation and the risk of AV blockage.A two-year-old child weighing 10 kg was referred for catheter ablation for drug-refractory SVT. Her mother reported a history of frequent hospitalizations despite maximal doses of oral verapamil and β-blocker medication. Electrocardiography (ECG) during sinus rhythm did not show pre-excitation. Echocardiography ruled out structural heart disease. A narrow QRS tachycardia at the rate of 260 bpm was documented during an SVT episode . Tachycardia could be easily induced by programmed atrial stimulation at 400 ms (S1), 350 ms (S2), and 230 ms (S3) with an AH jump. The tachycardia cycle length was 230 ms and coronary sinus electrograms showed a concentric atrial activation pattern . The ventricular entrainment protocol confirmed AVNRT.RF ablation was performed under intravenous sedation. Twelve-lead ECG and intracardiac electrograms were continuously recorded using an electrophysiology system . Venous access was obtained from both the right femoral vein and the left femoral vein. Baseline sinus rhythm showed normal AH (94 ms) and HV (39 ms) intervals  medium-curve RF ablation catheter  resulted in good junctional rhythm at the 400-ms cycle length  . The total fluoroscopy time was five minutes and the procedure lasted for 30 minutes. Postablation tachycardia could not be induced despite an aggressive induction protocol. Incremental atrial pacing showed AV Wenckebaching at a 380-ms cycle length, confirming the elimination of slow-pathway conduction . Fast-pathway conduction remained intact as programmed atrial stimulation revealed AH block at 400 ms (S1), 350 ms (S2), and 250 ms (S3) . The AH and HV intervals after ablation were 94 ms and 40 ms, respectively . The child was discharged the next day without any complications and remained symptom-free at 12 months after the procedure.Ablation at the posterior part of Koch’s triangle with a fractionated atrial signal with slow-pathway potential  and to stop ablating when there existed a fast junctional rhythm at a cycle length of less than 300 ms.Drug-refractory SVTs are rare during childhood. The most common arrhythmias are accessory pathway–mediated AVNRT. Although there are several reports of successful ablation of orthodromic AV-reciprocating tachycardia in infants, AVNRT is rare. Our case is unique in that the AVNRT was drug-refractory despite optimal therapy and RF ablation was performed instead of cryoablation. Two major challenges exist with this protocol: (1) obtaining venous access and (2) avoiding causing injury to the AV node while ablating the slow pathway. In this present case, we restricted our venous access to the femoral vein . Venous Doppler imaging was performed before discharge and ruled out venous thrombosis. To avoid AV nodal block during ablation, it was deemed safe to target fractionated atrial signals with an AV ratio of 1:10 5 AVNRT can be safely cured by slow-pathway modification in the posterior aspect of Koch’s triangle. Cryoablation is the modality of choice in infants and children as it can reduce the incidence of AV block. However, we had to employ RF energy as cryoablation is not yet available in our region.AVNRT is the second most-encountered SVT in the pediatric population. The AV node consists of two pathways: the fast pathway, which is composed of transitional cells in the region extending from the compact node to the anterior aspect of Koch’s triangle, and a slow pathway composed of a deeper inferoposterior extension.6 The varied intracardiac and venous anatomy often makes it difficult to ablate in this population. In many centers, the procedures are modified with the usage of fewer catheters than in the adult population and the adoption of transesophageal catheters to pace the left atrium and 4-Fr ablation catheters to avoid vascular complications. The reported complications during pediatric RF ablation include complete heart block and thrombus formation. Cardiac perforation and death are rare complications and are more frequent in correlation with smaller patient sizes and left-sided procedures. Blaufox et al.7 showed the feasibility of catheter ablation for cardiac arrhythmias in small children weighing less than 15 kg. Of 268 RF catheter ablation procedures, 18 were performed in 14 patients weighing less than 15 kg. Orthodromic AVRT was noted in nine patients, atrial tachycardia was seen in one patient, and ventricular tachycardia was found in four patients. The complications reported included pericardial effusion, mitral regurgitation, and myocardial infarction. In the AVRT subgroup, the indexed total application time trended higher during complicated as compared with during uncomplicated procedures (40.6 versus 6.6 s/kg). The authors concluded that RF ablation can be successful in small children; however, complications appear to be related to the RF dose indexed for body size. Elsewhere, the MAP-IT registry8 highlighted the safety of pediatric ablation with a significant reduction in radiation exposure among the 1,417 procedures done. Cryoablation was performed in one-quarter of the cases. Two percent of the patients were younger than three years of age and their success rate and complications were not different from those of older patients.The most common challenge that we come across in the pediatric population is the small size of the heart and the varied anatomy associated with congenital heart diseases.Despite all these challenges and complications, however, catheter ablation for AVNRT is a safe procedure in the pediatric population when performed by experienced hands.AVNRT is the second most common variety of SVT in children. Drug therapy remains the first option for treating pediatric arrhythmias. In rare instances where drugs are not effective in controlling the arrhythmia, RF catheter ablation can be safely performed while safeguarding the AV node. Although single case results cannot be extrapolated to the general population, further studies could provide additional insights and confirm the safety of RF ablation in toddlers.


