Accurate early diagnosis of malignant skin lesions is critical in providing adequate and timely treatment; unfortunately, initial clinical evaluation of similar-looking benign and malignant skin lesions can result in missed diagnosis of malignant lesions and unnecessary biopsy of benign ones.To develop and validate a label-free and objective image-guided strategy for the clinical evaluation of suspicious pigmented skin lesions based on multispectral autofluorescence lifetime imaging (maFLIM) dermoscopy.We tested the hypothesis that maFLIM-derived autofluorescence global features can be used in machine-learning (ML) models to discriminate malignant from benign pigmented skin lesions. Clinical widefield maFLIM dermoscopy imaging of 41 benign and 19 malignant pigmented skin lesions from 30 patients were acquired prior to tissue biopsy sampling. Three different pools of global image-level maFLIM features were extracted: multispectral intensity, time-domain biexponential, and frequency-domain phasor features. The classification potential of each feature pool to discriminate benign versus malignant pigmented skin lesions was evaluated by training quadratic discriminant analysis (QDA) classification models and applying a leave-one-patient-out cross-validation strategy.Classification performance estimates obtained after unbiased feature selection were as follows: 68% sensitivity and 80% specificity with the phasor feature pool, 84% sensitivity, and 71% specificity with the biexponential feature pool, and 84% sensitivity and 32% specificity with the intensity feature pool. Ensemble combinations of QDA models trained with phasor and biexponential features yielded sensitivity of 84% and specificity of 90%, outperforming all other models considered.Simple classification ML models based on time-resolved  autofluorescence global features extracted from maFLIM dermoscopy images have the potential to provide objective discrimination of malignant from benign pigmented lesions. ML-assisted maFLIM dermoscopy could potentially assist with the clinical evaluation of suspicious lesions and the identification of those patients benefiting the most from biopsy examination. Classification of dermoscopy images of benign and malignant skin lesions using different deep learning approaches has also been reported. Harangi––,–,It has been widely established that autofluorescence responses of intrinsic fluorophores vary significantly between normal and neoplastic tissues.Preferential excitation of these endogenous fluorophores in the tissue by multiple excitation sources could shed light on the biochemical changes in the target lesion area.–ex vivo biopsy skin lesions under 355- and 440-nm excitations, and the average fluorescence lifetime was found to be useful in discriminating basal cell carcinoma (BCC) from normal skin tissues at the emission band between 390 and 600 nm. Galletly et al.Several animal and human tissue studies have been published on the autofluorescence properties of skin cancer lesions.In this work, we developed and validated a label-free and objective image-guided strategy for the clinical evaluation of suspicious pigmented skin lesions based on maFLIM dermoscopy. In addition, a computationally efficient frequency-domain deconvolution of maFLIM data is explored, and three different pools of global image-level maFLIM features were evaluated for machine-learning (ML)-based objective discrimination between malignant and benign pigmented skin lesions.2A summary of the complete methodology performed in this study is shown in 2.1A total of 30 patients  of both the preprocessed concatenated signal and the concatenated IRF. The FT of the signals A phasor representation for the normalized frequency response From the phasor representations of the maFLIM images at specific frequency components, N . The “di=|μ1−μ2| . The det=|Σ1−Σ2| . The “anibutions . Finallys=σp2σq2 . The difThe fluorescence frequency response 2.4For maFLIM dermoscopy-based automated classification of benign versus malignant skin lesions, a simple quadratic discriminant analysis (QDA) model was explored with the global features described in Sec. Since the LOPO-CV iterates 2.5QDA classifiers trained on the best features, 33.1The distribution of patients  was limited based on the sample size.Classification performance was dependent of the feature pool used in the model. The most frequently selected intensity feature was –The phasor representation of fluorescence lifetime imaging data analysis is a noniterative, model-free, fast approach to visualize the lifetime components (and their distributions) of the fluorescence emission of a sample.Feature selection starting with combinations of feature pools were also explored, although the resulting models showed lower classification performance overall . On the bability . These rSome of the studies summarized in Recent advances in artificial intelligence (AI) are allowing the development of CAD systems for discriminating benign from malignant skin lesions based on digital dermoscopy data. Although these CAD systems have not been translated yet to the clinic, preliminary validation studies demonstrate their potential to discriminate typical benign from malignant lesions. Dermoscopy data, however, provide information limited to the visual appearance of the lesions; thus, AI-assisted digital dermoscopy is less suitable for the discrimination of visually similar benign and malignant skin lesions. maFLIM dermoscopy data, on the other hand, can capture autofluorescence-based biochemical and metabolic biomarkers of skin malignant transformation, which is independent of lesion visual appearance. This property is especially important in distinguishing visually similar benign and malignant lesions, thus minimizing the number of false positives and, in turn, reducing the number of unnecessary biopsies. In particular, the lesion types included in this work—pSK and melanoma, are visually similar benign and malignant lesions, which can be easily misdiagnosed during dermoscopic evaluation. Therefore, maFLIM dermoscopy has the potential to complement digital dermoscopy by providing superior performance in the discrimination of visually similar benign and malignant skin lesions.4.1Although this preliminary clinical study demonstrates the potential of maFLIM-derived autofluorescence features to discriminate malignant from benign pigmented skin lesions, a number of limitations are recognized. First, the database of maFLIM images is limited in both the type of benign and malignant skin conditions, and the number of samples per condition. A more comprehensive and larger database will be needed to fully develop accurate enough classification methods for skin lesion discrimination and to rigorously quantify their performance in prospective studies. Second, the lack of histopathology-based assessment of the maFLIM imaging data at the pixel-level prevented to specifically quantify the capabilities of maFLIM dermoscopy as a tool for not only detecting malignant skin lesions but also determining their true extension and margins. Third, the current maFLIM dermoscopy system provides nonspecific excitation and spectral detection of skin autofluorescence component emission. Finally, the current implementation of the ML classification models does not allow for real-time processing of maFLIM data. Ongoing research efforts aiming to overcome these limitations include collecting maFLIM dermoscopy images from a plurality of nonpigmented and pigmented skin lesions from patients of various skin tones, performing accurate pixel-level registration between the lesion maFLIM imaging data and histopathology tissue sections, developing improved maFLIM dermoscope systems with multiwavelength excitation and narrow-band emission detection capabilities, and implementing optimized CAD using field programmable gate arrays and graphics processing units technologies for real-time maFLIM data processing, pixel-level classification, and tissue mapping visualization.4.2The incidence of skin cancer including melanoma continues to increase yet most providers is forced to rely on their own visual recognition skills and experience to identify concerning lesions. In addition, many patients do not have access to a trained dermatologist which can place them in a potentially precarious situation since early detection of skin cancer leads to better survival rates. The importance of early detection cannot be understated, as it not only saves lives but also reduces the invasiveness of the treatment patients undergo and conserves precious medical resources, leading to quality, cost-conscious care. A noninvasive, label-free, fast, accurate, and objective tool capable of discriminating most common malignant from benign skin lesions would improve the clinical management of patients. Currently, there is no objective device providers can use to independently identify cancerous skin lesions. In the hand of primary care physicians, such a tool will enable the early identification of patients in need of referral to a dermatologist. In addition, the dermatologists could use such tool to identify lesions in need of a biopsy, thus reducing the rate of unnecessary biopsies and adverse events such as pain, infection, and scarring. Such a tool would also assist with monitoring cancer recurrence without the need of regular and frequent biopsies. This work demonstrates that maFLIM dermoscopy aided by ML models could potentially have the capabilities of such tool, thus impacting the clinical management of skin cancer patients for the better.5in situ detection of malignant from benign skin lesions, with the potential to impact the clinical management of skin cancer patients.The results of this study demonstrate the capabilities of maFLIM dermoscopy to clinically image a plurality of autofluorescence biomarkers of malignant skin pigmented lesions. Moreover, some of these autofluorescence biomarkers were identified as promising for malignant lesion identification, particularly those quantifying the time-resolved fluorescence characteristics of skin lesions. In addition, these relevant autofluorescence biomarkers were successfully used as features in ML models trained to discriminate malignant from benign pigmented skin lesions with promising accuracy (Click here for additional data file.


