This pilot study outlines the development and psychometric evaluation of a therapist adherence coding measure for a novel treatment, Family-Based Treatment Interoceptive Exposure (FBT-IE).The IE Adherence Coding Framework (IE-ACF) was developed from the FBT-IE Manual using an iterative process. Items on the IE-ACF were coded by two independent coders as either present or absent with therapists considered adherent if both independent coders coded the item as “present.” Videotaped sessions of FBT-IE of 30 adolescents with low-weight eating disorders  and their families were coded. Participants received the FBT-IE intervention as part of a randomized controlled trial.Seventy FBT-IE videos were coded. The IE-ACF identified a mean (SD) rating of 80% (±5%) therapist adherence to the protocol across the six-session treatment, with a per item adherence ranging from 36–100%. Two independent coders demonstrated moderate to almost perfect inter-rater reliability (κ range 0.78–0.96) across the sessions.IE-ACF measured therapist adherence to our novel FBT-IE treatment for adolescents with low-weight eating disorders. Through this study, we demonstrated that 1) our therapists were adherent to the FBT-IE manual in the context of an ongoing clinical trial and 2) that independent coders reliably coded sessions using our novel IE-ACF. Therapist fidelity measures are intended to examine the degree of adherence to an intervention and are essential to ensure that evidence-based treatments are delivered as intended. Adherence to treatment refers to the extent to which a therapist delivers the intervention with integrity and according to the procedures outlined by the manual . TherapiFamily-based therapy (FBT) is the leading evidenced based treatment for adolescents with anorexia nervosa (AN). However, not all patients recover using this treatment with low sustained remission rates  at one Our novel six-session FBT-IE treatment is based on the ‘broad anxiety’ model of AN  and is dWe developed a treatment manual outlining the six intervention sessions, which the therapists reviewed and followed for the research study. In conjunction, we developed an Adherence Coding Framework See , which iThus, the aim of this paper is to describe the development and psychometric validation of a treatment fidelity instrument, the IE-ACF, for adolescents with low-weight eating disorders. Data for this study were collected from an ongoing randomized controlled trial testing a short form of FBT-IE based on the ‘broad anxiety’ model of AN , 9, 16. This six-session FBT-IE intervention served as a proof of concept with the intention of ensuring reliability. The sample for this study included videotaped sessions of 30 adolescents, ages 12–18, with low-weight eating disorders  and their parent(s) who were randomized to FBT-IE.The study was reviewed and approved by the institutional review board of the hospital in which the study took place. Adult participants and parents provided written consent and adolescents provided written assent.Four therapists delivered the FBT-IE treatment. Therapists were either licensed psychologists or post-doctoral fellows with eating disorder expertise who were trained to administer the manual based FBT-IE treatment. Forty-nine percent of FBT-IE therapy sessions were recorded and coded for treatment fidelity according to the IE-ACF See . Each viThe development of the IE-ACF was an iterative and collaborative process with the senior author (T.H.) creating a coding framework based on the FBT-IE Manual. Items were then reviewed with a team of coders comprised of researchers, clinical psychologists, postdoctoral fellows and graduate school externs. Items were reviewed for clarity, redundancy, and accurate representation of items in the manual. Subsequently, selected videotaped therapy sessions were viewed by the independent coders and reviewed in a group format to discuss challenges, discrepancies, and consensus on particular items. The coding framework was then revised as needed until the IE-ACF was finalized.The IE-ACF developed from this process is a checklist that includes 12–15 items for each of the six therapy sessions . Items oThe eight coders included a post-doctoral psychology fellow specializing in eating disorders and trained in delivering the treatment intervention, bachelor and masters level research assistants and undergraduate volunteers working in an eating disorders clinical research setting. All coders were considered fully trained in the coding process after undergoing training with T.H. or D.P., which included didactics, role plays, and reviewing therapy videos from all six sessions of FBT-IE over the course of several weeks. All coders attended ongoing supervision throughout the duration of the coding period.Therapists were considered adherent to each item if both independent coders marked them as adherent (e.g. 1). Inter-rater reliability was examined by calculating kappa scores for each of the six treatment sessions. Kappa values range from -1.0 to 1.0 with the latter indicating perfect reliability . Kappa sThis pilot study is the first to develop and validate an adherence coding measure (the IE-ACF) to evaluate treatment fidelity to a novel FBT-IE treatment for adolescents with low weight eating disorders. The data demonstrated that 1) six sessions of FBT-IE can be delivered with adherence to the treatment manual in the context of an ongoing clinical trial and 2) that independent coders reliably coded sessions as adherent using our novel adherence coding tool.Inter-rater reliability was moderate to almost perfect across the study sessions (κ range 0.77–0.96), which suggests that IE-ACF is a reliable measure for evaluating therapist adherence to the FBT-IE treatment. Therapist adherence to the manual was present across the sessions (range 76–88%), while adherence to individual session items varied considerably (range 36%-100%). Across sessions, Sessions 1 and 2 demonstrated the highest inter-rater reliability, which we attribute to greater clarity in the coding items for these sessions. Two broad features of the IE-ACF likely contributed to the high levels of adherence and inter-rater reliability, namely the use of a treatment manual and binary coding. Treatment manuals reduce the variability in session content, promote treatment fidelity, and facilitate the training of therapists, ongoing supervision, and the training of adherence coders. The use of a binary coding scheme facilitated the use of objective assessments and promotes inter-rater reliability.To examine more specific factors that may have affected our outcomes, the lowest scoring items were reviewed to understand reasons for variability in adherence. The item “Did parents encourage/push child to drink more of shake during the IE exercise?” was consistently low (range: 50–70% adherence) as it proved challenging for the parents to push their child to consume the shake amidst resistance, uncertainty, and the expression of disgust. The item “Did therapist encourage parents to adopt role as ‘coach’ during the IE exercise?” was also consistently low across sessions. In delivering this treatment intervention, the therapist only used the term “coach” when the sports analogy was salient and relevant to the family. While therapists generally adhered to the treatment framework, they approached the intervention flexibly acknowledging that each family is unique and not all families identified with every metaphor. This balance of structure and flexibility reflects the general approach to the delivery of manual-based treatment in the field more broadly. We believe this item would have demonstrated greater adherence if the item assessed whether the therapist encouraged the parents to assume a supportive or authoritative role. We, therefore, calculated mean adherence per session with and without this item included .Variability in adherence to other treatment items can be attributed to different approaches by the therapist in administering therapeutic content or different interpretations by the coder in coding the items. Objective items such as “did the therapist provide the shake” had higher adherence than less objective items such as the therapists’ explanation of how to apply a skill during the week. There were also practical elements that impacted adherence, such as the therapist not having a finger trap available during the session that included the exercise utilizing it.The findings of this study should be considered in light of the primary limitation of sample size. Only 49% of total available sessions were videotaped, which may have introduced a selection bias attributable to random recording loss due to sound quality, extracting data, or uploading videos. However, all videotaped sessions with adequate audio quality were coded, which reduces the chance of a systematic bias. Additionally, data from the IE-ACF are consistent with others in the field. Perfect inter-rater reliability scores are rare, and previous studies in FBT report a wide range from poor to almost perfect inter-rater reliability scores for ratings of treatment fidelity . FinallyIn summary, the psychometric properties of IE-ACF showed 80% adherence of therapists to the treatment manual and moderate and almost perfect inter-rater reliability in the coding of adherence by two trained, independent coders. Future research should examine the relationship between therapist adherence to FBT-IE and treatment outcomes.S1 Appendix(DOCX)Click here for additional data file.