The successful maternal tolerance of the semi-allogeneic fetus provides an apparent immunologic paradox. Indeed, deep invasion of placental trophoblast cells into maternal uterine tissue and the following growth of the fetus have to be tolerated by a pregnant woman’s immune system. Among the various possible protective mechanisms that may be involved in human pregnancy, the expression of a non-classical pattern of human leukocyte antigen (HLA) class I molecules and the complete lack of expression of HLA class II molecules in placental tissues seem to be the most relevant mechanisms of fetal escape from maternal immune recognition. The importance of HLA molecules in fetal toleration by the maternal immune system is highlighted by pregnancy complications occurring in cases of abnormal HLA molecule expression at the maternal–fetal interface. In this review, we summarize evidences about the role of placental HLA molecules in normal and pathological pregnancies. The successful maternal tolerance of the semi-allogeneic fetus provides an apparent immunologic paradox. Human pregnancy is commonly considered a nature’s allograft, but it is actually the placenta, not the fetus, which constitutes the transplant.To avoid immunological recognition and rejection of fetal-derived tissues by the maternal immune system, three main mechanisms of immune escape occur in human pregnancy: (a) anatomical separation between mother and fetus tissues through the placenta; (b) modification of Human Leukocyte Antigen (HLA) molecule expression in the placenta; (c) suppression of maternal cell-mediated immunity.In this full literature review, we describe the physiologic modification of HLA molecule profiles in the human placenta required for a successful normal pregnancy. Suppression of HLA molecule transcription in placental tissues prevents classical T-cell responses to fetal antigens. Furthermore, fetal somatic cells that fully express HLA molecules are normally anatomically separated from the maternal immune system by the placental trophoblast barrier, preventing direct contact and, thus, fetal antigens presentation to maternal T cells. As an additional protective mechanism to the fetus, maternal cellular immunity undergoes a hypo-reactive shift. Any defects in the reciprocal immunological adaptation between the fetus and the mother may compromise placental development and fetus growth. Particularly, it has been suggested that complete failure of these mechanisms would cause miscarriage, while partial failure of fetal immune tolerance could cause poor placentation and dysfunctional utero-placental perfusion ,2. Here,Using PubMed and Google Scholar databases, we performed comprehensive literature searches in the English language for studies on the expression and function of HLA antigens in both normal pregnancy and main obstetric disorders . We performed a categorical review of the literature by using the following search terms: “Human Leukocyte Antigen”, “Major Histocompatibility Complex”, “maternal-fetal interface”, “recurrent pregnancy loss”, “preterm delivery” “pre-eclampsia” and combinations of these. Articles from 1990 to 2020 were screened for relevance, validity and quality.Semi-allogeneic trophoblast forms several interfaces with the maternal immune system depending on gestational age and anatomic location  Figure . In the The earliest interface (interface I) comprises ST of the implanting embryo and the uterine decidua. This is the only time that ST lies at a tissue interface. Chorionic villi are bathed directly in uterine gland secretions allowing a histotrophic nutrition  Figure a until tDuring the second trimester, three new interfaces replace the interface I: (i) interface II between invading extravillous trophoblast (EVT) and maternal immune cells in the decidua; (ii) interface III between decidua parietalis and amniotic membranes; (iii) interface IV between the ST and maternal blood. ST represents the epithelial subtype surrounding chorionic villi and shows a large surface area directly in contact with the maternal blood b.It is worth noting that ST continuously shed extracellular vesicles (EVs) into intervillous space and, thus, into maternal circulation. EVs are membrane bound, cell-derived particles released as part of both normal physiological functions—such as hemostatic regulation and cell maintenance—and as a consequence of cellular stress (such as in pre-eclampsia) ,4. The tIn the first half of pregnancy, interfaces I and II dominate, and this is where the success of the pregnancy is determined early ,5. InterThe Human Leukocyte Antigen (HLA) system is a gene complex encoding the Major Histocompatibility Complex (MHC) proteins, or HLA molecules, in humans. These cell-surface proteins are also called human transplantation antigens and are responsible for the regulation of the immune system in humans .HLAs class I  molecules (Ia) consist of a glycosylated heavy chain and a light chain β2-microglobulin. The heavy chain has three extracellular domains , a transmembrane region and an intracytoplasmic domain. The α1 and α2 domains contain variable amino acid sequences, and these domains determine the antigenic specificities of the HLA class I molecules a. Class On the other hand, HLA class II molecules  are heterodimers of two non-covalently associated glycosylated polypeptide chains: α and β b. The α HLA class II molecules are expressed constitutively on professional antigen-presenting cells (APC), such as dendritic cells, mononuclear phagocytes and B cells. The antigens presented by class II peptides are of extracellular origin and are loaded onto HLA class II molecules by phagocytosis. These antigens stimulate the proliferation