Musculoskeletal (MSK) disorders are one of the leading causes of disability for people of all ages and impart significant socio-economic burdens on society ,2. MSK dOsteoarthritis is a disease of the entire joint. This includes synovial fibroblasts, articular cartilage chondrocytes, underlying cells within the subchondral bone, as well as invading vasculature, neurons and hematopoietic cells within the joint. Understanding how each of these cell types contribute to OA will help design therapies to mitigate disease progression. Two manuscripts within this Special Issue characterize the synoviocyte secretome and its impact on cartilage destruction. Vasoactive intestinal peptide (VIP) is a hormone that has broad effects, including immunomodulatory properties. Prior studies demonstrated that VIP can prevent joint destruction and limit inflammation within OA joints , but howCathelicidin-related antimicrobial peptide (Cramp) is an antimicrobial molecule produced by innate immune cells that functions to promote cell proliferation and migration. In work by Choi et al., the authors demonstrate that inflammatory mediators induce Cramp expression by chondrocytes and that Cramp stimulates chondrocyte catabolism, and accelerates OA progression in a murine model . RamesovAcomys cahirinus) that have a longer gestational period and fewer pups per litter to better mimic the effects of pregnancy on the body in humans [Inflammation and innate immune cells likewise promote bone loss. Bone mass in the adult skeleton is controlled through the balanced actions of bone-resorbing osteoclasts and bone-forming osteoblasts. In addition, osteocytes and hematopoietic cells within the bone marrow also influence this process. Numerous conditions, including pregnancy, lactation, advanced age and glucocorticoid use, can alter the balance of bone formation to bone resorption, resulting in net changes to bone mass. In this Special Issue, Tomaszewska et al. utilize spiny mice . Magnesium alloys simulate the mechanical properties of bone and have low toxicity, but the high degradation rate in vivo elicits an inflammatory response. Negrescu et al. show that coating a magnesium alloy with electrospun poly(ε-caprolactone) fibers, loaded with coumarin and/or zinc nanoparticles, reduced the degradation rate of magnesium alloys . FurtherTherapeutic use of glucocorticoids attenuates inflammation, but also has detrimental side effects on the musculoskeletal system. This includes loss of bone and muscle mass. Work by Webster et al. shows that global loss of the enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-Hsd1) protects against glucocorticoid-induced muscle wasting in a murine model of polyarthritis . The authors also demonstrate enhanced 11β-HSD1 activity within muscle biopsies of rheumatoid arthritis patients that correlates with inflammatory markers . In addition to these important basic research manuscripts, this Special Issue also includes pertinent literature reviews within the field of musculoskeletal development and skeletal pathophysiologies. Our hope is that this work provides some insight into the ongoing efforts to prevent and treat musculoskeletal diseases.


Idiopathic pulmonary fibrosis (IPF) is a serious disease of the lung parenchyma. It has a known polygenetic risk, with at least seventeen regions of the genome implicated to date. Growing evidence suggests linked multimorbidity of IPF with neurodegenerative or affective disorders. However, no study so far has explicitly explored links between IPF, associated genetic risk profiles, and specific brain features.We exploited imaging and genetic data from more than 32,000 participants available through the UK Biobank population-level resource to explore links between IPF genetic risk and imaging-derived brain endophenotypes. We performed a brain-wide imaging-genetics association study between the presence of 17 known IPF risk variants and 1248 multi-modal imaging-derived features, which characterise brain structure and function.17q21.31) and 8 (DEPTOR). Through co-localisation analysis, we confirmed that cortical thickness in the anterior cingulate and more widespread white matter microstructure changes share a single causal variant with IPF at the chromosome 8 locus. Post-hoc preliminary analysis suggested that forced vital capacity may partially mediate the association between the DEPTOR variant and white matter microstructure, but not between the DEPTOR risk variant and cortical thickness.We identified strong associations between cortical morphological features, white matter microstructure and IPF risk loci in chromosomes 17 (DEPTOR expression, unrelated to lung function, and more widespread microstructural white matter changes consistent with hypoxia or neuroinflammation with potential mediation by lung function.Our results reveal the associations between IPF genetic risk and differences in brain structure, for both cortex and white matter. Differences in tissue-specific imaging signatures suggest distinct underlying mechanisms with focal cortical thinning in regions with known high This study was supported by the NIHR Nottingham Biomedical Research Centre and the UK Medical Research Council. Idiopathic pulmonary fibrosis (IPF) is a condition in which the lungs become scarred (fibrosed). Although IPF primarily affects the lungs, co-occurrence with impaired brain function, such as cognitive decline, increased risk of neurodegenerative disorders, cerebrovascular accidents, depression, and anxiety have been reported. The nature of this association is unclear and no post-mortem or in-vivo investigations have been performed to explore this directly. At the genetic level, 17 regions of the genome have been found to drive the genetic risk for IPF.DEPTOR gene locus on chromosome 8, was associated with focal cingulate cortical thinning and more widespread changes in white matter microstructure. The cortical association signature was observed in regions with known DEPTOR expression. The white matter findings may be mediated by forced vital capacity (measure of impaired lung function), hinting to distinct direct (cingulate) and indirect  brain effects of DEPTOR risk alleles.Using previously identified IPF genetic variants and neuroimaging-derived features from 32,431 participants available through the UK Biobank, we performed a brain-wide association study for IPF risk variants. We identified brain endophenotypic associations with two IPF risk associated genetic variants, one in chromosome 17 and one in chromosome 8. In particular, the presence of the IPF risk variant at the The reported brain-wide IPF risk association patterns reveal two potential mechanisms that may explain the known association of IPF and brain disorders: (i) direct and focal, thought to be related to paralimbic mTOR dysregulation and (ii) indirect and widespread, in keeping with secondary effects from impaired lung function, such as hypoxia. Taken together, these data support the hypothesis that genetic risk profiles may explain some of the observed comorbidity of IPF and brain disorders.Idiopathic pulmonary fibrosis (IPF) is a serious chronic lung disease of unknown aetiology affecting around five million people worldwide.,,Although the pathogenesis of IPF is incompletely understood, there is a growing body of evidence that multiple risk factors including ageing, genetic alterations, and environmental factors, such as cigarette smoke exposure, contribute to disease risk. Genome-wide association studies (GWAS) have identified a number of loci associated with increased genetic risk in IPF.,,There has been scattered evidence in the literature for brain-lung relationships, across the spectrum of respiratory disorders.,Neuroimaging can enable unique insight into the nature of the association between IPF and brain dysfunction due to its remarkable sensitivity to subtle structural and functional brain changes. It can reveal topographical and tissue-specific brain signatures linked to genetic risks of primary brain disorders or comorbid brain health in systemic disease. Brain imaging has been successfully used to provide intermediate phenotypes (sometimes referred to as endophenotypes) to assist GWAS studies in brain disorders,In this study we used a brain-wide exploratory approach, capitalising on population-level datasets available through the UK Biobank.,a priori selection criteria. We considered participants that had: i) Neuroimaging (magnetic resonance imaging—MRI) and genetic data; Based on the UK Biobank data released in April 2020, only 41,984 subjects had brain imaging data. ii) Good-quality anatomical MRI (T1-weighted) data; We excluded 2289 subjects because of poor structural imaging data .Neuroimaging and genetic datasets from the population-level UK Biobank resource were used.,1-weighted, T2-weighted, and susceptibility-weighted imaging (SWI)) that provides anatomical and morphological information; ii) Diffusion MRI (dMRI) that reflects white matter microstructural complexity and integrity derived from two models, the diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI); and iii) Functional MRI (fMRI), which indirectly reflects neural activity and cortical connectivity during task-free (resting-state) and task-based conditions. To minimise redundancy in the original set of IDPs, we considered a reduced set of N = 1248 IDPs for each participant, representing all the above modalities and features, but minimising overlap   extracted from all available imaging modalities using a standardised processing pipeline,,As imaging-derived features can be affected by non-biological parameters, we de-confounded them following the recommendations in.,,As suggested in,,−8) with increased genetic risk in IPF .k in IPF , from a We tested the association between each of the 17 IPF variants and each of the 1248 IDPs across 32,431 individuals. For each IPF variant, separate analyses were performed using a general linear model  Body measurements. We used standing height (Data-Field 50), and weight (Data-Field 21002) as covariates. Any missing value in height and weight data was substituted by the imputation  data in the BWAS model to identify brain-wide Imaging-Genetics associations. As suggested in,The BWAS covariates were de-meaned and unit-variance normalised. In total, 25 variables were used as covariates in the BWAS models . When muFor the genetic variants that were found to be associated with brain IDPs, we performed co-localisation analysis using the COLOC methodX), a single mediator (FVC M), and a single dependent variable (brain IDPs Y). This aimed to quantify the direct and indirect relationships between IPF risks, IDPs, and FVC. The direct and indirect standardized effects were calculated using multivariate-adjusted linear regression analysis and a Sobel testTo explore whether associations between neuroimaging features (IDPs) and presence of IPF risk genetic variants, as derived from the BWAS regression model, were indirect effects from subclinical IPF risk manifestation, we undertook mediation analysis focusing on basic lung function that could plausibly affect brain health. We used forced vital capacity , a cumulative measure of lung function ,The statistical software, threshold, sample size, inclusion/exclusion criteria, and methods of each analysis are described in the sections above. All the analysis was conducted using PLINK v2.0,http://www.ukbiobank.ac.uk/ethics/), and these ethical regulations cover the work in this study. Written informed consent was obtained from all participants.No new data were collected from this study. We used publicly-available data from the UK Biobank (under Project 43822). The UK Biobank has approval from the North West Multi-centre Research Ethics Committee (MREC) to obtain and disseminate data and samples from the participants —17q21.31 in chromosome 17) were found to be significantly associated with brain IDPs. The number of associations reaching the Bonferroni-corrected threshold for statistical significance  were 19 and 174 for the chromosome 8 and chromosome 17 IPF variants, respectively  .Fig. 3ThDEPTOR IPF variant that survived Bonferroni correction, along with the sign and magnitude of the association (t-stat). Cortical thickness in the caudal anterior cingulate was negatively associated with IPF risk (lower thickness ↔ presence of IPF risk variant in chromosome 8). A number of white matter (WM) IDPs  and the NODDI intracellular volume fraction (ICVF), and radial diffusivity indices) of major fibre bundles  were also associated with the DEPTOR IPF variant. These IDPs represent WM integrity and microstructure within these bundles. ICVF and FA correlated positively with the presence of IPF risk variant  variant included indices of white matter integrity and microstructure , the NODDI ICVF, and mean diffusivity (MD)), and cortical morphological measures  volumes), with the most significant association corresponding to “cortical surface area of fusiform—right hemisphere (RH)”. No functional measures associated with this IPF variant either. Presence of IPF risk variant in chromosome 17 was associated with increased cortical thinning in certain areas , with lower diffusivities in white matter   variant, where 174 associations with brain IDPs were found . The mode matter , and higl areas) .To explore whether the association of IPF genetic risk with the brain IDPs was likely due to the same causal variant, we performed co-localisation analysis for the IDPs that were found to be significantly associated with IPF variants. Seventeen of the nineteen significant IDP associations for the chromosome 8 IPF locus showed statistical evidence through co-localisation of a likely shared causal variant with the IPF association (posterior ≥ 0.8DEPTOR (chromosome 8) IPF variant and 17 brain IDPs, representing cortical morphology and white matter microstructure. We kept these 17 IDPs for subsequent analysis, indicated by the triangles with bold outlines in Taken together, the above results provide strong evidence—through complementary analyses—of a potentially causal association between the To explore potential mechanisms underlying the identified associations, we conducted a mediation analysis. Given that IPF is a restrictive lung disease characterised by impaired lung capacity, we used forced vital capacity (FVC), which is used for IPF diagnosis and characterisation,DEPTOR IPF variant and the anterior cingulate cortical thickness was not mediated by lung function, as captured by FVC  databaseDEPTOR IPF variant, has a relatively high expression level for the DEPTOR gene. That provides evidence of biological plausibility that the observed association between IPF risk gene variant and IDP changes was detected in a cortical region where the risk gene is indeed strongly expressed.The lack of any mediation through FVC in the case of anterior caudate cortical thickness can hint to a likely direct gene effect that is limited to the anterior caudal cingulate cortex. To corroborate the likely direct nature of this effect, we computed a bulk gene expression map of the DEPTOR variant associations by lung function in keeping with an indirect effect such as systemic hypoxia or inflammation. Conversely, the anterior cingulate thinning was independent of lung function suggesting a direct effect from DEPTOR variant expression in view of the known strong DEPTOR gene expression in the anterior cingulate cortex.We undertook a large brain-wide multi-modal imaging and genetic association study in 32,000 participants of the UK Biobank to establish brain endophenotypes of IPF genetic susceptibility. Strong associations with a likely shared causal variant were found for several of the 1248 studied brain imaging-derived phenotypes (IDPs) for two of the 17 IPF risk associated variants on chromosomes 8 and 17. Co-localisation provided additional evidence that the associated neuroimaging features and IPF share a single causal variant at the chromosome 8 locus. The association pattern consists of focal cingulate cortical thinning and more widespread microstructural alterations in major white matter tracts, such as the corpus callosum and corona radiata. Furthermore, we suggest potential partial mediation of the subcortical IDP–DEPTOR in a very large blood eQTL dataset, a large lung eQTL dataset, and multiple tissues in Genotype-Tissue Expression (GTEx) (including the lung). In addition, it has been also shown that the RP11-760H22.2, TAF2, and KB-1471A8.1 co-localised with the IPF risk signal in GTEx (but not the other larger eQTL databases). Although we would never be able to completely rule out the variants acting through another gene, given the variants were located in DEPTOR, DEPTOR had the strongest evidence for gene expression in relevant tissue and had strong biological supporting evidence,DEPTOR was the most likely gene of interest and was selected as the IPF variant in this locus.Our study builds upon our previous workDEPTOR in chromosome 8 encodes for the Dishevelled, Egl-10 and Pleckstrin (DEP) domain-containing mechanistic target of rapamycin [mTOR]-interacting protein, which is a key modulator  of the mTOR pathways interacting with both of its complexes (mTORC1 and mTORC2),DEPTOR lead to decreased mTOR activity.DEPTOR, major roles have already been established in cancer, metabolism, and immunity explained by its ubiquitous tissue expression and modulation of fundamental cellular processes. In IPF, the recently identified DEPTOR IPF risk allele together with decreased gene expression in lung tissueβ1-mTORC1 axis may hold considerable promise as an anti-fibrotic strategy with the potential to impact multiple IPF pathomechanisms.DEPTOR inhibition was also found in brain tissue in Alzheimer's DiseaseDEPTOR/mTOR ratio is considered to regulate the neuroprotection/neurodegeneration balance in pro-inflammatory states via autophagy regulation. Moreover, DEPTOR central nervous system (CNS) expression in the hypothalamus, circumventricular organs, and autonomic nervous regions support increasing evidence for a further critical role in brain-body homeostatic control.DEPTOR dysregulation through the IPF