The study estimates the usability and attitude assessment of users for India's first approved rapid antigen self-test kit; theCoviSelf™. India approved its first AI-powered self-test for Covid-19 in April 2021 a few weeks after the first approval in the US. Wepresent here a study on usability and attitude assessment of users of India's first approved rapid antigen self-test kit; theCoviSelf™. The study evaluates participants' understanding of and performance of test procedure and interprets the results. Analysisrevealed that more than 90% study participants followed steps correctly as illustrated in the user's manual. Age group and gender-basedanalysis showed comparable scores for usability of the test kit suggesting users of different age groups has same ease in using thetest kit. What we learnt from this study could be start of self-test revolution, where rapid tests could expand the access ofdiagnostics for hundreds of diseases including HIV, HPV, and dengue to millions of people who could not get access to diagnosticsbecause we lacked manpower or facility to conduct tests. Self-testing could break the barriers for diagnostics that Internet did forinformation. The first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) known as COVID-19 was reported in China in December. FrequenWe used the Mylab CoviSelf™ COVID-19 Rapid Antigen Self-Test Kit developed by Mylab Discovery Solutions Pvt Ltd of India for theusability assessment. We conducted a usability testing study to understand how subjects used the India's first ICMR approved Covid-19Rapid antigen self-test kit. The study was performed with 150 study participants across socio-economic status and education level. Thestudy participant involved in this survey belonged to different socioeconomic status ranging from daily wage workers (n=99), officestaff (n=28), food industry staff (n=18), maids (n=6), household members (n=12) involving both male (n=55) and female participants(n=95). The age of the participants was ranging from 15 to 50 years. The consent of the participants was also taken for theirparticipation in the study. This study will serve as a reference in understanding if users can perform self-tests for disease diagnosiseffectively and to understand the user attitude towards self-testing.The Mylab CoviSelf™ - COVID-19 rapid antigen self-test kit is based on lateral flow principle and has five components includingsterile nasal swab, prefilled lysis buffer tube, QR-coded test card, biohazard bag, and instruction for use (IFU) manual. The user orsomeone on their behalf can use the CoviSelf™ mobile App to view instruction video in local language, interpret test result and toreport it to ICMR server. Each testcards are confined with the unique quick response (QR) code for assignment of report numbergenerated directly from the Indian council of Medical Research (ICMR) portal. The details for the overall test procedure have beenexplained in user manual for the self-test.The CoviSelf™ app (available on Google Play Store & Apple App Store in India) is a uniquely designed app based on the artificialintelligence (AI) model wherein, the image or picture of the testcard needs to be scanned and the model predicts the result. Wedeveloped an image processing model using Convolutional Neural Networks (CNN) which was trained on 100,000 images which were generatedsynthetically from 300 real images with different concentrations of attenuated viral antigen samples. This was an important step asthe app were to be used by different people in different conditions - with variation in lighting, background, presence of absence ofshadow, orientation of the cassette. These images helped develop a very accurate model which could easily create bounding boxes andpredict results with 98.6% accuracy.Our usability testing framework was informed by1) Guidance document - applying human factors and usability engineering to medical devices guidance for industry and food and drugadministration staff of February 20162) EN 62366-1:2015 Medical devices - Part 1: Application of usability engineering to medical devices3) ISO 14971:2019 Medical devices - Application of risk management to medical devices guidelines for usabilityThe usability was evaluated on parameters which can be categorized into three fundamental dimensions including (1) Ability tounderstand/follow Instructions to test, (2) Performance of test procedure and (3) Interpretation of test result. Questions relating touse's safety, effectiveness of the test kit and procedure, ease of sample collection, testing process, result interpretation,understating the user manual and labels were asked in the questionnaire.The study participants were provided with the Mylab CoviSelf™ COVID-19 rapid antigen self-test kit and the user feedback form. Theusers were instructed/demonstrated for use of device or were asked to read the user manual provided in the kit. The user was monitoredby trained moderators for the use of provided kit. The observations and errors were recorded by the moderators at each step. After thesuccessful self-testing the user were asked to fill the user feedback related to their understating of user manual and labels, ease ofsample collection, testing process, result reporting. Also, they recorded their concerns on safety and overall satisfaction with thetest kit.Responses recorded by the study participants after using the Mylab CoviSelf™ COVID-19 rapid antigen self-test kit were tabulatedinto the data matrix. Also, the observations noted by the trained moderators appended to the data matrix for each participant. Thesevalues were then aggregated and transformed into the percent values for each study parameter. User's feedback was also transformed intothe percent values. Analysis of variance (ANOVA) was performed for the comparison of satisfaction scores recorded by the participantsacross socioeconomic status and age groups and t-test based analysis was performed between the members of gender using GraphPad Prism. We also separately evaluated responses of participants from different age groups and gender, wherein for theage group-based analysis study participant were grouped into four groups from 18 years up to 50 years of age.Data matrix generated based on the observations of the trained moderators was used for the analysis. Analysis revealed that morethan 90% study participants followed all the steps correctly as illustrated in the user's manual and demonstrated by the technician.93% users handled the sterile swab carefully (n=140) and effectively collected the sample. 94% (n=141) users dipped the swab into thebuffer after taking sample. 93% users handled the test cassettes properly and 92% followed the proposal protocol for disposed of testcartridges. Also, 99% of the study participants observed the cassette for 15 mins for final conclusion of the test results. It was Users were asked to offer their scores to different satisfaction parameters ranging from 1 (not satisfied) to 5 (extremely satisfied).The overall satisfaction score of the users was 4.4 out of 5. Overall, it has been noted that 75% study participants were extremely(Score 5), 15% were very satisfied (Score 4), 8% were moderately satisfied (Score 3) while only 1% were slightly satisfied (Score 2)and 1% were not satisfied (Score 1) with the self-testing process using Mylab CoviSelf™ - COVID-19 rapid antigen self-test kit. We haveHere, the study participants have different job profile to represent various socioeconomic strata of population. Analysis of resultssuggested that in all these groups the usability ratings were comparable across these groups suggesting user-friendly applicabilityirrespective of the socioeconomic status .We have analyzed user responses to the overall usability of the test kit by age groups. We grouped the users into four groupswherein, first age group included participants from 18 to 20 years, second age group between 21 to 30 Years, third age group between31 to 40 years and fourth age group between 41 to 50 years. Here, we have observed that in the first, second, third and fourth agegroups the number of participants were 34, 54, 45 and 17, respectively. The average overall satisfaction rating with the Ag test kitwas ≥4.5 across all the age groups. Age group-based analysis also showed comparable scores for the usability of the test kitsuggesting users of different age groups have same ease in using the test kit .SimilarFor the detection of Covid-19 molecular and rapid antigen detection measures were used and RAT were extensively used by trainedmanpower in laboratory settings for rapid screening of the massive population ,15. ConWe have noted that, amongst the different survey parameters, the lowest value  was opted by 4% patient primarily due tolinguistic issues . LanguagOverall, our observations and experience suggest that time has come for India to embrace the self-test's for other diseases too. Itopens the opportunity for the development of RAT for other opportunistic diseases such as Dengue fever, Diphtheria, Hepatitis, Malariato mention a few. These tests can be linked to various disease control programs conducted by the Govt of India with or without supportfrom world health organization (WHO). The way forward to control spread of any disease is its timely diagnosis. If self-test kits arepromoted and the public in general is made aware of how to conduct them, it will be a paradigm shift in a country like India wherepopulation density itself makes healthcare inaccessible and unaffordable.The results of this study points towards the idea that self-testing kit is an effective diagnostic tool especially for large orunderserved populations. The overall response in terms of ease of sample collection, safety, efficacy and testing is comparable acrossuser members of different socioeconomic status, gender and age groups. Users have reported that the kit is very user friendly and canbe used very effectively by the common public and does not demand any specific training. Quoting from popular culture, it seems thatself-testing kits seems to be the idea whose time has come.RT-PCR: Reverse transcriptase polymerase chain reaction; NGS: Next-generation sequencing; RAT: rapid antigen test; ICMR: Indiancouncil of medical research; ANOVA: Analysis of variance.The study has been done on the ICMR approved self-test kit available in the market. However, written informed consent has beenobtained from the participants.All the data has been reported in the manuscript. However in case some data is needed that will be made available on request tocorresponding author.All authors declare no financial or any conflict of interest.The study was funded Mylab Discovery Solutions Pvt. Ltd. Pune.DSC, VG SG and SP conceived the study. VS and SP designed the questionnaire. DSC and VG conducted the survey under the supervisionof SP. KB contributed in the design of Mylab CoviSelf mobile application. DSC analyzed the data and prepared the first draft of themanuscript. DSC, SP and SG contributed in the manuscript revision. SP supervised the study.