of T-helper cells, which in turn elicit B-cells to secrete antigen-specific antibodies . In partIn human pregnancy, tight control of human leukocyte antigens (HLA) class I and II expression in chorionic and EVT is essential for successful outcome .In humans, the villous ST does not express any HLA class I or class II molecules  so that Although trophoblasts have been demonstrated to contain the IFN-γ receptor and the necessary transduction mechanism, they do not express HLA class II antigens, even after IFN-γ exposure .The lack of HLA-A and HLA-B, and general lack of HLA class II expression on EVT prevents maternal T cell allo-immune responses against paternal-derived HLA antigens. Furthermore, the only expression of the classical HLA-C and of the atypical class I antigens (Ib), such as HLA-G and HLA-E molecules, is thought to protect EVT from destruction by decidual natural killer (dNK) and T cells  Table 1Table 1.As EVT invades maternal uterine tissues during the implantation process, 80% of maternal leukocytes are represented by dNK, 10% by macrophages and, for the remaining 10%, by T cells . HoweverThus, during the first half of pregnancy, NKs are relatively abundant in maternal decidua compared to other maternal immune cells. dNKs show a tolerogenic phenotype due to the loss of NK cytotoxic activity and the acquisition of immunomodulatory properties. In particular, low cytotoxicity in dNK cells can be explained by their particular receptor expression profile. They express the killer cell immunoglobulin-like receptors , the natural killer group 2 receptor , the immunoglobulin-like transcript 2 receptor  and .HLA-C is a central molecule in the NK and T cells’ immune activity. In particular, it has been shown that levels of HLA-C expression on the cell surface influence the efficacy of cellular immune responses to viral-, allo- and self-antigens . In partIn addition to HLAC–KIR interaction at immunological interface II (NK-EVT), human trophoblast has been shown to adopt another mechanism of inhibition of dNK cytotoxicity. Particularly, it is known that the cytotoxic activity of NK cells is commonly induced by the interaction of the NK cell receptor NKG2D with its ligands, namely the MHC class I chain-related (MIC) proteins A and B and the UL-16 binding proteins (ULBPs). This receptor–ligand interaction activates a perforin-mediated cytotoxic pathway leading to the elimination of damaged and/or infected cells. Interestingly, in human placenta MIC ad ULBPs expression is constitutive, and these proteins are released in the soluble form by STEVs during pregnancy . PlacentAdditionally, maternal decidual CD8+ T cells directly recognize allogenic HLA-C molecules of paternal origin. This immunological cross-talk is a key process in the development of the immune tolerance of the fetus during pregnancy. Interestingly, decidual CD8+ T cells show high expression of the co-inhibitory molecules Cytotoxic T-Lymphocyte Associated Protein-4 (CTLA4), Programmed Cell Death 1 (PD1) and Lymphocyte Activation Gene-3 (LAG3) and low expression of cytolytic molecules. This uterine microenvironment is functional to inhibit CD8+ effector T cell activity and to maintain placental tolerance . HoweverAdditionally, maternal regulatory T cells (Treg) play a pivotal role in establishing immune tolerance to invading EVT and preventing inflammatory responses to placental antigens ,21. IndeIn conclusion, we can summarize that the HLA-C molecule has a central role in modulating the activity of the main factors of the cell-mediated maternal tolerance to the fetus: NK, CD8+ and Treg cells.In contrast to a classical HLA-C, that is, a class Ia molecule, which is highly polymorphic, with a high number of alleles encoding a high number of functional proteins, HLA class Ib molecules display a very low polymorphism, with a small number of alleles encoding a limited number of proteins. Similarly, to HLA Ia molecules, HLA Ib molecules can also bind peptides generated through a proteasome-driven degradation of cytosolic proteins and present them to specific subpopulations of CD8+ T cells . The maiSuppression of maternal cell-mediated immunity towards placental antigens, whether fetal-derived antigens-presentation might erroneously occur, is an additional, and not secondary, mechanism of immune tolerization at the maternal–fetal interface.Induction of apoptosis of immune cells is one of the main mechanisms involved in the negative regulation of T cell proliferation. Interestingly, it has been shown that the human placenta is able to release bioactive Fas ligand (FasL) carried by STEVs able to perform apoptosis of maternal T cells, thus promoting the fetal allograft survival .In addition, trophoblast cells sustain the maternal–fetal tolerance by secreting various chemokines and cytokines. In particular, trophoblast cells selectively recruit peripheral NK and T cells to the decidua via the secretion of a strictly controlled cascade of chemokines such as CXCL12, CXCL16 and CCL3 . FurtherRecently, it has been demonstrated that immunosuppressive cytokine IL-35 is constitutively expressed in human first-trimester trophoblasts and acts by inhibiting the proliferation of human naive T cells and converting them into IL-35-producing induced regulatory T cells (iTR35) in an IL-35-dependent manner through phosphorylation of STAT1 and STAT3 [Inadequate maternal tolerance of EVT has been proposed as a possible immunological trigger of insufficient trophoblast invasion of the maternal uterus. According to the extent of the defective tolerization towards the semi-allogeneic fetus by the maternal immune system, subsequent miscarriage or pre-eclampsia may occur ,36,37.Before 8 