risk variant is linked with cortical thinning in the anterior cingulate and microstructural changes of major white matter tracts. Moreover, our mediation analysis hints to potential direct DEPTOR and indirect lung phenotypic effects using forced vital capacity (FVC), as an established lung function marker in IPF.DEPTOR bulk gene expression in the Allen Human Brain Atlas.,DEPTOR variant will also reduce DEPTOR expression in areas of high expression, such as the anterior cingulate, resulting in the observed cortical thinning. In turn, the affection of the anterior cingulate may well explain the development of neuropsychiatric comorbidities as evidenced by a large body of neuroimaging studies.Our analysis provides exciting insights that https://open.win.ox.ac.uk/ukbiobank/big40/pheweb33k/variant/8:120934126-A-G). Taken together, hypoxia and chronic neuroinflammation are plausible mechanisms for the observed pattern of subcortical changes in diffusivity.In addition, we propose a second indirect mechanism for the associations found between the chromosome 8 IPF risk variant and more widespread changes in major white matter tracts with potential mediation through FVC. Even if the mediation results were weak, the plausibility of such mechanism cannot be ruled out. Particularly, when considering that the specific characteristics of these imaging associations point to a neuroinflammatory signature that may relate to chronic systemic pro-inflammatory state or tissue hypoxia. High ICVF and reduced diffusivity measures that were correlated with the presence of IPF variant in chromosome 8 correspond to findings in acute neuroinflammation and injuries,DEPTOR risk variant and also overlaps spatially suggesting a similar indirect pathomechanism warranting further mechanistic and mediation studies. Interestingly, the cortical chromosome 17 risk variant signature showed a distinct spatial profile and displayed a dichotomy with cortical thinning but increased cortical surface area. Such a pattern has been reported in a GWAS study, which confirmed the ontogenic dichotomy between thickness and surface area.DEPTOR risk variant). Direct comparisons between our findings and the ones reported inWe detected conspicuously strong effects of IPF genetic risk on brain structure for chromosome 17 that are noteworthy, despite the inconclusive co-localisation analysis. The subcortical endophenotypic pattern of the chromosome 17 IPF risk variant was broadly similar to the microstructural changes seen for the ,,Our results showed no association between IPF genetic risk variants and functional imaging features . This is not surprising and agrees with previous studies,DEPTOR and showed co-localisation with IPF), meaning that the effective degrees of freedom are much lower than 17 .A limitation of our study is that the potential partial mediations did not survive Bonferroni multiple comparison correction, they were only nominally significant. In the mediation analysis, we used an absolute FVC measure (in litres) and accounted for age, sex, height, and ethnicity (our study cohort is restricted to white European ethnic background). We found strong covariance structure between the 17 IDPs used  and chromosome 17 (17q21.31). Through co-localisation a shared causal gene locus was identified for the DEPTOR variant and associated brain signature, and for cingulate cortical thinning no mediation effect from lung function was found. Taken together, these data support the hypothesis that genetic risk profiles may explain some of the observed comorbidity of IPF and brain disorders with further mechanistic studies warranted to characterise additional indirect effects.In summary, we exploited imaging and genetic data from more than 32,000 participants available through the UK Biobank population-level resource to explore links between IPF genetic risk and imaging-derived brain endophenotypes. We identified strong associations between cortical thickness (in the anterior cingulate) and white matter microstructure  with IPF risk loci in chromosome 8 . Our study was performed under UK Biobank Project 43822.All data used in this study are publicly available from the UK Biobank (github.com/Alirezamnk/BWAS_IPF) at the time of publication.Analysis code will be available on GitHub (RGJ reports research funding from AstraZeneca, Biogen, Galecto, GlaxoSmithKline, RedX, Pliant, and Genetech; personal fees from Bristol Myers Squibb, Daewoong, Veracyte, Resolution Therapeutics, RedX, Pliant, Chiesi, Roche, PatientMPower, AstraZeneca, GSK, Boehringer Ingelheim, Galapagos, and Vicore; non-financial support from NuMedii and Action for Pulmonary Fibrosis, outside the submitted work. LVW reports research funding from GSK and Orion Pharma and have conducted consultancy for Galapagos. DPA reports research funding from Biogen. The other authors have no conflict of interest to disclose.


Olfactory hedonic evaluation is the primary dimension of olfactory perception and thus central to our sense of smell. It involves complex interactions between brain regions associated with sensory, affective and reward processing. Despite a recent increase in interest, several aspects of olfactory hedonic evaluation remain ambiguous: uncertainty surrounds the communication between, and interaction among, brain areas during hedonic evaluation of olfactory stimuli with different levels of pleasantness, as well as the corresponding supporting oscillatory mechanisms. In our study we investigated changes in functional interactions among brain areas in response to odor stimuli using electroencephalography (EEG). To this goal, functional connectivity networks were estimated based on phase synchronization between EEG signals using the weighted phase lag index (wPLI). Graph theoretic metrics were subsequently used to quantify the resulting changes in functional connectivity of relevant brain regions involved in olfactory hedonic evaluation. Our results indicate that odor stimuli of different hedonic values evoke significantly different interaction patterns among brain regions within the olfactory cortex, as well as in the anterior cingulate and orbitofrontal cortices. Furthermore, significant hemispheric laterality effects have been observed in the prefrontal and anterior cingulate cortices, specifically in the beta ((13–30) Hz) and gamma ((30–40) Hz) frequency bands. Hedonic evaluation is integral to our sense of smell, and, in this context, subjective pleasantness is a primary dimension in the perceptual characterization of olfactory stimuli . Even thEvidence obtained via structural and functional neuroimaging also demonstrates the centrality of hedonic processing in olfactory perception. There is considerable overlap in the functional neuroanatomy underlying olfactory, affective and reward processing . After cDespite these advances, there exist several issues that demand further inquiry. First, while it is understood that olfactory hedonic processing is implemented across multiple brain areas, it is unclear how these brain areas communicate and interact with each other during online hedonic evaluation of odors. Furthermore, olfactory hedonic processing occurs on a fast timescale, with cortical responses occurring as soon as 250 ms following stimuli, and further cognitive and behavioral responses unfolding within several hundred milliseconds . NeuroimSecond, uncertainty still surrounds the lateralization of hedonic processing in the brain. Hedonic appraisal of positive experiences has been thought to implicate the left hemisphere more so than its right counterpart ,30. HoweThird, particular relevance pertains to the application of functional connectivity analysis in the context of stimuli featuring the same valence level (the hedonic tone of an event). Previous studies ,21,34 coThe objective of this study is to analyze functional connectivity of the olfactory hedonic network during exposure to exclusively pleasant olfactory stimuli. Electroencephalography (EEG) was chosen due to its high temporal resolution. This allows unraveling of the fast timescales at which olfactory hedonic responses occur, as well as scrutinizing oscillatory mechanisms involved at different frequency bands. EEG signals were recorded while participants were presented with exclusively pleasant odors (fragrances); these were rated on pleasantness and intensity immediately after each presentation. The EEG data underwent source localization to uncover the activity of five selected brain areas—the amygdala, OFC, mPFC, ACC and the olfactory cortex—whose involvement in olfactory processing has been discussed previously. Functional connectivity and graph theoretic analyses were subsequently performed in an exploratory manner in the delta ((1–4) Hz), theta ((4–8) Hz), alpha ((8–13) Hz), beta ((13–30) Hz) and gamma ((30–40) Hz) frequency bands, as prior literature documents significant EEG modulations within these ranges during olfactory perception ,37. To oIt was hypothesized that fragrances of different levels of pleasantness (high vs. low) elicit significantly different network