COVID-19, the global pandemic of twenty-first century, has caused major challenges and setbacks for researchers and medical infrastructure worldwide. The CoVID-19 influences on the patients respiratory system cause flooding of airways in the lungs. Multiple techniques have been proposed since the outbreak each of which is interdepended on features and larger training datasets. It is challenging scenario to consolidate larger datasets for accurate and reliable decision support. This research article proposes a chest X-Ray images classification approach based on feature thresholding in categorizing the CoVID-19 samples. The proposed approach uses the threshold value-based Feature Extraction (TVFx) technique and has been validated on 661-CoVID-19 X-Ray datasets in providing decision support for medical experts. The model has three layers of training datasets to attain a sequential pattern based on various learning features. The aligned feature-set of the proposed technique has successfully categorized CoVID-19 active samples into mild, serious, and extreme categories as per medical standards. The proposed technique has achieved an accuracy of 97.42% in categorizing and classifying given samples sets. The CoVID-19 also termed as coronavirus 19 is classified as Severe Acute Respiratory Syndrome Coronavirus 2 (SAR–CoV–2) is declared a global pandemic by World Health Organization (WHO) in early 2020 as the first case reputed in Wuhan province of China in December 2019 [The author, Ismael, A.M  in the rThe battle against COVID-19 is much effective if detected on early grounds. Even if limited by the possibility of false negatives, chest X-Ray represents the first approach in the emergency setting  due to iThe fundamental paradigm required for the validation and processing COVID-19 images via X-ray images are limited to feature-set selection and attribute based clustering using training models. In this study, we proposed a method based on thresholding approach of extracted features and clustering parameters using TVFx technique.The purpose of this research article is to classify the COVID-19 images under minimal feature-set using thresholding approach of extracted features and clustering parameters using TVFx technique. The input dataset for the proposed technique is X-Ray images validated by the Kaggle digital library and processed under a feature distributed technique for re-alignment of datasets. The inter-connected feature set is then aligned and generated with a threshold parameter to support a rapid classification and decision support of CoVID-19.Classification of COVID-19 images under minimal feature setMaking use of thresholding approach to extract the featuresClustering parameters using TVFx techniqueOur main contributions in this research study are as follows:This research paper article is organized as: literature review is discussed in section "The CoVID-19 detection and early treatment is an alarming concern and thus, many researchers have proposed various solutions and methodologies in combatting this novel virus. In this regard,  a fast dCovidAID is proposed by  under thThe process of detection using deep learning is processed under an automation  process The process of classifying COVID-19 under given X-ray images dataset, the process of independent techniques are evaluated as shown in Table The literature details on the multi-dimensional dataset processing  with refThe proposed technique is supported by an aligned feature set-based thresholding framework for classification and decision support of CoVID-19. The approach is supported and coordinated by pre-processing of X-Ray images under noise removal and image segmentation approach to categorize the labels in processing datasets as shown in Figs. The decision support is then processed and aligned with a dual-mode of information matching and validation with reference to trained threshold value matching for an unambiguous decision support in classifying the dataset sample as Covid positive. The summarization is further extended towards report generation and validation. The proposed TVFx technique assures the decision support to be validated under a dual inter-dependent correlation of attributes.The decision support vector in the proposed TVFx technique is aided under the influence of a dedicated neural networking ecosystem. The support of features and attributes correlation is summarized into the intermediate trained datasets named as “aligned features”. These intermediate datasets are processed and combined with trained datasets towards supportive decision-making. The TVFx technique is thus updated to centralized training datasets for providing a reliable decision trained and self-learned approach.Under the proposed technique of “Feature Thresholding” for CoVID-19 X-Ray images classification, the predictive model uses a dedicated Neural networking model and an independent feature set evaluation approach. Consider the input set (S) of set of CoVID samples as SC such that, represented in Eq. Each of feature set (F) is functionally associated with a series of interconnected attributes set i.e. mentclass2pt{minimWith functional parameters of CoVID-19 focused datasets (SC) the resultant input data is further segmented into smaller order of attributes correlation, the segmented attributes with respect to incoming signals is related as Eqs. With inclusion of iterative function, the functional attributes of The system is functionally extracted in threshold feature set. The feature set of each segment is represented in The process is assigned with an interconnected set of features set (FS), extracted with reference to Now, the rational feature are extracted and evaluated with generation of aligned features, typically, the aligned feature are the intersecting features of main (raw) datasets features with respect to feature set (F) and resultant aligned features  as demonstrated in Eq. Thus, the study technique suggest the functional values are streamline into an overall feature set “Aligned” on. Hence the values are further expanded with evaluation in decision support as discussed in Table The feature set  i.e. Thus, the function decision support is classified the given CoVID-19 samples into mild, medium and extreme categories with reference to given datasets. These categories are functional in nature and thus validated under medical observation. The datasets are centric towards the consideration of X-Ray datasets for providing a rational comparison.The proposed technique features (extracted) and features  are inter-computed using a dedicated channel of neural networking model. The system is supported via a MATLAB 2015R based image processing tool kit. The model is simulated on a regional matrix of 155 datasets of X-Ray images with a comparative outcome observed in Table The proposed schema has evaluated the input samples via a series of processing and implementation as shown in Table The proposed system has recorded a performance efficiency of 97.17% over 155 COVID X-Ray image datasets with reference to trained accuracy and validated accuracy as discussed in The proposed technique has successfully classified and extracted CoVID-19-positive samples and categorized them into mild, medium, and serious bandwidth. The proposed technique, i.e. feature thresholding approach on interconnecting and feature evaluation has demonstrated a higher order of prediction accuracy. The proposed system has recorded a performance efficiency of 97.17% over 155 COVID X-Ray image datasets with reference to trained accuracy and validated accuracy, the validated accuracy has achieved a higher order of performance compared to trained datasets. The technique has primarily supported the prediction and classification of CoVID-19 disease under regular X-Ray samples. The prediction ratio of implementation using the proposed TVFx technique with reference to the value projection of features and attributes velocity of correlation. The TVFx technique is subjected to a self-learning framework for training and validating COVID-19 datasets in the near future.


Teaching Point: Magnetic resonance imaging is a valuable imaging tool in Parsonage-Turner syndrome, a rare neurological disorder that presents as acute denervation in the distribution of the brachial plexus. A 57-year-old man consulted the orthopaedic surgeon because of atraumatic left shoulder pain that had been present for over five months. He experienced activity-related pain and had trouble carrying out overhead movements. Clinical examination revealed limited shoulder mobility and slightly diminished force exerted by the infraspinatus muscle. A magnetic resonance imaging (MRI) arthrography was performed, which showed tendinopathy and a partial thickness tear of the supraspinatus tendon. Also, T2 weighted images with fat supression (FS T2-WI) showed hyperintense oedematous infiltration of the infraspinatus muscle  and 2.Electromyography (EMG) showed isolated neuropathy of the suprascapular nerve with signs of denervation of the infraspinatus muscle. There were no signs of external compression of the suprascapular nerve on the MRI exam.Treatment by means of physiotherapy and vitamin B supplementation was initiated. MRI examination nine months later showed resolution of the oedematous changes in the infraspinatus muscle with minor muscle atrophy and fat infiltration of the infraspinatus muscle belly . InfraspIt is a bit unusual for the patient to present with chronic pain, as Parsonage-Turner syndrome typically manifests as acute onset of severe shoulder pain and/or muscle weakness, but this can probably be attributed to his concomitant rotator cuff disease. It is unclear why only the infraspinatus muscle was involved, since the affected suprascapular nerve also innervated the supraspinatus muscle.Parsonage-Turner syndrome is a rare neurological disorder, also known as ‘acute idiopathic brachial neuritis’ . PatientDiagnosis is made by a combination of clinical history, EMG results, and imaging findings. EMG may show signs of acute denervation in the distribution of the brachial plexus, with the suprascapular nerve being most frequently affected. The suprascapular nerve is a branch of the superior trunk of the brachial plexus, innervating the supraspinatus and infraspinatus muscles.MRI is a sensitive tool in demonstrating signal abnormalities in the shoulder musculature that reflect denervation. These signal abnormalities can vary widely and change depending on the stage of the disease. In the early acute phase, the signal intensity of the muscles may be normal on MRI. The earliest sign of denervation visible on MRI is an increase in T2 signal intensity reflecting muscular edema, which usually develops at about two weeks after the symptom onset. Muscular edema is best appreciated on fluid-sensitive sequences, which are more sensitive for the detection of muscular edema than conventional T2-WI sequences. The increase in T2-weighted signal may occur with or without an accompanying change in T1-weighted signal. In the subacute phase, T2-weighted signal abnormalities persist and muscular atrophy and T1-hyperintense fatty infiltration may start to develop. This can progress rather quickly over the course of 2-5 weeks. Muscular atrophy and fatty infiltration are best evaluated on T1-WI without FS (T1-weighted imaging without fat saturation), preferentially in the oblique sagittal plane. The chronic phase is characterized by muscular atrophy and fatty infiltration and lasts several weeks or months, after which signal abnormalities may disappear. In some patients, however, there is no resolution of the abnormalities.MRI is also useful to detect structural abnormalities, such as spinoglenoid and suprascapular notch masses that may compress the nerve, and to rule out more common causes of shoulder pain. Direct MR arthrography as performed in the case may be helpful in the evaluation of rotator cuff disease, a common cause of shoulder pain, but can render evaluation of muscular edema more difficult due to contrast leakage in the muscles and is therefore not recommended when Parsonage-Turner syndrome is suspected. However, as was the case in our patient, findings suggestive of Parsonage-Turner syndrome are often found on MRI exams performed for other reasons.Parsonage-Turner syndrome is typically self-limiting and clinical symptoms and abnormalities on MRI may disappear after a few months. Treatment consists of analgesics and physiotherapy.