weeks, the spiral arteries are plugged by CT and there is no intervillous perfusion. Hypoxic environment establishing at the implantation site is functional to the neo-angiogenetic process. Between 8 and 12 weeks the arteries progressively unplug starting the intervillous circulation and, thus, the change from histotrophic to haematochorial placenta. When trophoblast invasion of the placenta bed is inadequate, intervillous perfusion occurs prematurely. Then, either miscarriage ensues or pregnancy continues with dysfunctional placental perfusion which leads to pre-eclampsia (PE) .Spontaneous miscarriage occurs in about 15–20% of all clinically recognized pregnancies . RecurreReduced expression of HLA-G has been observed in miscarriage tissues collected from women with a history of RM . In partThe importance of the proper expression of the fetal HLA-C molecule for a successful pregnancy outcome has been indirectly suggested by the evidence that HLA-C antibodies could be involved in the pathogenesis of unexplained RM .As an additional immunological anomaly responsible for RM, decreased proportions of decidual Tregs have been reported in cases of unexplained RM compared to miscarriage with karyotype abnormalities  as well Abnormal expression of HLA-DR in CT and ST from miscarriages  and in SThese observations support the evidence that proper trophoblast expression of both HLA class I and II molecules is essential for a good pregnancy outcome. Aberrant trophoblast expression of HLA molecules early in pregnancy might represent an additional mechanism involved in the pathogenesis of unexplained miscarriage.PE is a relatively common disorder, complicating about 3–5% of all pregnancies. It is still a major cause of severe maternal and newborn morbidity and mortality worldwide . It is dTherefore, a reduced tolerance of placental antigens by the maternal immune system is believed to constitute the primum movens in the etiopathogenesis of PE, but the precise immunological defects occurring early in pregnancy are still unknown.It has been shown that the type of combination of maternal KIR with fetal HLA-C genes influences the risk of PE and reproductive success . In partIn a recent study, we have shown aberrant expression of HLA-DR in STEVs obtained by dual placental perfusion only from patients with PE but not from normal pregnancies . ImmunohThe transcriptional coactivator CIITA is required for HLA-D expression. In human trophoblast CIITA has been shown to be repressed epigenetically, likely as an effect of hypermethylation . A mechaOur main hypothesis is that the PE defective suppression of HLA-DR might occur in the ST cells during early implantation. If HLA-DRs were of fetal origin, they would be highly immunogenic towards the maternal immune system. This would be likely to negatively interfere with the tolerization process in the maternal–fetal interface and cause a defective placentation that would later reveal clinically as overt PE. It is also likely that the oxidative stress and tissue inflammation occurring in the placenta of PE women might induce HLA-D aberrant expression later, in the third stage of the syndrome. In this case fetal HLA-D molecules, whether able to process and present to maternal immune cell fetal-derived antigens, could contribute to amplifying a systemic inflammatory response in the mother. Finally, it cannot be excluded that aberrant expression of HLA-D molecules in the ST might have a role in all three stages of the disease, involving different mechanisms of the maternal immune response.Currently available data do not allow to draw any definite conclusions. More studies are required: (i) to confirm placental HLA-DR expression in a larger number of pre-eclamptic compared to healthy pregnant subjects; (ii) to confirm whether the HLA-DR is of fetal origin; (iii) to define its mode of synthesis in the ST; (iv) to evaluate the immunogenicity of HLA-DR positive STEVs.Datema and co-workers have specifically investigated whether the abnormal placental expression of HLA class I or II molecules might occur in pregnancy complicated by spontaneous preterm delivery (PTD). They did not observe differences in the expression of HLA on chorionic and extravillous cytotrophoblasts in the cases of PTD analyzed compared to normal pregnant women. However, higher expression levels of HLA class Ia molecules in amnion epithelial cells in PTD has been reported . More reRecently, other lines of investigation have proposed a pivotal role for HLA-C allo-recognition by dNK in the delicate process of limiting EVT invasion and preventing deep invasion and placentation that is associated with the placenta accrete spectrum. Indeed, those conditions are associated with abnormal adherence of the placental trophoblasts to the uterine myometrium, which can lead to maternal fatal bleeding at delivery .As a whole, these observations suggest that failure of one or more mechanisms allowing fetus immune tolerance could be mainly responsible for the development of pregnancy complications.Among the immunological protective mechanisms that may be involved in successful pregnancy, the complete suppression of HLA class II molecules in both CT and ST cells and the unique expression of a non-classical pattern of HLA class I molecules seems to be relevant and crucial. This extraordinary modulation of HLA molecule expression on trophoblast explains how successful pregnancy is possible, only because both the female immune system and the placenta undergo deep changes of protein expression. Any defect of this elegant and complex process of reciprocal immunological adaptation between the fetus and the mother might potentially translate into an obstetric failure.