connectivity patterns across brain areas, which are quantified in terms of standard metrics (provided by graph theory), and across brain hemispheres. Elevated connectivity may be found in both left- and right-hemisphere brain areas, respectively, as previous literature on the topic presents non-uniform conclusions.This section outlines the experimental design, collection and processing of data, as well as the construction of pertinent functional connectivity networks. Subsequently, the mathematical and statistical frameworks underlying relevant analyses are introduced.Twenty-one female subjects aged 21 to 45 were recruited. Exclusion criteria consisted of respiratory dysfunctions, neurological disorders, disorders affecting the olfactory system, or presence of any metallic implants that could affect data quality. Approval of the experimental protocol was granted by the Institution Review Board (IRB) of the National University of Singapore (study reference code N-18-051). Subjects received monetary remuneration for participating in the study.Subjects were blindfolded to avoid the influence of any visual stimuli on brain activity and equipped with a nasal respiration sensor for the monitoring of breathing. The experiment was conducted in a temperature-controlled, isolated laboratory room to prevent noise and other confounding influences from affecting data acquisition and the presentation of odors. Four olfactory stimuli consisting of exclusively pleasant fragrances  were used, with subjective pleasantness and intensity being monitored via behavioral questionnaires. Subjects were presented one fragrance at a time over a trial period lasting 8 s. The experiment comprised a randomized sequence of ten trials for each fragrance, totaling 40 exposures. Following each trial, subjects were asked to instantly rate the pleasantness and intensity of the presented stimulus on a scale of 0 to 10. The inter-trial interval was kept at 2 min and—to avoid odor masking—coffee beans were presented to the subjects after each trial, following completion of stimulus rating . The behEEG signals were recorded using a standard 64-channel ANT-Neuro cap at a sampling rate of 512 Hz using Ag/AgCl electrodes. Conductive electrolyte gel was applied between the scalp and the electrodes; impedance was kept below 5 kΩ. The EEGLAB toolbox  was usedSubsequently, source localization was performed using standardized-Low Resolution Electromagnetic Tomography (s-LORETA) to estimate the cortical sources generating the recorded scalp level EEG signals . The s-LAfterwards, Dimitriadis’ orthogonal minimum spanning tree (OMST) algorithm  was usedTo characterize neural responses to pleasant fragrance stimuli, several graph theoretic metrics were estimated, including the weighted nodal degree (WD), betweenness centrality (BC) and clustering coefficient (CC). These can capture changes in the configuration of functional connectivity networks in response to different stimuli, both in terms of localized, as well as distributed processing .As elaborated by Fornito et al. , the nodt-tests were subsequently used to identify statistically significant differences between high- and low-pleasantness stimuli within individual regions. Results were corrected for multiple testing in accordance with the procedure introduced by Storey  Hz). Such oscillations have been previously identified to play a major role in supporting integration of various cortical areas, and across cognitive systems. The beta band has also been reported to be particularly involved in sensory perception, as well as being linked to brain mechanisms relevant to olfactory  and rewaFinally, a focal interest of the paper revolves around unearthing laterality effects with regards to regions encompassing the olfactory hedonic network. Functional lateralization, i.e., the differential activation of the brain’s hemispheres for achieving specialized functions in certain tasks, has been previously associated with neural processing in olfaction ,69, as wOur findings seem to support the latter hypothesis. We found high-pleasantness fragrances to elicit both left- and right-dominant lateralization across different frequency bands, especially with regards to the medial pre-frontal cortex (mPFC). In particular, the beta band ([13–30] Hz) contained a right-dominant response, with the weighted nodal degree and betweenness centrality of the right mPFC exhibiting larger magnitudes than their left-hemisphere counterparts. Conversely, the gamma band ([30–40] Hz) included a left-dominant activation of the mPFC when considering the weighted degree. These findings may suggest that different sub-networks operating at distinct oscillation modes drive the observed hemispheric lateralization. Our results also highlight the important hub-related activity of the mPFC—a key region in processing the hedonic value , as wellCrucially, the current study was not set out to map the direction of interactions between brain areas subserving olfactory hedonic processing. Characterizing directed functional connectivity within the olfactory hedonic network  presents the most proximate avenue for prospective future work. It is likely that many of the functional interactions considered in the study involve both feed-forward and feedback signaling acting along the reciprocal structural pathways connecting the proposed model.Furthermore, participants recruited for this study were exclusively female; this was done for two reasons: first, to avoid heterogeneity due to gender differences, and, second, due to the previously reported difference in the olfactory ability of females and males . As estaThe present study investigated how functional connectivity among brain areas involved in olfactory hedonic processing changes in response to odor stimuli featuring different levels of pleasantness. Graph metrics were used to compare key brain regions involved in the olfactory hedonic processing network and informed an investigation into laterality effects. Several significant differences regarding these regions were found, most notably including the olfactory cortex, as well as the orbitofrontal and medial pre-frontal cortices. Our results strengthen the current scientific consensus regarding the importance of the OFC and mPFC in olfactory hedonic processing, while also supporting a more recently emerging view that favors an increasingly localized understanding of hemispheric laterality.The design of our study features three key characteristics. First, by utilizing fragrance stimuli of exclusively pleasant nature, different levels of positive hedonic evaluation were compared, in order to avoid cross-valence confounding effects; this would be the case when comparing positive vs. negative stimuli. Second, functional connectivity was assessed at the cortical source level, yielding a network of relevant brain regions which allows for accurate modeling of lateralization. Third, EEG signals were used to unearth neural activity pertaining to olfactory hedonic processing. Due to its non-invasive nature, coupled with a high temporal resolution, ease of implementation and relatively low cost, EEG presents a feasible option for brain-computer interface (BCI) applications. This is especially relevant for the field of consumer neuroscience, which relies on neural signals to discern customer preferences and make more informed decisions regarding product development. Other relevant areas include clinical applications where tools for objective affective evaluation of olfactory stimuli are needed .


Little is known about cardiovascular safety profiles for monoclonal antibody products that received the FDA Emergency Use Authorization for COVID-19. In this study, data from the FDA Adverse Event Reporting System from the first quarter of 2020 to the second quarter of 2022 were used to investigate cardiovascular safety signals associated with seven monoclonal antibody products  in COVID-19 patients. Disproportionality analyses were conducted using reporting odds ratio and information component to identify safety signals. About 10% of adverse events in COVID-19 patients were cardiovascular adverse events. Four monoclonal antibody products  were associated with higher reporting of hypertension. Tocilizumab was associated with higher reporting of cardiac failure and embolic and thrombotic event. Casirivimab + imdevimab and bamlanivimab were also associated with higher reporting of ischemic heart disease. No cardiovascular safety signals were identified for sotrovimab and tixagevimab + cilgavimab. The results indicate differential cardiovascular safety profiles in monoclonal antibodies. Careful monitoring of cardiovascular events may be considered for certain COVID-19 patients at risk when they are treated with monoclonal antibodies. As coronavirus disease 2019 (COVID-19) continues to be a global public health concern, various biologics have been developed or repurposed as a prophylactic or therapeutic strategy in the past number of years , previouPharmacovigilance studies using real world data could be an appropriate