Controlled electrical stimulation and the ability to provide directly analyzed functional readouts are essential to evaluate the physiology of cardiac tissues in the heart-on-chip platforms. In this scenario, a novel heart-on-chip platform integrating two soft conductive hydrogel pillar electrodes was presented here. Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) and cardiac fibroblasts were seeded into the apparatus to create 3D human cardiac tissues. The application of electrical stimulation improved functional performance by altering the dynamics of tissue structure and contractile development. The contractile forces that cardiac tissues contract was accurately measured through optical tracking of hydrogel pillar displacement. Furthermore, the conductive properties of hydrogel pillars allowed direct and non-invasive electrophysiology studies, enabling continuous monitoring of signal changes in real-time while dynamically administering drugs to the cardiac tissues, as shown by a chronotropic reaction to isoprenaline and verapamil. Overall, the platform for acquiring contractile force and electrophysiological signals   •A heart-on-chip platform for 3D cardiac tissues generation.•Novel soft conductive pillar electrodes integration with stimulation capabilities.•Reproducible contractile quantification of 3D cardiac tissues.•real-time during drug testing.High-quality electrophysiology measurement in  A. Ain sit-on-chip . This suIn terms of contractility, the contractile activity of the tissues cultivated under conditions with or without electrical stimulation was evaluated and analyzed using custom-developed software for monitoring the movement of the hydrogel pillars. The tissue's contractile force, which was computed using the hydrogel pillars' stiffness k, is proportional to the displacement of the tip of the pillars d and e. It's interesting to note that up to 1.5–1.8 Hz, all unstimulated tissues could be paced; beyond this frequency, tissues could no longer match the external pacing rate. Every other pulse was skipped, resulting in a beating frequency that was half of the applied frequency f. A grap3.5We next assessed the calcium handling after the course of electrical stimulation. Uniaxial conduction was visible using calcium imaging across the heart tissues, and the stimulated tissues showed improved synchronization of calcium waves compared to the controls a and b. 3.6A key advantage of our heart-on-chip platform is the ability to record the electrophysiologic characteristics of cardiac tissues in real-time. As a proof of concept, we exploited the two conductive hydrogel pillars to monitor tissue's action potential propagation activity as an extracellular field potential and detected the changes in electrophysiology when administered with drugs that cause well-known electrical alterations.As shown in 4In the present study, we reported a novel heart-on-chip platform that generates 3D cardiac tissue and was capable of applying electrical stimulation to improve functional performance. A major innovation of this study was the demonstration that soft conductive hydrogel pillar electrodes were promising 3D structures for both relevant electrophysiology measurement and reproducible contractile quantification. Moreover, we further illuminated that the stimulated tissues respond to isoprenaline with an increasing beat frequency trend, demonstrating the dependability of this heart-on-a-chip platform for use in cardiac toxicity screening and medication efficacy testing. Overall, the designed system can be regarded as a flexible, mass-produced platform for pharmaceutical development and disease modeling.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


A minority of American youth meet CDC physical activity (PA) recommendations; children in the Bronx face additional structural barriers to engaging in PA. The B’N Fit Power expansion draws on pilot programming to increase the proportion of middle school students who engage in one hour of daily PA. The COVID-19 pandemic presented additional obstacles, including increased food insecurity and suspension of organized PA programming. This research aimed to evaluate differences in baseline target behavior attainment before and after the start of the COVID-19 pandemic to inform future programming to help children reduce their risk of obesity.Afterschool program leaders at three Bronx public schools collected demographic and target behavior data at baseline and attendance data throughout the school year.During the 2016–2017 and 2017–2018 school years, 76 students enrolled and completed one year of programming, which was administered at a single site . Of these, 76 (100%) completed a baseline target behaviors questionnaire. During the 2021–2022 school year, 417 students enrolled and completed one year of programming at one of the three sites . 89 (21%) completed a baseline target behaviors questionnaire. Participants surveyed after the start of the COVID-19 pandemic reported drinking more sugar-sweetened beverages , sleeping less , and consuming fast food more frequently  than those surveyed prior to the start of the pandemic. The number of PA hours completed each week trended toward significant decline  in students tracked after the start of the pandemic.The attainment of several target behaviors among school children linked to the reduction of childhood obesity declined during the COVID-19 pandemic. These findings can be applied to enhancing existing real-world afterschool PA programming. A minority of American youth meet CDC physical activity recommendations . Nearly Children and adolescents in urban settings such as the Bronx face additional barriers to engaging in physical activity. The Bronx has the state of New York’s highest proportion of children living in poverty (38% immediately before the start of the COVID-19 pandemic) and is a majority-minority county . Nearly The B’N Fit Power pilot study aimed to address high youth obesity prevalence in the Bronx by evaluating the real-world efficacy of a multipronged intervention to increase physical activity and nutrition activities in afterschool programming. B’N Fit Power was piloted at one public middle school in the Bronx in 2016; the programming and its outcomes have been detailed previously .The B’N Fit Power expansion to two additional sites draws on lessons learned from the pilot afterschool physical activity and nutrition programming to increase the proportion of middle school students who achieve seven core nutrition and physical activity behaviors. This research aims to evaluate differences in baseline target behavior attainment before and after expansion and the COVID-19 pandemic shutdown to inform future programming to help children reduce their risk of obesity.The study uses a repeated cross-sectional design to examine the impact of the B’N Fit Power afterschool program on target behavior attainment. The B’N Fit Power program was piloted in one public middle school in the Bronx during 2016–2018 and expanded to two additional schools in the Bronx in 2021 in a real-world setting. Students’ target behaviors and afterschool attendance were collected 3–4 times during the school year. In this study, we aimed to compare baseline target behavior outcomes and attendance throughout the school year before and after the start of the COVID-19 outbreak. The Albert Einstein College of Medicine IRB approved the pilot (IRB #2015–5917) and the expansion study (IRB #202113679). For the pilot study, students were directly involved and informed consent was obtained from parents. For the expansion study, students were not directly involved and the Albert Einstein College of Medicine IRB waived written informed consent.The B’N Fit Power was implemented at three public middle schools in the Bronx, New York.B’N Fit Power involves the integration of daily physical activity components into a community-run afterschool program that takes place in public schools in the Bronx. A detailed description of the B’N Fit Power program is described elsewhere . As the In expanding from one site to three sites, staff members from the overseeing community organization met monthly with site youth directors to ensure that PA programming was consistently implemented across sites, discuss challenges in tracking, and troubleshoot problems.All students participating in afterschool programming at the three schools received B’N Fit Power programming. This is a change from the pilot pre-COVID-19 cohort, wherein a subset of students participating in the afterschool program was specifically screened, consented, and enrolled in the study/program, as previously described  were considered their baseline responses.Data analysis was conducted on data provided by schools. The number of PA hours was extracted from attendance data for activities relating to PA. Target behavior data was collected by administering a self-reported target behaviors survey directly to afterschool program participants.The distribution of participant characteristics was summarized using descriptive statistics. The categorical variables were summarized using frequency count and percentages, while continuous scale variables were summarized as mean (standard deviation) or median (interquartile range) as appropriate.Survey responses to target behavior were dichotomized as attained/not attained; “attainment” was aligned with evidence-based recommendations for each behavior. One point was allocated for each behavior attained. The points were then summed into a multi-component composite score with a maximum of seven; students received one point each for: (1) eating breakfast and lunch daily, (2) eating 2–3 servings of fruit daily, (3) eating 3–6 servings of vegetables daily, (4) drinking at least 8 cups of water daily and drinking no more than one cup of a sweetened beverage daily, (5) getting at least eight hours of sleep daily, (6) limiting fast food and unhealthy snack consumption to no more than once weekly, and (7) getting at least an hour of physical activity daily. An eight-component score was also computed; students could receive an additional point for having 2 hours a day or fewer of recreational screen time. Differences between groups pre- and post-shutdown cohorts were evaluated using the Mann-Whitney U-test for continuous or ordinal variables and Fisher’s exact test for categorical variables. Data were analyzed in R 4.2.0.Pre- and post-pandemic shutdown, the median baseline self-reported seven-component composite scores were 2 (IQR 2–3) and 2 , respectively. While the median did not change, the overall distribution shifted towards fewer target behaviors attained after the COVID-19 pandemic shutdown. When evaluating the eight-component score, which also included recreational screen time, the median pre-pandemic score was 3 (IQR=2–3), while the post-shutdown score was 2 .Differences in individual pre-and post-pandemic shutdown behaviors at the beginning of the school year were also evaluated. Consumption of unsweetened beverages at baseline rose from 5 (IQR=3–8) to 7  pre- to post-shutdown. Consumption of sweetened beverages at baseline also increased from 2 (IQR 1–4) to 3 . There were additionally statistically significant changes in the distribution number of hours of sleep and the frequency of fast-food consumption. The number of hours of daily screen time students engaged in rose significantly from 3 (IQR 2–5) to 5  The number of self-reported days in which students engaged in an hour of PA trended toward a significant decline from a pre-pandemic of 4 days (IQR 3.5–5) to 3 . There were no other significant changes between pre- and post-COVID-19 shutdown behaviors. The distribution of target behavior frequency can be seen in In the pre-pandemic period, 20% of students identified getting one hour of physical activity as their target behavior goal; post-pandemic shutdown, 12% identified this as their goal. Pre-pandemic, 16% of students identified eating breakfast and lunch daily as their target behavior goal; post-shutdown, 29% identified this as their goal .The B’N Fit Power program has expanded from one NYC public school in the Bronx to three during the COVID-19 pandemic, allowing for greater reach among students. During the COVID-19 pandemic, afterschool program attendance records indicate a significant decline in PA hours completed during programming. Self-reported baseline target behavior attainment fell during the COVID-19 pandemic, with median composite scores declining in the post-pandemic cohort compared to the pre-pandemic cohort. Additionally, the proportion of students identifying physical activity as the target behavior they wanted to improve fell by nearly half. In contrast, the proportion who identified eating daily breakfast and lunch as their goal nearly doubled.It was noted in the pilot of B’N Fit POWER that the targets of behaviors, sorted into binary “achieved/not achieved,” might obscure sub-threshold improvements in behavior; for example, going from no servings of vegetables daily to one . As noteThe rise in childhood inactivity during the COVID-19 pandemic has been previously described in the literature . RegularThis study’s backslides in target behavior attainment underscore the importance of building healthy behaviors in children’s environment, including their school and afterschool programming. During this critical period of regression, participation in PA programming has fallen. This could be due to various factors, including adjusting PA options to be COVID-safe, interruptions in attendance due to personal illness, and scaling back programming compared to pre-pandemic levels. It is vital to continue to provide robust PA programming to stem any backslide in daily PA participation. While meeting daily physical activity recommendations is important in its own right, data show that this goal can also improve other behaviors, such as sleep and screen time , 16.Pre-pandemic, the target behavior that a significant proportion of students was interested in working toward was participating in one hour of daily physical activity; post-pandemic shutdown, the target behavior with the most interest was consuming daily breakfast and lunch. However, there was no significant shift in the median number of days students consumed these meals. This observed discrepancy between the desired to consume daily breakfast and lunch yet no baseline change in this behavior may reflect increasing food insecurity; there was a nearly one-third increase in food insecurity during the COVID-19 pandemic . Food inOne limitation of this research is the differential completion of baseline target behavior surveys pre- and post-pandemic shutdown. All students participating in the pilot program completed the target behaviors survey. However, during the program expansion in the 2021–22 school year, all students participating in afterschool programming received the B’N Fit Power program. While this increased the program’s reach, staffing limitations prevented all students from taking the baseline behaviors survey; consequently, the survey response rate was lower in the expansion than in the pilot. However, this analysis broadly shows that the COVID-19 pandemic has had an unmistakable impact on behaviors linked to childhood obesity.Data from this real-world program provide insight into how specific obesogenic behaviors can be intervened upon in future programming to help children engage in healthier lifestyle behaviors and reduce their risk of obesity. The B’N Fit Power expansion offers an opportunity to do just this.This research can inform future programming by further investigating participant desires and aligning programming to them. If, as hypothesized, the shift to identifying daily breakfast and lunch as a target goal reflects increased food insecurity, then expanding programming that supports food security will likely be beneficial. For example, the sites are currently working to begin hydroponics garden towers; these towers will provide fresh produce to participants, potentially promoting vegetable consumption and reducing burdens created by food insecurity.Overall, this study found that target behavior attainment for behaviors related to obesity prevention in youth declined after the start of the COVID-19 pandemic. Consumption of sugar-sweetened beverages and fast food increased, while hours of sleep declined; hours of physical activity programming also fell after the pandemic. As programming resumes and expands to additional sites, these insights can increase the number of physical activity hours offered, provide education related to healthy nutrition and sleep habits, and tailor programming to specific student needs.