To improve the understanding of the middle-ear hearing mechanism and assist in the diagnosis of middle-ear diseases, we are developing a high-speed digital holographic (HDH) system to measure the shape and acoustically-induced transient displacements of the tympanic membrane (TM). In this paper, we performed measurements on cadaveric human ears with simulated common middle-ear pathologies. The frequency response function (FRF) of the normalized displacement by the stimulus (sound pressure) at each measured pixel point of the entire TM surface was calculated and the complex modal indicator function (CMIF) of the middle-ear system based on FRFs of the entire TM surface motions was used to differentiate different middle-ear pathologies. We also observed changes in the TM shape and the surface motion pattern before and after various middle-ear manipulations. The observations of distinguishable TM shapes and motion patterns in both time and frequency domains between normal and experimentally simulated pathological ears support the development of a quantitative clinical holography-based apparatus for diagnosing middle-ear pathologies. The mOver the past decade, various non-invasive optical methods, for example, holographic interferometric methods, were developed to quantify TM dynamics such as excitation-induced displacements, and physical characteristics such as shape and thickness ,16–26. HThe high-speed digital holographic system we developed measures the TM’s shape and transient acoustic-induced displacement nearly instantaneously (<200 ms) with a spatial shape resolution of 50–200 μm and a displacement resolution of 15 nm at an acquisition rate of 67,200 Hz ,28,30–32To investigate if such a high-speed digital holographic (HDH) system can be used as a diagnostic tool for middle-ear pathologies, this paper describes a study on the shape and displacement measurements on post-mortem temporal bones with different experimentally introduced middle-ear pathologies. We compared the full-field-of-view shape measurements and the time and frequency domain analysis of displacements under various middle-ear conditions  joint interruption) to identify TM motion patterns, and data trends associated with each middle-ear condition.2.2.1.2.1.1.1 and λ 2 at two hologram exposures is described as follows:The multiple wavelength holographic interferometry (MWHI) shape measurements are based on the principle of variations in the wavelength of illumination with a constant optical path length (OPL) –37. The The synthetic wavelength Λ defines the sensitivity of the measurement. Assuming several synthetic wavelengths, the longest one determines the unambiguous measurement range, while the shortest synthetic wavelength gives the lowest uncertainty.As described in , the MWHϕ  is the singular value matrix ; [V] is the right singular vector matrix (unitary); and H marks the Hermitian (conjugate transpose) of matrix. The CMIF is defined as the main diagonal elements of the singular value matrix.Complex mode indicator functions (CMIFs) were calculated by taking singular value decomposition , Equatio of each 3.3.1.The MWHI method has been verified to reach an accuracy of 0.045 mm and exhibited repeatable measurements with 17 μm accuracy on a  traceable ball and artificial samples . This paWe used the shape information to derive TM transient surface-normal displacements. We investigated using the root mean square (RMS) of the motion of the entire TM surface to define an indicator to evaluate and distinguish different middle-ear manipulations. We also compared the umbo displacement in the time domain among different middle-ear manipulations. The umbo displacement profiles with time show distinguishable differences among different middle-ear conditions for all three bones, as shown in 3.2.To visualize and compare all the data of the entire surface of the TM across different manipulations, the complex mode indicator function (CMIF) was used as a generalized presentation of the membrane’s frequency response. 4.This study provides a complete description of TM mechanics, including the 3D shape information and full-field TM surface normal vibration in both the time and frequency domains.The shape results show that the TM shape is affected by various middle-ear manipulations. The different manipulations overall introduce a maximum shape change of less than 0.3 mm. The fluid injection pushes the TM to deform towards the ear canal side, while the IS joint interruption seems to pull the TM toward the middle-ear cavity side, which is interesting and may suggest the cochlear load produced tension on the TM. No differentiable shape change is identified for open cavity and stapes immobilization.Displacements in the time domain show we can confidently distinguish half fluid injection and full fluid injection by checking the RMS results and the open cavity case. Fluid injections will surpass the TM motion. Opening the cavity causes the TM surface to displace more compared to the normal middle-ear cavity condition (closed cavity).In the frequency domain, we observed trends in different CMIFs associated with different middle-ear conditions. In open cavity cases, the first significant CMIF peak appears around 4 kHz. Half fluid and full fluid injections decrease the CMIF across the whole frequency range. Stapes immobilization reduces the CMIF at a lower frequency up to 2.5 kHz for TB3 and TB4 and increases it for TB5 at a higher frequency (12–14 kHz). IS joint interruption adds additional peaks to the CMIF at different frequencies.Time domain and frequency domain analysis results can separate different middle-ear pathologies, suggesting the potential for clinical diagnosis. In the future work, we will investigate the accuracy of potential diagnostics through further experiments—identify trends in the data associated with different pathologies and test the sensitivity and selectivity of these analyses for clinical diagnosis. Artificial intelligence (AI) and data mining will be applied to automate the analysis process and assist in the separation of normal and diseased states.