approach to addressing the research question of the post-marketing safety surveillance for approved drugs. Of particular interest are cardiovascular adverse events possibly associated with the use of monoclonal antibodies for COVID-19 management. This interest is due to the following reasons. First, cardiovascular safety signals have been reported for other medications used to treat COVID-19, such as cardiac arrhythmias, torsade de points and QT prolongation associated with hydroxychloroquine/chloroquine ,9,10 andThe objective of the study is to examine cardiovascular safety signals associated with seven monoclonal antibody products for management of COVID-19 using data from the FDA Adverse Event Reporting System (FAERS). The FAERS is a post-marketing safety surveillance database for adverse events of pharmaceutical products submitted to FDA by healthcare professionals, consumers and their representatives . The infp < 0.001). Similarly, there was a higher percent of patients with life-threatening as the outcome from cardiovascular adverse events associated with use of tocilizumab . However, the percent of patients with hospitalization as the outcome from cardiovascular adverse events was lower than that from non-cardiovascular adverse events associated with use of tocilizumab . There was a higher percent of patients with hospitalization as the outcome from cardiovascular adverse events associated with use of casirivimab + imdevimab or bamlanivimab + etesevimab, compared to hospitalization from non-cardiovascular adverse events associated with the same monoclonal antibody product . The percentage of patients reporting other serious important medical events as the outcome was lower in cardiovascular adverse events compared to non-cardiovascular adverse events associated with use of casirivimab + imdevimab . Comparisons of other outcomes or comparisons from other monoclonal antibody products were not statistically significant.Outcomes from cardiovascular adverse events and non-cardiovascular adverse events associated with use of each monoclonal antibody product for COVID-19 are presented in Different cardiovascular safety signals for different monoclonal antibodies for COVID-19 were identified in the present study. For example, there is higher reporting of hypertension associated with use of casirivimab + imdevimab, bamlanivimab, bamlanivimab + etesevimab, and bebtelovimab for COVID-19. By contrast, there is a higher reporting of cardiac failure and embolic and thrombotic event associated with tocilizumab for COVID-19. Casirivimab + imdevimab and bamlanivimab for COVID-19 were also associated with higher reporting of ischemic heart disease as an adverse event. No safety signals were identified for sotrovimab and tixagevimab + cilgavimab. The results reveal differential safety profiles among various monoclonal antibodies and highlight the need for awareness of risk of certain cardiac events when treating COVID-19 patients with monoclonal antibodies.The frequently found higher reporting of hypertension associated with several monoclonal antibodies requires further attention. While there have, to our knowledge, been no previous pharmacovigilance studies of monoclonal antibodies in COVID-19 patients from the published literature available for comparison with data from the present study, a randomized clinical trial evaluating the prophylactic effect of bamlanivimab on the incidence of COVID-19 reported hypertension to be the second-most common adverse event observed; nevertheless, there was no statistical difference when comparing the percentage of patients reporting hypertension as an adverse event following bamlanivimab administration with that in the placebo group . SimilarWhile hypertension is one of the most commonly reported cardiovascular adverse events, different monoclonal antibodies for COVID-19 may also have a different cardiovascular safety profile as observed in the present study. Indeed, network meta-analysis of published clinical trials revealed a similar finding on the incidence of serious adverse events from different monoclonal antibodies for COVID-19, with sotrovimab ranking at the top in terms of the reduction in odds of serious adverse events . In thisTocilizumab was associated with increased reporting of cardiac failure and embolic and thrombotic event in the present study. Recent clinical trials also reported cardiac arrhythmias  or embolThe present study also compared outcomes of reported cardiovascular adverse events versus non-cardiovascular adverse events for each monoclonal antibody product. It was found that most of the outcomes were not significantly different between cardiovascular adverse events and non-cardiovascular adverse events. However, percentage of death and life-threatening outcomes for cardiovascular adverse events was higher than that for non-cardiovascular adverse events, for tocilizumab but not for other monoclonal antibody products. This may be because tocilizumab was authorized for hospitalized patients with severe COVID-19 condition, which are inherently associated with a higher risk for death or life-threatening outcomes, whereas other products were authorized for pre-exposure prophylaxis or treatment of mild to moderate COVID-19 conditions .There are several limitations in the present study. First, the FAERS database consists of reported information from various sources; there can be a reporting bias as well as incomplete information in the report. Similar to other spontaneous reporting systems for adverse events for drugs, underreporting usually occurs due to reasons such as lack of awareness of reporting, uncertainty about causal effect, or simply because people may believe single case reported may not contribute to knowledge . Second,FAERS data were used in the study. Description of the data in the FAERS is available elsewhere . BrieflyThe present study identified patients with COVID-19 using information from the “Indication” dataset and selected the following narrow standardized MedDRA query (SMQ) terms: COVID-19, COVID-19 pneumonia, Coronavirus infection, COVID-19 treatment, SARS-CoV-2 test positive, Suspected COVID-19, Corona virus infection, and Coronavirus test positive. Cases with these COVID-19-related preferred terms as indication were selected and records for these cases were extracted. Duplicated records were removed by keeping only the most recent version of the report from the same patient in the analysis. The present study was exempt from IRB review as publicly available, de-identified data were used.As of June 2022, monoclonal antibodies under FDA Emergency Use Authorization (EUA) include casirivimab + imdevimab, bamlanivimab + etesevimab, sotrovimab, tocilizumab, bebtelovimab, tixagevimab + cilgavimab . BamlaniCardiovascular adverse events from the “Reaction” dataset were identified using preferred terms falling into the following SMQ categories using the narrow scope of MedDRA (version 25.0): cardiac arrhythmias, cardiac failure, cardiomyopathy, embolic and thrombotic events, hypertension, ischemic heart disease, pulmonary hypertension, and Torsade de pointes/QT prolongation. This is similar to a previous study that comprehensively examined cardiovascular adverse events related to another medication using the FAERS dataset . The lisDemographic information such as age, gender, and body weight; reporting source information; and outcome information  were extracted from relevant datasets for identified cases. When multiple outcomes were reported for a case in the dataset, only the most severe outcome was counted in the analysis . For exaCardiovascular safety signals were identified by disproportionality analyses using reporting odds ratio (ROR) and information component (IC). Both ROR and IC are valid methods for safety signal detection in pharmacovigilance studies ,40 and hn (%) for categorical variables. Results from disproportionality analysis were presented as forest plots to facilitate visualization of safety signals. Outcomes from cardiovascular adverse events and non-cardiovascular adverse events associated with each monoclonal antibody product were compared by Chi-square test or Fishers exact test as appropriate; Bonferroni-corrected p < 0.05/49 = 0.001 was considered to be statistically significant.Data from relevant records in the FAERS dataset were imported into SQLite Studio  for processing. Statistical analysis was performed using Python . Descriptive analysis was conducted to examine demographic characteristics and reporting source information. Data were presented as mean ± standard deviation for continuous variables or In conclusion, differential cardiovascular safety profiles for monoclonal antibodies for COVID-19 were observed with pharmacovigilance analysis of FAERS data. Future clinical trials may consider adding cardiovascular safety as a secondary outcome. In clinical practice, careful monitoring of cardiovascular events, particularly blood pressure monitoring, may be considered for COVID-19 patients at risk when they are treated with monoclonal antibody administration.