Small Regulatory RNAs: From Bench to Bedside’ was held in Santa Fe, New Mexico from May 1–4, 2022. The symposium was organized by Frank J. Slack, Jörg Vogel, Ivan Martinez and Karyn Schmidt, and brought together scientists working in noncoding RNA biology, therapeutics, and technologies to address mechanistic questions about small regulatory RNAs and facilitate translation of these findings into clinical applications. The conference addressed four specific aims: Aim 1. Focus on the exciting biology of small regulatory RNAs, highlighting the best current research into the role that small RNAs play in fundamental biological processes; Aim 2. Focus on the latest efforts to harness the power of these RNAs as agents in the fight against disease and provide the basic understanding that will drive the invention of powerful clinical tools; Aim 3. Attract leaders from both academia and industry working in small RNAs to one place for critical discussions that will advance the field and accelerate the bench to bedside use of this technology; Aim 4. Provide a stimulating environment where students, postdoctoral researchers and junior investigators, along with scientists from Biotechnology and Pharmaceutical companies specializing in small regulatory RNAs, can present and discuss their research with the best minds in the field.The Keystone Symposium ‘ The Keynote address entitled ‘Viral Noncoding RNAs: New Insights into RNA Structure’ was given by Joan A. Steitz from Yale University. She talked about the Kaposi’s sarcoma-associated herpesvirus (KSHV) noncoding, polyadenylated nuclear (PAN) RNA that is required for late protein synthesis and virus production . RemarkaThe first session focused on the role that small RNAs play in cancer. Joshua T. Mendell  described different modes of microRNA (miRNA)-target interactions and specific post-transcriptional modifications that determine the fate of the target RNA and the Argonaute protein ,15. GeorThe second session highlighted miRNAs in therapeutics. Ivan Martinez (Western Virginia University) showed that SARS-CoV-2 infection specifically reduces cytoplasmic Drosha expression and that alternative splicing of Drosha is regulated differently by distinct SARS-CoV-2 variants. Vishal Patel  highlighted the promises and challenges of developing anti-miR-17 therapy for autosomal dominant polycystic kidney disease . Raman B7G modification of Arg-TCT tRNA drives oncogenic transformation and that targeting oncogenic tRNA Arg-TCT is a promising anti-cancer strategy [HMGN2 expression. Ruben Garcia Martin  provided insights into defining cell-type specific miRNA codes controlling exosomal sorting and cellular retention [The third session examined diverse small regulatory RNAs. Richard I. Gregory  showed that METTL1-mediated mstrategy . Jörg Vostrategy . Sandra strategy . Gisela strategy ,32. Danietention .The next session focused on small regulatory RNA functions and non-canonical pathways. Shobha Vasudevan  discussed the post-transcriptional regulatory mechanisms involving regulatory noncoding RNAs that contribute to chemoresistance and persistence of quiescent cancer cells. Martin J. Simard  described the function and regulation of the miRNA-mediated gene silencing pathway during animal development and showed that serine 642 dephosphorylation of Argonaute ALG-1 controls miRNA-induced silencing complex (miRISC) formation . Monika Drosophila early embryos and mouse spermatids beyond transposon silencing, and that piRNA 3’ ends are defined by the PIWI-Ins element and contribute to piRNA targeting efficiency [let-7 disruption in neuroblastoma [let-7 agonist H19 long noncoding RNA (lncRNA) are highly expressed in MYCN non-amplified neuroblastoma.The next session examined therapeutic opportunities for small RNAs. Mofang Liu  showed that PIWI/piwi-interacting RNAs (piRNAs) regulate protein-coding genes in ficiency . Stefan ficiency . Karyn Sficiency ,40. Franficiency , and desficiency . John T.blastoma  and showThe final session highlighted emerging technologies and novel applications for small RNAs. William J. Greenleaf (Stanford University) described a high-throughput sequencing-based method to identify rules for miRNA target binding and cleavage by Argonaute2 (AGO2) and showed that knockdown can be explained by a biophysical RNAi kinetic model incorporating binding and cleavage rates in live cells . SabrinaAt the end of the last session, Frank J. Slack, Jörg Vogel, Karyn Schmidt, and Ivan Martinez concluded the conference by sharing their thoughts on the growing importance of small noncoding RNAs in medical therapeutics, highlighting the cutting-edge basic and translational research presented at the meeting, with a focus on the inclusion of all kinds of small noncoding RNA species and the diverse range of model systems employed to study them. Importantly, a number of collaborations are already beginning to form – stemming from the conference presentations. Each of the organizers agreed that specific outcomes and promising future directions included: A highlight of the number of advances the field of small noncoding RNAs is currently experiencing; A focus on the connections and collaborations formed from this meeting, and the incorporation of novel techniques into laboratories based on the conference presentations; An emphasis on how the discoveries and therapeutics presented at this meeting are not necessarily islands, but that these discoveries could change how we think about biology and new medicines; A forward focus on what is achievable in the coming years through the discovery of new small RNA species and their implication for our understanding of disease processes and the consequent discovery of novel, RNA-based therapeutics.The conference offered poster sessions and diverse workshops, which provided an opportunity for researchers to present on emerging topics in the small regulatory RNA field, as well as a career roundtable, which resulted in discussions, guidance and mentoring for early career professionals and facilitated excellent networking opportunities. The emerging topics workshop covered a wide range of topics, including the role of miRNAs in Islet Autoimmunity, miRNA-based anti-tumour therapy, and their role in mitochondrial diseases. The roundtable included sessions from Christine Eischen from Thomas Jefferson University, Stefan Engelhardt from the Technical University of Munich, and John T. Powers from Dell Medical School at the University of Texas at Austin. This represented three different research stages in academia, and they were able to answer specific questions from students – tailoring advice based on student experience and goals.Overall, conference attendees experienced a set of presentations (from the podium and the posters) at the cutting edge of RNA therapeutics, with a growing appreciation for the potential and challenges that lie ahead. Given the optimal size of the conference, attendees had the opportunity for extensive interactions that will drive innovations in the future. The organizers concluded that the four aims of the conference were achieved.