Gene editing may prevent or cure a disease by inducing genetic changes at endogenous loci. Genome editing includes not only the insertion, deletion or replacement of nucleotides, but also the modulation of gene expression and epigenetic editing. Emerging technologies based on ZFs, TALEs, and CRISPR/Cas systems have extended the boundaries of genome manipulation and promoted genome editing approaches to the level of promising strategies for counteracting genetic diseases. The parallel development of efficient delivery systems has also increased our access to the CNS. In this review, we describe the various tools available for genome editing and summarize  Neurological disorders are the principal cause of disability and the second leading cause of death worldwide . CentralThe development of therapeutic strategies for CNS disorders is challenging, given the considerable diversity of cells involved, the extreme complexity of the neural circuits and associated functions, poor tissue regeneration and our incomplete understanding of the underlying pathological processes. Pharmacological efficacy depends on our ability to take all of these factors into account. For some disorders, such as traumatic and neurodegenerative conditions, the timing of treatment may also be important, with therapeutic success decreasing as neurodegeneration progresses. Moreover, the blood–brain barrier (BBB) limits the diffusion of most molecules delivered by conventional methods. Consequently, the doses of drugs delivered systemically often have to be increased to ensure that therapeutic concentrations are reached in the CNS, which may lead to toxicity.ex vivo and in vivo. Ex vivo gene therapy entails: (1) the collection of cells from the patient, (2) the culture and modification of these cells in vitro and (3) the transplantation of the modified cells back into the recipient. The in vivo approach involves modification of cells directly in the individual. One of the major advantages of gene therapy is that it can be used to modify most biological pathways through the targeting of the underlying genes. It can halt or reverse disease progression by targeting the underlying pathogenic processes, whereas conventional medicine often focuses on symptom relief. In addition, stable transgene expression or permanent genome modification may make it possible to treat disorders in a single administration.As a result of these challenges, approval rates are much lower for CNS-targeting drugs than for drugs targeting other parts of the body . This ha®) for SMA  mutations is based on the replacement of the defective gene with the wild-type (WT) cDNA. The treatment of familial lipoprotein lipase deficiency (LPLD) with Glybera  the size of the transgene may be limited by the delivery system, (2) this approach is usually restricted to the expression of a single gene isoform and (3) the lack of a transgene chromatin signature often results in non-physiological levels of expression . Conversex vivo and in vivo therapeutic approaches are currently undergoing clinical testing for the treatment of various diseases  a DNA-binding domain recognizing a unique target sequence and (2) an effector element for inducing precise genetic/epigenetic modifications. The genome editing tools currently available are based on three major DNA-binding platforms: zinc fingers (ZFs), transcription-activator like effectors (TALEs), and clustered regularly interspaced short palindromic repeats (CRISPR/Cas).Zinc fingers are eukaryotic DNA-binding domains consisting of two anti-parallel β-sheets and one α-helix, the residue composition of which specifies binding to particular triplets . MergingXanthomonas, a plant-pathogenic bacterium  followed by a wild-type TadA resulted in the most efficient ABE (ABE 7.10). The DNA repair mechanisms for removing ionosine from the DNA are less efficient than those for removing uracil, and these tools were, therefore, able to induce high levels of adenine conversion without the need for ionosine repair inhibitors. Consequently, indel events were much less frequent (barely detectable) than in untreated samples. As for BE4max, the efficiency of ABE7.10 was also increased by the development of ABEmax  transform adenine into ionosine (A→I), which is then converted to guanine (G), resulting in the conversion of A⋅T into G⋅C base pairs . ABEs wehia coli . After sf ABEmax . The Tadfor ABEs .In vivo base editing applications have been described for hypercholesterolemia , the transactivating domain of the NF-kB p65 subunit (p65), heat shock factor 1 (HSF1) and Epstein–Barr virus R transactivator (RTA) . The tarin vivo . Gene exin vivo . They al through histone acetylation   or with nic mice . Heteroztylation . Finallytylation , histonetylation , and histylation   by half while having no or minimal impact on the total APP protein. No additional in vivo tests were performed to evaluate treatment efficacy in the context of AD (Alzheimer’s disease (AD) is the main cause of dementia, affecting millions of people worldwide . One of xt of AD , but thext of AD . Four wein vitro several ZF-based epigenome modifiers targeting the proximal promoter region of dlg4/PSD95 for the activation or repression of PSD95 expression  is the second most common neurodegenerative disorder, affecting 2–3% of people under the age of 65 years . PD patiin vitro  is a neurodegenerative disorder caused by an inherited dominant CAG trinucleotide expansion mutation on the HTT gene. tivation  and the tivation . Yang ettivation . The injtivation , it stiltivation . With thT allele . They de WT gene . In thes WT gene . This syin vivo, decreasing mHTT mRNA levels by about 30% in the brains of R2/6 mice receiving AAV1-ZF-Kox1 injections. Despite the achievement of selective repression in vivo, the mutant allele in R6/2 mice contains 115–160 repeats, a number not consistent with the degree of CAG expansion in most HD patients. Zeitler and coworkers recently generated a second-generation ZF-KRAB that preferentially recognizes pathogenic CAG repeats, and demonstrated highly significant mHTT suppression with wild-type allele preservation in patient derived-iPSCs (ed-iPSCs . They obStaphylococcus aureus Cas9 (SaCas9). The CRISPR system was packaged into a single AAV9 variant (double-tyrosine mutant) shown to enhance gene transfer to the CNS  is the most common single-gene form of autism spectrum disorders (ASDs), for which there is currently no effective treatment . It is cTraumatic CNS injuries and stroke are very common causes of disability, and the treatments currently available are very limited. CNS trauma involves an initial mechanical injury, which is followed by a cascade of molecular and cellular phenomena, ultimately leading to neuronal death by apoptosis. Genome editing therapy strategies have focused on VEGF, which is a neuroprotective factor that favors endothelial cell proliferation and blood vessel formation . These sGM2-gangliosidoses are autosomal recessive disorders caused by the deficiency of a lysosomal enzyme, β-hexosaminidase, resulting in the accumulation of GM2 gangliosides. Biallelic LOF mutations of the Hex α-subunit (HEXA) or Hex β-subunit (HEXB) genes lead to Tay-Sachs disease and Sandhoff disease, respectively. Ou and coworkers recently used a cross-correction strategy based on liver-targeted HDR-mediated CRISPR editing to restore the function of β-hexosaminidase in the brain, in a Sandhoff mouse model . They intmc1 gene, leading to the neurodegeneration of sensory hair cells. This disease is of particular interest due to the existence of an orthologous mouse mutation, Beethoven (Bth), which also causes hearing loss in mice  is an inherited disorder and the most common cause of progressive vision loss . It is dCEP290 alleles. The IVS26 point mutation creating a new splice donor site is the most frequent defect. It alters transcript splicing and generates a premature stop codon in the processed mRNA. Maeder and coworkers recently reported an exhaustive drug dosing study of the use of AAV5-SaCas9-mediated NHEJ to correct the IVS26-driven aberrant CEP290 splicing in retina photoreceptor cells (EDIT-101)  is an autosomal recessive condition causing early blindness in infancy . It is dDIT-101) . The proThe field of genome editing is rapidly evolving and there is now a broad genome editing toolbox that can be used for therapeutic purposes. The efficacy of genome-editing therapies for CNS disorders will depend on the choice of the most appropriate tool to tackle the genetic defect and the type and magnitude of editing required for therapeutic benefit. In addition, the types of cells and CNS areas to be edited should be taken into account. Local genome editing may be sufficient for some disorders, but others may require the editing of large areas. For instance, eye disorders are more accessible due to their peripheral localization and the relatively small area targeted, whereas the neuronal damage in AD covers large brain regions . It is, The immunogenicity induced by genome editing tools is another topic of concern due to potential inflammatory responses . For insTransient systems have also been developed to decrease off-target modifications. We showed that off-target events were reduced with the KamiCas9 compared to the constitutively expressed Cas9 . Other gFinally, on-target events should also be properly characterized. Gene editing generates chimeric outcomes by introducing heterogeneous indels. For instance, the CRISPR/Cas9 targeting of the HTT translation starting site followed by NHEJ may generate truncated proteins with polyserine or polyalanine expansions, which have been shown to play a role in the disease . Furtherin vivo therapies for CNS disorders (In this review, we have focused on examples of isorders , but extisorders  and the isorders . In summBoth authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Accurate prediction of binding between class I human leukocyte antigen (HLA) and neoepitope is critical for target identification within personalized T-cell based immunotherapy. Many recent prediction tools developed upon the deep learning algorithms and mass spectrometry data have indeed showed improvement on the average predicting power for class I HLA-peptide interaction. However, their prediction performances show great variability over individual HLA alleles and peptides with different lengths, which is particularly the case for HLA-C alleles due to the limited amount of experimental data. To meet the increasing demand for attaining the most accurate HLA-peptide binding prediction for individual patient in the real-world clinical studies, more advanced deep learning framework with higher prediction accuracy for HLA-C alleles and longer peptides is highly desirable.We present a pan-allele HLA-peptide binding prediction framework—MATHLA which integrates bi-directional long short-term memory network and multiple head attention mechanism. This model achieves better prediction accuracy in both fivefold cross-validation test and independent test dataset. In addition, this model is superior over existing tools regarding to the prediction accuracy for longer ligand ranging from 11 to 15 amino acids. Moreover, our model also shows a significant improvement for HLA-C-peptide-binding prediction. By investigating multiple-head attention weight scores, we depicted possible interaction patterns between three HLA I supergroups and their cognate peptides.Our method demonstrates the necessity of further development of deep learning algorithm in improving and interpreting HLA-peptide binding prediction in parallel to increasing the amount of high-quality HLA ligandome data. HLA-peptide binding is crucial for epitope presentation on the human cell surface and the elicitation of subsequent T cell immune response. In silico prediction of binary HLA-epitope binding or HLA-epitope binding affinity score has become one of the most essential criteria in target identification for a variety of applications in the immunotherapy , 2. In gHere we propose a novel deep learning HLA-epitope binding prediction method which takes advantage of the intrinsic ability of bi-directional LSTM to extract information from longer sequence and the ability of multiple head attention mechanism to capture contextual dependence from different angles. The