Salmonella (NTS) is a common cause of gastroenteritis in humans and animals, but intra-abdominal abscesses or organ space surgical site infection (SSI) secondary to this organism has been rarely reported, making diagnosis and management difficult. Our case of intra-mesenteric abscess caused by NTS species is the only case reported in the literature. Immunocompromising conditions such as diabetes and human immunodeficiency virus (HIV) are important risk factors for invasive nontyphoidal Salmonella. Most patients are treated initially with intravenous antibiotics. Treatment often requires operative drainage by laparoscopy or laparotomy alone, although percutaneous drainage has been performed more frequently in recent years. Early clinical signs and radiographic features of intra-abdominal abscess may be diagnostically challenging. It is important for clinicians to have high index of suspicion based on history and symptomatology as prompt treatment is essential to prevent further morbidity and mortality.Nontyphoidal  Salmonella (NTS) causes approximately 153 million cases of gastroenteritis and 57,000 deaths globally each year Nontyphoidal Salmonella Thompson in a diabetic patient.NTS primarily causes self-limited gastroenteritis symptoms of diarrhea, abdominal pain, fever, and vomiting Salmonella Thompson is a salmonella serotype that has been implicated in numerous food-borne disease outbreaks throughout the world S. Thompson to be the seventh most common serotype found in imported seafood S. Thompson infection rarely develop complications, typically reporting diarrhea, abdominal pain, fever, and vomiting A 53-year-old male with a past medical history of diabetes mellitus presented as an interfacility transfer for suspected ruptured superior mesenteric artery (SMA). The patient reported a 2-week history of constipation and diffuse, constant abdominal pain, failing to resolve with laxative use. At the outside hospital a computed tomography (CT) abdomen/pelvis with intravenous (IV) contrast was performed and was remarkable for a five-to-six-centimeter contrast containing fluid collection with surrounding inflammation in the right mid abdomen concerning for ruptured SMA aneurysm .Fig. 1In9/L) and lactic acid 0.8 (mEq/L).On arrival to our institution, he was afebrile, normotensive and heart rate 80 beats per minute, normal respiratory rate and oxygen saturation. On exam, his abdomen was soft with moderate diffuse tenderness to palpation and bilaterally palpable femoral pulses. Labs were notable for hemoglobin 12.3 (g/DL), white blood cell count 13.0 (10The patient was taken to the operating room (OR) for emergent aortoiliac and SMA angiogram. SMA angiogram demonstrated normal branching of the proximal and distal SMA, and angiogram of the ileocolic and its branches did not reveal any active extravasation. No SMA aneurysm was noted. An immediate diagnostic laparoscopy did not reveal any peritoneal findings. The patient was subsequently admitted to the medical/surgical unit where he was initiated on IV ceftriaxone and metronidazole for presumed sepsis secondary to a right lower quadrant (RLQ) abscess. Blood cultures were obtained prior to antibiotic initiation and did not show evidence of bacteremia. A colonoscopy was performed which did not yield any colonic pathology.On hospital day nine, repeat CT abdomen/pelvis was performed due to the patient’s inability to tolerate PO intake and demonstrated a progressive 8.4 cm complex collection with surrounding mesenteric edema in the RLQ contiguous with the cecum, ascending colon, and terminal ileum and suggestive of an abscess or arteriovenous malformation . Repeat Salmonella thompson, and the patient was transitioned to oral levofloxacin for a four-week course per recommendations by our infectious disease consultant. The patient completed his antibiotic course at home. He was evaluated in the clinic four weeks postoperatively with complete resolution of his pain and has regained his bowel function.Given the patient’s persistent abdominal pain and intolerance to diet, the patient was taken to the OR for exploratory laparotomy on hospital day ten. A large intra-mesenteric abscess abutting the cecum and right colon was drained and a drain was placed. The patient was continued on IV antibiotics and discharged on post-operative day eight. Operative cultures were positive for We describe the first reported case of intra-mesenteric abscess caused by NTS. Although primarily confined to the GI tract, NTS may cause extra-intestinal infection via systemic spread or local invasion. NTS may spread systemically by invading the bloodstream causing bacteremia or propagating into the lymphatic system, contributing to remote abscess formation of the pathogen in various organs S. enteritidis-contaminated meal were more likely to be medication-dependent diabetics Immunocompromising conditions such as diabetes and HIV are important risk factors for invasive NTS infection. In one case-control study, patients who developed an infection after exposure to an Salmonella bacteremia. There was also no history of open trauma or anatomic abnormalities seen in surgery that may have contributed to abscess formation.The exact etiology in our case of intra-mesenteric abscess is unknown. We speculate our patient likely had a primary GI infection given his two-week history of diffuse abdominal pain. The pathogen likely invaded and proliferated within the mesenteric lymph nodes, forming an abscess. Blood cultures acquired prior to antibiotic administration show no growth, providing lower suspicion for Salmonella infection, the mean duration of symptoms before diagnosis was 13 days Intraabdominal abscesses can be difficult to diagnose based on clinical presentation alone. In a study of 50 patients with intraabdominal The Surgeon Infection Society and the Infectious Diseases Society of America have released evidence-based guidelines for the treatment of intraabdominal infection The primary management of intraabdominal infections involves source control procedures to remove infected fluid and tissue and/or antimicrobial treatment to target sites of infection and prevent spread or recurrence Selection of source control procedure should be predicated on careful assessment of the patient’s physiologic function and optimization of infection management NTS intraabdominal infections can be effectively treated with ampicillin, amoxicillin, trimethoprim-sulfamethoxazole, and chloramphenicol after appropriate source control Salmonella intraabdominal infections is favorable, with one study reporting 90 % survival in a study of 50 patients Prognosis for NTS infection is commonly associated with gastroenteritis, but in 8 % of cases, it may present as extra-intestinal infection The authors report no conflict of interest or funding sources.


Airway webs are abnormal fibrous membranes in the airway lumen that rarely occur but can lead to serious or even life-threatening symptoms because of critical airway obstruction. Airway webs can be acquired or congenital. Acquired webs are likely to be secondary to trauma, infections, or neoplasm. Congenital laryngeal, subglottic and tracheal webs present early in infancy or childhood and are more common than congenital bronchial webs. To our knowledge, there are a few reports on the bronchial web in the literature, and the true incidence of these lesions is unknown as many probably go undetected across the lifespan.We here report a case of a congenital bronchial web and provide a review of the literature of all reported bronchial webs. Our patient is a teenage boy who was diagnosed with a congenital bronchial web obstructing the right main-stem bronchus (RMB) and causing right lung hypoplasia and persistent right middle and right lower lobe collapse. The web was treated successfully using endoscopic ablation by argon plasma coagulation and balloon dilatation. Treatment resulted in remarkable relief of right main stem obstruction and significant improvement in right lung collapse as well as clinical, spirometric, and radiological findings.Due to the rarity of bronchial web, the clinical knowledge and the bronchoscopic interventional strategies demonstrated of this report make it relevant. Furthermore, it emphasizes that early diagnosis and management lead to favorable clinical outcomes. APCArgon plasma coagulationBPDBronchopulmonary DysplasiaBWBronchial webFBFlexible BronchoscopyRLLRight lower lobeRMBRight main-stem bronchusRMLRight middle lobeRPARight pulmonary artery1The patient is a 13-year-old boy who was referred to our pediatric pulmonology clinic for an occasional “whistling cough” exacerbated by exercise and viral respiratory infections, which was not responsive to bronchodilators or inhaled steroids.His past medical history was significant for being born prematurely at 29 weeks gestational age and requiring prolonged stay (three months) in the neonatal intensive care unit (NICU) due to respiratory distress syndrome. Early chest X-rays (CXRs) reported changes consistent with bronchopulmonary dysplasia (BPD) and bilateral pulmonary interstitial emphysema (PIE). At 19 days of life, the patient developed complete right lung collapse, which was not responsive to suctioning and chest physiotherapy. Bronchoscopy was performed three times (one flexible and two rigid) during his extended NICU stay. The initial rigid bronchoscopy findings revealed a small membrane in the right main stem bronchus but was not mentioned on the two subsequent flexible bronchoscopy reports. All three bronchoscopies reported excessive airway sections.The patient was discharged home from NICU on room air but with persistent right middle lobe (RML) and right lower lobe (RLL) collapse on chest X-ray. During the first five years of life, the patient had recurrent chest infections requiring short hospitalizations and antibiotics administration. Subsequently, the frequency of chest infections decreased with time until he was referred to us at the age of 13 years because of the whistling cough.By our evaluation, patient appeared healthy