Schizophrenia (SZ) is an inherited mental illness that affects 1% of the world’s population. Schizophrenia is a common functional psychosis with some unifying features that appears to have a universal distribution. Much of the research on SZ seeks to identify physiological, biochemical, or genetic features that differ between patients and healthy individuals. Biochemical factors represent an imbalance of certain biochemical substances in the brain, especially neurotransmitters. Early studies focused on the brain biochemistry of patients with SZ in terms of dysregulation of the neurotransmitter network. There is evidence that elevated dopamine concentrations are associated with positive symptoms  of the disease. For example, L-DOPA decarboxylase (DDC) is an enzyme involved directly in dopamine and serotonin synthesis and indirectly in noradrenaline synthesis. Therefore, the DDC gene can be considered a candidate gene for schizophrenia and its activity is a good candidate for functional analysis via epigenetic repression.We aimed to create a cellular model with a deregulated DDC gene.We constructed two lentiviral vectors, one expressing the dCas9-KRAB-MeCP2 repressor under the control of a synthetic tetracycline inducible promoter, and the other carrying a cassette expressing two sgRNAs with spacers against the DDC promoter. The SH-SY5Y cell line was sequentially stably transduced with both lentiviral constructs, and cells carrying both constructs were selected by the fluorescence of the GFP and RFP reporter proteins encoded in the lentiviral construct backbones.Methyl-sensitive real-time PCR followed by high-resolution fusion showed methylation of the DDC promoter. Correspondingly, real-time PCR showed a two-fold decrease in DDC expression in SH-SY5Y during tetracycline-induced expression of the CRISPR repressor.We developed a cellular model to study the contribution of DDC deregulation to SZ-related molecular mechanisms.None Declared


Signatures of immune dysregulation as clinical biomarker for psychosis have remained unclear. We aimed to compare the Neutrophil-to-lymphocyte ratio (NLR) of patients with acute non-affective first-episode psychosis (FEP) with healthy controls after accounting for emotional states. We also explored the associations of NLR with symptom severity, onset profile and cognitive functions. The NLR was enumerated from complete blood count taken within a week of assessment. All FEP patients were rated on the Positive and Negative Syndrome Scale (PANSS) and the Clinician Global Impression-Severity (CGI-S) with verbal memory and executive functions assessed with the Cambridge Neuropsychological Test Automated Battery. Prevailing emotional state was measured with Beck Depression Inventory-II and Beck Anxiety Inventory. Out of seventy-nine consecutive FEP patients presenting to the study site, twenty-seven subjects were eligible and recruited. Twenty-seven age-/sex-matched controls were recruited. FEP patients had an NLR of 1.886 over the controls after accounting for scores on emotional states. The NLR of FEP patients was positively associated with CGI-S scores, PANSS positive symptom, disorganization and excitation scores. There was no significant correlation between NLR with the duration of untreated psychosis and cognitive performances. These findings support using NLR as a clinical biomarker in FEP, purporting further prospective study to measure NLR changes in the course of treatment. Alterations in circulating blood cytokine network were reported6. Abnormal immune cell counts have been reported in patients with schizophrenia and those with first-episode psychosis (FEP)9. Some studies revealed upregulation of pro-inflammatory cytokines10 and high sensitivity C-reactive protein (CRP)11 in psychosis. A recent meta-analysis also confirmed an imbalance of pro-inflammatory status and a reduction of anti-oxidant signals in patients with FEP compared with healthy controls12. Treatment with antipsychotics was shown to modulate the inflammatory status in patients with psychosis, although the effects were inconsistent across different psychotropics13. Other studies revealed differential immune status with levels of psychotic symptom severity14, and among antipsychotic responders or non-responders in FEP15. Symptoms aside, alterations of immune status were associated with abnormal cognitive functions in schizophrenia, as reported in a recent systematic review and meta-analysis. However, the associations found in these studies were weak, given the small effect size of the correlations reported17. Specific profiles of inflammatory biomarkers were reported to correlate with some cognitive domains in FEP patients18.Inflammation and immune dysregulation have been implicated in the pathogenesis of major neuropsychiatric disorders, including mood or anxiety-related disorders19. NLR has been reported as a prognostic indicator in disease entities like cancer20, metabolic syndrome21, sepsis22, and inflammatory bowel diseases23. A recent cross-sectional study revealed an increased NLR in more than 13,000 clinically diverse service users attending a regional psychiatric service in South London. Such transdiagnostic association in psychiatric service users was also influenced by age (positive correlation), psychotropics, and ethnicity (white over non-white) relative to the profiles of healthy controls (n > 3000) drawn from a National Health Survey24. Another recent meta-analysis pooling data from retrospective or cross-sectional studies showed an elevated NLR in patients with psychosis over healthy controls25. Emerging evidence supports a possible association of NLR with positive psychotic symptoms in schizophrenia26 and a positive association of higher NLR with the severity of psychotic symptoms in unmedicated patients with schizophrenia27. However, the results of these studies could not discriminate between clinically remitted patients and those who were acutely psychotic.Routine serum assays of inflammatory biomarkers are often unavailable in psychiatric clinical settings. On the other hand, neutrophil-to-lymphocyte ratio (NLR) is a clinically accessible candidate biomarker easily enumerated from complete blood count (CBC) measured in routine clinical care. A ratio between the neutrophil and lymphocyte count conjugates innate and adaptive immunity. An increase in neutrophil levels could reflect an elevated systemic inflammatory status augmenting neutrophil-mediated killing with adaptive regulatory immunity in various diseases28. Given some earlier reports suggesting the association of altered NLR in mood disorders29, the emotional state is a potential confounder to be considered in the analysis of NLR in psychosis. Further, the evidence from a retrospective review of a multi-ethnic clinical registry suggested the role of ethnicity in moderating the association of NLR and psychiatric disorder in a UK cohort24, in which data on Chinese subjects were lacking. It also remains unclear whether NLR is a state or trait marker in psychosis, and notably, its linkage to symptom severity and cognitive impairment has remained obscure. Many studies included patients with a relapsing course of schizophrenia, in which long illness duration and chronic psychotropic treatment might confound the clinical association of the inflammatory status30. Data were lacking in patients with FEP, a relatively homogenous clinical population in terms of duration of illness and exposure to psychotropics.In summary, there are main knowledge gaps in the understanding of clinical correlates of NLR in psychosis. First, existing case-controlled studies in patients with psychosis did not account for the emotional states of the patients with psychosis even though stress and emotion have complex interplay with inflammatory activityThis case–control study primarily aimed to compare the NLR of ethnic Chinese patients with non-affective FEP and the age-/sex-matched healthy controls. It also aimed to explore the association of NLR with severity of psychotic symptoms and cognitive function after accounting for current emotional states.31, the mean NLR assumed was 2.7 in FEP patients and 1.6 in control, and a pooled standard deviation of 1.9 and 0.6, respectively. Taking the probability of type I error (α) as 0.05 and power level (1-β) as 80%, a sample size of 27 per group would be needed to adequately test for difference in the NLR between the subject group and healthy control. The research team posted an advertisement at TPH/AHNH in the same study period, when adult healthy volunteers signed up and were enrolled as control participants only if their age and gender matched the recruited cases with non-affective FEP. Non-affective FEP patients and control participants with informed consent were recruited and assessed from November 2020 to July 2021. Inclusion and exclusion criteria were summarized in Supplementary Table 25. Non-affective FEP patients were defined as having the first inpatient psychiatric hospitalization or outpatient FEP consultation while meeting the diagnostic criteria for schizophrenia spectrum disorder in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV). All clinical diagnoses were confirmed with a validated Chinese-bilingual version of Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) 32. All research was performed in accordance with relevant guidelines and regulations.The current study was approved by the Chinese University of Hong Kong (CUHK) – NTEC Clinical Research Ethics Committee (CREC reference number: 2020.250). We recruited consecutive patients ages 18–50 years with non-affective FEP from two clinical settings: 1) hospitalized patients presenting to a regional tertiary psychiatric inpatient unit  serving the New Territories East Cluster under the public sector; 2) those referred for assessment at the FEP clinic of Alice Ho Miu Ling Nethersole Hospital (AHNH). Based on a similar study design comparing the blood parameters of FEP subjects and healthy control The demographic and clinical data of non-affective FEP subjects were collected from a direct interview supplemented with electronic clinical record review. The research interviews were conducted on FEP subjects within 1 week after presenting to the inpatient or outpatient unit. All blood samplings were done in the morning. The earliest available blood count values were used to minimize the potential effects of healthcare interventions. The same protocols for blood sampling and clinical interview were carried out for the healthy controls. The assessor was blinded to the blood parameters while performing all clinical interviews or assessments. All blood assays were processed in an accredited pathology laboratory in AHNH. The NLR of each participant was not analyzed until all clinical data were collected.32. Non-affective psychosis was defined as those diagnosed with schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. The psychotic symptoms of all FEP patients were assessed using the PANSS with precise ratings34. PANSS positive, disorganization, negative, excitation, anxiety and depressive symptom scores were derived from previous factor-analytic study on FEP patients35. The emotional states were assessed with validated Chinese versions of BDI-II and BAI36 to record the prevailing mood symptoms in the past week. The neurocognitive assessment was carried out by a computerized system known as the CANTAB37. An earlier systematic review reported verbal memory and executive functions were the domains with the largest effect size in cognitive impairment of FEP38. Verbal Recognition Memory (VRM) tests, Spatial Working Memory (SMW) tests, and the One-Touch Stockings of Cambridge (OTS) tests were selected to assess verbal memory, working memory and executive functions. CGI-S was used to gauge the global clinical severity39.Psychiatric disorders were diagnosed with a validated Chinese-bilingual version of DSM-IV SCID-I40. Statistical analyses were performed using the IBM Statistical