proposed framework is more powerful in predicting the binding between HLA-C alleles and peptides. In addition, this framework is more robust than existing tools in predicting ligands ranging from 12 to 15 amino acids in length. Finally, this model can also help interpret the interaction between HLA alleles and peptides through multiple subspaces of interaction representation.Our training dataset is composed of data from IEDB , BD2013 To convert qualitative affinity data to quantitative values, we applied a similar rule as MHCflurry : positivanormal is normalized affinity and anM is the original nanomolar affinity value. The final training dataset is composed of 753,961 entries for 167 HLA class I alleles .To facilitate model training, we normalized the original nanomolar affinity between 0 and 1.The positive data of the test dataset was compiled from a recent large-scale HLA class I ligandome data covering 95 HLA alleles. Data entries from 16 HLA alleles which were previously generated by the same group [lseq*20, where lseq is the length of concatenated sequence of peptide and HLA pseudo-sequence, is then input into sequence learning layer  is encoyer Fig. a.Fig. 1TWe chose the long short-term memory network  to modelTo enhance the capability of our model to learn bidirectional dependence between n-terminal and c-terminal amino acid residues, bidirectional LSTM (bi-LSTM) was used . By inpumentclass2pt{minimith attention mechanism  with a head*1*1 filter is then applied to the combined vectors for a fusion vector by learning the weight of each head of attention  will thus affect loss. Moreover, Huber loss will degenerate to MSE loss when diff is less than expected value To minimize the influence of outliers (noise) on model training, we employ an optimized Huber loss function  during tm, RAdam  is able p values: 2.66e−16, 9.06e−12 and 4.91e−09 respectively, one-sided t-test over AUC scores of 10 cross-validation repeats)  was used for model evaluation as well as model comparison against top-performed allele-specific and pan-allele models—MHCflurry, netMHCpan and ACME . To ensuMost of previous methods tend to use sequence padding to handle flexible peptide lengths. Since LSTM is intrinsically designed for modelling longer sequence, we also examined the prediction performances of different tools over peptides ranging from 8 to 15 amino acids in length by fivefold cross-validation. The degrees of improvement by MATHLA over other models are positively correlated with the length of peptides Fig. b. EspeciThe foremost characteristic of a pan-allele model underlies its ability to accurately predict peptides bound to HLA alleles beyond the training dataset. To test the generalizability of MATHLA, we took the advantage of non-overlapping alleles between our training dataset and a set of mass spectrometry HLA ligandome data . In totaInspired by the observation that MATHLA shows exceptional improvement for non-overlapping HLA-C alleles, we further compared the performance of our model over different supertypes of HLA I molecules. We separately calculated AUC scores of our model over all the HLA-A, B and C alleles in the test dataset. Pan-allele methods netMHCpan 4.0 and ACME, as well as allele-specific model MHCflurry, were used for model comparison. Although the AUC of MATHLA shows marginal enhancement over the top performed competing method netMHCpan for HLA-A and -B alleles, the AUC of MATHLA corresponding to HLA-C group is significantly improved over the competing models  Fig. c. MoreovTo better understand the characteristics of model integrating bi-directional LSTM and multiple head attention mechanism, we investigated the attention weight scores corresponding to different supertypes of HLA class I molecules as well as ligands with different lengths. Previous motif analyses of HLA ligands revealed that the residue at the most C-terminal end was most likely to have recurring amino acids than other positions , which wMachine learning based HLA-peptide binding prediction have been undergoing rapid development in the past few years owing to the breakthrough of deep learning algorithm and emergence of large-scale mass spectrometry data. Meanwhile, prediction tools have been genuinely deployed in more and more clinical studies than before, due to the booming of cancer immunotherapy. The current criteria for selecting optimal tool in a real-world project mostly rely on the number of supporting alleles and average prediction accuracy measured by different metrics like AUC. However, in regard to prediction accuracy over individual alleles, there is no tool whose prediction accuracy is unanimously higher over all the individual HLA alleles. This fact has posed several questions about HLA-peptide prediction on top of previous criteria like average prediction performance. First, for any given individual patient subject to target identification for cancer immunotherapy, how to select from a variety of existing tools the most accurate one for the given HLA alleles of this patient? This question becomes even more urgent and critical for patients carrying rare HLA alleles or alleles with limited amount of experimental data. Second, for longer ligands (11mer to 15mer) whose prediction accuracy is relatively lower, how to further improve the prediction accuracy given the fact the increasing mass spectrometry data alone can only provide limited prediction power.Our model integrating bidirectional LSTM and multiple head attention mechanism has addressed these two questions by not only achieving prominent advantage in prediction accuracy for the HLA-C alleles but also attaining better prediction power for longer class I HLA ligands. Our work shows that advanced architecture of deep learning can provide an interpretive model to further improve and understand HLA-peptide binding prediction. We envision that introducing other alternative methods, such as self-attention mechanism and word2vec model, can provide better peptide representation to further improve prediction accuracy. Our framework will certainly benefit T cell-based vaccine development in treating cancers as well as for prevention of infectious diseases.