Package for the Social Sciences for Windows Version 26.0 . Descriptive statistics were used to summarize the demographic and clinical data. Continuous variables were expressed as means and standard deviations if the data were normally distributed, while median and interquartile ranges (IQR) if the data were not normally distributed. Categorical variables were presented as absolute numbers and proportions (percentages). A Kolmogorov–Smirnov test was used to examine each variable for normality. For comparing the sex- and age-matched subjects, continuous data were analyzed by paired t-test if the data were normally distributed. At the same time, Wilcoxon signed-rank test was used if the data were not normally distributed. Categorical data were analyzed by McNemar test (two categories only) and Marginal Homogeneity test (more than two categories). Spearman's rho correlation coefficient was used to investigate any significant relationship between two continuous variables. Generalized Estimating Equation (GEE) model was used in assessing the differences between the cases and controls by accounting for the working correlation matrix of putative confounders. The occupation status, years of education, BDI-II and BAI scores were included in the model for analyses. All tests were set with a significant level of p < 0.05.Power and sample size estimations were done using the computerized G-power analysisConsecutive FEP patients from November 2020 to July 2021 were screened for eligibility for the study as shown in Fig. p = 0.009) and neutrophil count (p < 0.001) but a significantly lower lymphocyte count (p = 0.002) than the healthy controls. There were no differences between the monocyte (p = 0.526) and platelet count (p = 0.469). The NLR was significantly higher in the FEP patients than the healthy controls (p < 0.001). All except three of the FEP patients were unmedicated. The medicated FEP patients had been prescribed the second-generation antipsychotics  within 1 week before hospitalization. A post-hoc analysis excluding the three medicated FEP patients found a significantly higher NLR in the FEP group than in the controls (p < 0.001). Excluding smokers in the analysis also yielded higher NLR in the FEP group than in the controls (p < 0.001).Analyses of blood count parameters are summarized in Table p < 0.001), reflecting the differences in the mood state of FEP patients in the week before the assessment (Table p < 0.001) over the controls after adjusting for the scores on BDI-II/BAI, years of education and occupation. The analysis suggested that the FEP case would have an NLR value 1.886 times higher than the healthy control group after accounting for the differences in emotional state, years of education, and occupation status. Repeating the analyses excluding the three medicated FEP patients and their respective matched controls yielded a higher NLR in the FEP patients than in healthy controls (data not shown). As there was ample evidence that the body mass index (BMI) could affect inflammatory status, and hence NLR41, we also analyzed BMI as a potential covariate, even though the BMIs were comparable between the two groups. We found that the NLR of FEP subjects was still higher than the controls after accounting for BMIs  , PANSS-disorganization score , PANSS-excitation score  as well as PANSS-anxiety and depressive symptom score . It did not have a statistically significant correlation with the PANSS-negative symptom score . The NLR was also found to be positively associated with the CGI-S score  (Table p = 0.134) , immediate recognition (VRM-IR) , and delayed recognition (VRM-DR)  were not correlated with the NLR. The performances in SWM-BE  and SWM-S  were not correlated with the NLR. For the OTS, no significant correlations were found between the performances in both OTS-PFSC  and OTS-MLC  with the NLR in the FEP patients   in patients with early schizophrenia compared with controls irrespective of antipsychotic treatment. An early stress with history of childhood maltreatment also linked to patients with increased NETs47.Our study is the first to report the clinical correlations of NLR in non-affective FEP presenting to a tertiary care setting in Hong Kong SAR, and was among the few clinical studies that examined the clinical correlations of NLR in psychosis with the inclusion of ethnic Chinese. NLR was significantly higher in non-affective FEP patients than in age-/sex-matched healthy controls after accounting for the emotional state, education, and employment status. Our findings were consistent with the results reported in the meta-analysis, which reported an increased NLR of 0.65 in a pooled sample of relapsed patients with schizophrenia than in healthy controls, and an increased NLR of 0.52 in the pooled FEP subgroup patients than in healthy controls26. The correlations between NLR and the different psychotic symptom severity could be altered by antipsychotic treatment27. Nonetheless, we still found a significantly higher NLR of the drug-naïve FEP patients than the healthy controls after excluding the three FEP subjects with prior antipsychotic treatment.Regarding the possible effect of drug treatment on NLR, other reports demonstrated years of antipsychotic treatment could reduce NLR48 or sadness49 might influence inflammatory status. The FEP patients in this study had more intense depressive and anxious states as measured with BDI-II and BAI, probably secondary to the underlying active psychotic symptoms and other social stressors. Interestingly, some published studies alluded to the effects of socioeconomic status, including education and income on inflammatory states, although there has not been any report on their direct association with NLR51. The correlations between the occupation status or years of education with BDI-II or BAI scores found no significant correlations (data not shown), with the variance inflation factor computed with either BDI-II or BAI scores toward occupation status and years of education to be 1.13, suggesting a low chance of multicollinearity between the variables in our data. Using a GEE model, a higher NLR in the FEP patients remained statistically significant when the emotional states, years of education, and occupation status were accounted for, implicating an independent association of higher NLR with FEP in an active psychotic state.Existing literature often overlooked the confounding effects of the prevailing emotional state on inflammatory status. For instance, anxiety-related states54. Some evidence suggests that inflammation is associated with the risk of suicide, at least in adolescents55. Some recent evidence supported the association of higher NLR with the severity of psychotic state in patients with schizophrenia27. Amongst the non-affective FEP patients (schizophrenia spectrum disorder) in this case–control study, we found positive correlations between symptoms severity  with higher NLR, but no significant correlations between NLR and the duration of untreated psychosis (DUP). Our study revealed no significant correlation between NLR and PANSS-negative symptom score, parallel to findings reported in the existing review56. Overall it suggested the potential role of NLR as a biomarker of clinical severity in the acute episode of FEP patients.A higher NLR might allude to unfavorable prognosis in various medical conditions57, while clinical studies have reported transdiagnostic associations of higher NLR with cognitive impairment in different psychiatric patients, including older adults62. Our study did not find a significant correlation between NLR and the selected tests on executive function and working memory in FEP patients. Intriguingly, the positive association between higher NLR and cognitive impairment was not merely neurotoxic. Some components of inflammatory cytokines could exert neuroprotective effects in maintaining certain cognitive performances63. Social stressors, which inevitably affect the hypothalamic-pituitary hormonal axis, have been implicated in impairing cognitive functions in FEP patients65. Considering the varying stress level that was not quantified in this study and the complex interplay of inflammatory status and cognitive performance, NLR on its own is not a sensitive marker to predict the level of cognitive performance during the active psychotic states in patients with FEP who had a relatively short duration of untreated psychosis.Some animal studies have reported an association of increased inflammation with cognitive impairment66, a recent meta-analysis concluded the DUP among FEP was not significantly related to the performances of most cognitive domains67. We also reported that our FEP patients across different DUPs performed similarly and had no statistically significant correlations in all the tested cognitive performances. Given the small sample size in this case–control study design, it might remain a caveat in interpretation that these sub-group analyses might not reflect a true null association of NLR with DUP.We considered the possibility of other associative factors, including the DUP, that have not been examined in previous studies. While the association of long DUP with cognitive impairment is generally accepted in chronic schizophrenia68, comparable to our present study showing a median NLR of 1.78 in the healthy controls. A more recent investigation that retrieved data from a routine examination center in Western China suggested a reference NLR could be 0.88 to 4.0 in a healthy ethnic Chinese Han population69. However, these studies offered limited information on the normative value of NLR, which is known to vary with age 70 and ethnicity24.The pre-requisite for applying NLR into clinical practice is defining the normative values of age-/ gender-/ethnic-specific NLR in a healthy population. An earlier study suggested the mean normal NLR in a healthy adult population was 1.6527. Rather than using a convenience sample for controls, healthy household family members of the FEP subjects could be recruited to optimize the matching of cases and controls as they might share closer environment such as diet. Aside, this case–control study did not measure and account for potential confounding factors such as differences in circadian rhythm in subjects across different seasons. Such uncontrolled confounder might possibly be remedied by measuring blood morning cortisol level, which is often unavailable in daily clinical settings. The inevitably stringent selection criteria has thus resulted in the small sample size, compromising the power of subgroup analyses and the generalizability of the observed results. In this regard, further studies by adding comparisons with FEP patients having affective symptoms might serve to offer valuable information not only to increase sample size, but also allowing subgroup analysis between patients with and without affective symptoms. It would also be of interest to include other possible psychiatric co-morbidities in FEP patients to assess their possible interactive or additive effects on NLR, given the transdiagnostic associations of NLR.Our study's findings have to be interpreted by considering the methodological limitations. Biased sex distribution  could be a potential bias, yet our control samples were sex- and age-matched with the FEP participants. Other published data also revealed no sex differences in NLRThe observations in the present study offered preliminary evidence in Hong Kong Chinese that NLR might be used to guide the assessment of acute exacerbation in non-affective FEP patients. Such clinical utility is especially promising when symptom reporting might be hampered by a lack of insight and often unsatisfactory therapeutic alliance in psychiatric care settings. Future studies should prospectively examine the NLR changes and clinical correlates in a broader spectrum of patients (in terms of chronicity and severity of illness) to elucidate the potential prognostic utility of NLR.Supplementary Tables.


Supplementary motor area (SMA) syndrome is characterised by transient disturbance in volitional movement and speech production which classically occurs after injury to the medial premotor area. We present two cases of SMA syndrome following isolated surgical injury to the frontal aslant tract (FAT) with the SMA intact. The first case occurred after resection of a left frontal operculum tumour. The second case occurred after a transcortical approach to a ventricular neurocytoma. The clinical picture and fMRI activation patterns during recovery were typical for SMA syndrome and support the theory that the FAT is a critical bundle in the SMA complex function.The online version contains supplementary material available at 10.1007/s00701-022-05466-6. Supplementary motor area (SMA) syndrome, first described by Laplane et al.  is typicThe SMA proper is located posteromedially in the superior frontal gyrus (SFG), immediately anterior to the primary motor area of the lower limb, is bounded inferiorly by the cingulate sulcus  but lackMeta-analysis of electrophysiology studies suggests a functional–anatomical role for the SMA/pre-SMA complex as a gateway for the executive control network , 17. TheWe present two consecutive patients who developed SMA syndrome, following surgical insults to the FAT but not SMA proper, to support this view and provide additional insight into the SMA complex.Two consecutive patients who sustained SMA syndrome following surgery at, or through, the lateral prefrontal area but not the SMA proper were identified from six cases of SMA syndrome at a single centre. Patients were identified by the senior author AG, between January 2019 and December 2021, from the records of 60 frontal tumours discussed at neuro-oncology multidisciplinary team meetings. The department provides regional neurosurgical care for 3 million people in the west of Scotland.Adults were included if functional MRI (fMRI), diffusion tractography and pre- and post-operative structural MRI were available. Three cases involving the SMA proper and one with significant pre-operative motor and language deficits were excluded.Anatomical and functional definitions can be found in the supplementary information (SI) 1.Independently ambulant and fluent patients fit to attend their first outpatient review (3-months post-operatively) were classified as recovered. Subsequent 3-monthly reviews followed in the first year unless directed by oncological concerns.A right-handed lady in her fifties, with well-controlled epilepsy, presented with new vacant episodes, altered awareness and confusion. Examination was unremarkable with no focal neurological deficits.MRI revealed extensive high fluid-attenuated inversion recovery (FLAIR) signal changes with heterogeneity in the left IFG, subcentral gyrus and anterior insula (supplementary information SI 2). Post-gadolinium T1-weighted enhancement was observed in the frontal opercular portion, together with calcification on CT and increased uptake on Thallium single-photon emission computerized tomography (SPECT). This raised suspicion of an oligodendroglioma with malignant transformation. Haemodynamic BOLD (Blood-oxygen-level-dependent) fMRI activation in the anatomically expected areas of the left hemisphere and, to a lesser extent, the right suggested language co-dominance with left hemispheric preponderance Fig. .Fig. 1PoMaximal safe resection of the enhancing portion of the tumour was performed via an awake craniotomy with intra-operative neurophysiological mapping of the language areas and motor cortex. The resection was limited by language disturbance (phonemic paraphasia and impaired articulation). This was interpreted as due to disruption of the FAT that normalized when the stimulation was stopped. Clinical and electrophysiological assessment confirmed the integrity of the corticospinal tract (CST) throughout surgery. The patient developed a right hemiparesis at the time of skin closure which progressed to right hemiplegia with associated aphasia immediately after surgery. The injury to the FAT in this case was not intended nor apparent during surgery.Integrated molecular histopathology revealed the lesion to be a Glioblastoma WHO grade IV, IDH wild type, MGMT methylated. Volitional movements were initially more severely impacted, with occasional reactive motor actions suggesting an intact CST. Language expression improved at day five, with the patient independently ambulant one-month post-operation. The post-operative MRI Fig. –d revealWritten-word-to-picture-matching (WPM) and picture naming tests improved significantly with only one semantic error after two weeks. Repeat fMRI showed bilateral motor cortex and bilateral SMA hemodynamic activation with right hand movements Fig. ; but onlA right-handed woman in her thirties presented with a two-week history of reduced visual acuity and diplopia. Examination demonstrated a left abducens palsy and papilloedema. MRI revealed a ventricular tumour attached to the septum pellucidum, fornix and thalamus causing unilateral ventriculomegaly secondary to obstruction of the left foramen of Monro (supplementary information SI 3). The patient underwent a left frontal craniotomy, with a transcortical transventricular approach to the lesion through the superior frontal sulcus. A near total resection of the tumour was achieved. The patient awoke with aphasia and right hemiparesis affecting only goal-directed actions, as seen in the SMA syndrome.Integrated molecular histopathology confirmed the lesion to be a central neurocytoma (Ki67 3%). Post-operative MRI Fig. –d confirTwo weeks later, she was ambulant with assistance and attempting to mouth words. One-month post-operatively, she was independent ambulant and spoke albeit with impaired fluency. fMRI performed at this stage showed bilateral motor cortex and SMA haemodynamic activation with right hand Fig.  and footThe patient was back to running and able to hold a telephone consultation two-months after surgery. Procedural assessment, WPM, and picture naming were intact, although a mild “staccato’’ quality remained.We report two consecutive cases of SMA syndrome after disruption to the FAT but preservation of the SMA proper. The clinical picture and fMRI activation patterns during recovery were typical for classical SMA syndrome.Parcellations of the SMA have been proposed to affect motor response thresholds through direct connection with the M1 ; the disHowever, MRI in both cases showed no injury to the SMA proper or CST. Therefore, similarities between the SMA syndrome and injury to the FAT described in the present report (affecting non-stimulus-driven/volition driven behaviour) suggest the syndrome may result from disruption of networks proximal to the SMA-CST connection.Electrophysiological and tractography studies have shown the FAT to be the main connection between critical dorsomedial parcellations, dorsolateral clusters (including area 55b), operculo-insular and inferolateral parcellations of the SMA complex across both hemispheres , 16. TheThe clinical manifestations of injury to the FAT presented here strengthen the theory that it is integral to SMA complex function , 4, 16. Preservation of the FAT bundle immediately adjacent to the SMA proper has been shown to reduce the incidence of SMA syndrome in surgical approaches to the posteromedial SFG . DespiteThe small number of cases, lack of EMG during fMRI and retrospective determination of the FAT reduces the strength of interpretations drawn from these cases.The importance of connections between the SMA and lateral pre-motor cortex in SMA syndrome remains poorly understood. We present two cases of SMA syndrome from isolated FAT injury that further our understanding of the SMA complex and provide insights to the optimal surgical corridor for frontal subcortical pathology.Supplementary file1 (DOCX 14 KB)Supplementary file2(PNG 6947 kb)High resolution image (TIFF 6802 kb)Supplementary file3(PNG 3685 kb)High resolution image (TIFF 6802 kb)Below is the link to the electronic supplementary material.


Wound management in patients with deep ulcerated wounds can be challenging, especially in the context of an outpatient setting. This is further confounded in patients undergoing chemotherapy. There is a lack of literature on the outpatient management of ulcerated breast wounds in patients having neo-adjuvant chemotherapy. This case report describes the use of a negative pressure wound treatment system leading to satisfactory wound healing and ultimately improving a patient’s quality-of-life during chemotherapy. Wound management in patients with deep ulcerated wounds can be difficult for patients undergoing neo-adjuvant chemotherapy for the treatment of breast cancer, especially in the context of an outpatient setting. This case report demonstrates the use of a negative pressure wound treatment system to address such a challenge in an outpatient setting.A 47-year-old female patient presented to the breast unit with a 1-month history of a left-sided breast lump emerging to the skin . The lefUpon examination and investigation by the breast team, the breast cancer was described as suspicious on mammogram. A further ultrasound demonstrated a 7 cm solid mass with abnormal axillary lymph nodes, which were all biopsied and shown to be benign. Histology of the tumour showed G3 invasive ductal carcinoma no-special-type, oestrogen receptor negative, progesterone receptor negative and Herceptin-2 (Her-2) receptor positive.A staging computerized tomography (CT) scan was requested, and the patient was referred for neo-adjuvant therapy. The CT showed locally advanced breast cancer with potential pectoralis involvement alongside two small indeterminate lung nodules. A multidisciplinary team discussion recommended neo-adjuvant chemotherapy along with anti-Her-2 treatment.The patient began chemotherapy and after one cycle the tumour responded very well to chemotherapy, however, the mass disappeared leaving a deep necrotic ulcer . She attThe patient underwent mastectomy and sentinel lymph node biopsy without immediate reconstruction. On final histology it was noted that the patient’s tumour had a pathological complete response with two negative lymph nodes.This case report describes an elegant and cost-effective modification to the use of negative pressure wound therapy to address a deeply ulcerated breast wound in an outpatient setting. The challenges of wound management can be further compounded by the lack of consensus or national guidelines on post-chemotherapy breast ulcers. This unique case report adds to the body of literature on NPWT in deep breast ulcers, ultimately resulting in cost-savings, effectiveness and patient satisfaction.The PICO negative pressure wound dressing systems have been advised by NICE technological guidance to treat closed surgical incisions in the NHS . NPWT anAdverse complications from breast cancer treatment such as neo-adjuvant chemotherapy is detrimental to the patient’s clinical outcome and quality-of-life . AlthougThe PICO system has previously described in the literature in plastic surgery departments for post-operative patients  with demThis case report describes the successful use of the PICO dressing system in an outpatient setting to treat a deep necrotic ulcer with a satisfactory outcome. The patient ultimately avoided numerous trips to the breast unit for daily dressing change and had a completely healed wound whilst still receiving chemotherapy. This has led to a better quality-of-life in a setting where patients can become quite unwell with other complications of treatment. In addition to this, following her surgery the patient had a pathological complete response to treatment.