except for mild scoliosis. Vital signs were normal. Oxygen saturation was 96% on room air. Chest examination was remarkable for decreased air entry, dullness, and monophonic wheezing over the right hemithorax. Cardiovascular examination was significant for right-displacement of heart sounds with no murmurs.Chest X-ray showed an overall small right lung with persistent RML and RLL atelectasis and mediastinal shift to the right -A. ChestDiagnostic flexible bronchoscopy was then performed, which revealed a thin fibrovascular membrane occluding the lumen of the right main bronchus except for a tiny opening (about 2 mm) at its periphery -A. SecreTreatment of the bronchial web with ablation using argon plasma coagulation (APC) and balloon dilatation was discussed at a multidisciplinary meeting. The goal of the procedure was to relieve airway obstruction, mobilize secretions, and improve exercise endurance, if possible, even though expansion of the chronically collapsed lung was in doubt.The patient underwent the APC procedure followed by balloon dilatation under general anesthesia and mechanical ventilation using a flexible bronchoscope via an endotracheal tube (ETT). APC was applied in short pulses with an application time of 1–2 seconds each, during which oxygen was discontinued to avoid airway fire. The interval between pulses was around 2–3 seconds. Pulses were applied first around the opening then moving towards the periphery. APC settings used were: power of 20 W and gas flow rate of 0.5 L/min. After APC ablation of most of the web was achieved, repeated balloon dilatation was performed using 6 mm balloons that were inflated for 30 seconds twice.APC ablation and dilatation resulted in near-complete resolution of the obstruction with a remnant edge -B. AfterThe patient tolerated the procedure with no blood loss and he was discharged home on the same day on room air. A month after the procedure, the patient reported easier breathing, better appetite, and exercise tolerance during a follow-up clinic visit. The previously reported whistling cough has completely disappeared.Post-procedure spirometry revealed significant improvement in forced expiratory volume in 1 second (FEV1%) by 540 ml and forced vital capacity (FVC) by 520 ml compared to pre-procedure spirometry . AdditioThe patient continues to follow in our pulmonology clinic closely to observe for signs of reformation of the web or recurrence of lung collapse (re-emergence of symptoms or decline in FEV1%), which might require re-evaluation with flexible bronchoscopy.A Bronchial web is a congenital or acquired airway abnormality that can cause significant airway obstruction. Most acquired cases of bronchial webs are secondary to trauma, infections, or post-lung transplant. Congenital bronchial webs, on the other hand, are extremely rare. Bronchial webs can result in atelectasis or hyperinflation due to complete or partial airway obstruction. Bronchial webs are not easily differentiated from other cases of bronchial obstruction  based on clinical and radiological presentation alone. Flexible bronchoscopy is the diagnostic procedure of choice for all causes of bronchial obstruction and, therefore, is indicated in all cases of unexplained persistent unilateral atelectasis or hyperinflation.If a diagnosis of the bronchial web is missed or left untreated, it can lead to bronchiectasis and/or permanent lung damage, hypoxemia, hypoventilation, and/or exercise limitation . FortunaDefinitive treatment of bronchial webs can be achieved by surgical removal of the web using various techniques, which include open and endoscopic procedures. Removal of the web using flexible bronchoscopy is the safest approach. Different endoscopic methods have been reported, including Wang needle, Laser, APC, balloon dilatation, or various combinations of these techniques . In our In conclusion, our case represents a rare cause of airway obstruction. Our case highlights the clinical knowledge and the bronchoscopic intervention that are rarely encountered in pediatric age group. Moreover, it demonstrates how early recognition and intervention diagnosis lead to favorable clinical outcomes.None.Non-funded article.


Hereditary neuropathy with liability to pressure palsy (HNPP) makes nerves increasingly susceptible to mechanical pressure at entrapment sites. Neuralgic amyotrophy (NA) can cause sudden regional weakness following events to which the patient is immunologically predisposed, such as vaccination. However, NA related to human papilloma virus (HPV) vaccination is seldom reported. We describe the case of a child with NA as the cause of a dropped shoulder following the administration of the HPV vaccine. Underlying asymptomatic HNPP was confirmed in this patient based on the electrodiagnostic findings and genetic analysis. We speculate that HPV vaccination elicited an immune-mediated inflammatory response, resulting in NA. Our patient with pre-existing HNPP might be vulnerable to the occurrence of an immune-mediated NA, which caused the dropped shoulder. Hereditary neuropathy with liability to pressure palsy (HNPP) is a rare autosomal dominant peripheral nerve disorder . ClinicaNeuralgic amyotrophy (NA) is a markedly underdiagnosed or misdiagnosed peripheral nerve disease due to the heterogeneity of clinical appearance . It reprThis study was approved by our institutional review board (IRB number: 2021-01-079). Written informed consent was obtained from the patient’s legal guardian. This report describes the case of a female child who presented with a dropped shoulder due to NA following administration of the human papillomavirus (HPV) vaccine. We found that she also had underlying HNPP during the diagnostic process. There are currently no published cases of NA with concomitant HNPP occurring after HPV vaccination. HPV vaccination is suspected to elicit an immune-mediated inflammatory response, resulting in NA. Patients with pre-existing HNPP, although asymptomatic, might have potential vulnerability to the occurrence of an immune-mediated NA, thus causing symptoms, such as dropped shoulder.A 12-year-old female child received her first dose of Cervarix  vaccination for HPV prophylaxis in the left deltoid muscle. Five days after vaccination, the child complained of a sudden onset of painless dropped shoulder on the left side. She denied any history of trauma, notable physical exercise, or previous medical illness. No adverse events had occurred following the suggested pediatric immunization program and she had not been vaccinated for coronavirus disease 2019 (COVID-19). The patient’s parents denied any family history of notable genetic diseases. On initial physical examination, there was Medical Research Council (MRC) grade 2 weakness of the shoulder abductor and flexor muscles and grade 3 weakness of the internal and external rotator muscles without atrophy. The sensation of the left upper lateral limb was altered on light touch. Deep tendon reflexes were normal, and no upper motor neuron lesion signs were observed.Laboratory findings—including C-reactive protein, erythrocyte sedimentation rate, creatine kinase, antinuclear antibody, rheumatoid factor, and anti-GM1 ganglioside antibodies—were negative. We have also excluded infectious neuritis, including human immunodeficiency virus infection and Lyme disease. Magnetic resonance imaging (MRI) of the brain, cervical spine, and brachial plexus performed one week after symptom onset revealed no abnormal findings. Nerve conduction studies revealed the absence of the left lateral antebrachial cutaneous sensory nerve action potential (SNAP) and decreased amplitude in left axillary compound motor action potential (CMAP). It also showed generalized demyelinating polyneuropathy, including the following signs: slowing of the bilateral median, bilateral ulnar, bilateral common peroneal, and bilateral tibial nerve conduction velocity; prolonged distal latency of bilateral median SNAP; and borderline distal latency of bilateral median, bilateral ulnar, and bilateral common peroneal CMAP close to the upper limit of normal . Needle PMP22 gene . Coffalyser.Net (MRC-Holland) was used for fragment analysis. The height ratio of the polymerase chain reaction (PCR)-derived fluorescence peaks was measured to quantify the amount of PCR products after normalization, and CNVs were identified when the ratio was <0.65 or >1.3. The MLPA revealed a contiguous heterozygous gene deletion of chromosome 17p11.2 that includes COX10, PMP22, and TEKT3, which confirmed the diagnosis of HNPP  was performed by probe mixes P033-B4 to detect copy number variations (CNVs) in the  of HNPP .The patient received oral prednisolone for 10 days  and underwent two courses of this treatment. Five months after the onset of symptoms, the patient recovered completely.PMP 22 gene that results in sausage-like focal thickening of the myelin sheath [HNPP is a hereditary neuropathy caused by deletion of the n sheath . It is mNA typically represents a preceding episode of severe pain before the sudden onset of paralysis . HoweverHPV infection—caused by HPV types 16, 18, 31, and 45—is the major cause of cervical cancer . FurtherThe common adverse effects of an HPV vaccine are injection site discomfort—such as pain, swelling, and redness—due to an inflammatory response to virus-like particles ,9. It caPMP 22 deletion, which is the key feature of HNPP. The child did not meet the other criteria for HNPP diagnosis, which are as follows: autosomal dominant family history, age at symptom onset around the second decade, and rapid onset sensorimotor deficit preceded by a minor injury [Our patient only had a clinical presentation of NA after HPV vaccination; however, the electrodiagnostic findings led us to suspect underlying diffuse polyneuropathy. Inflammatory demyelinating polyneuropathy was excluded because of the negative results of cerebrospinal fluid analysis and brachial plexus MRI. Genetic testing demonstrated r injury . HoweverIn our patient, NA was potentially triggered by an immune-mediated inflammatory response due to HPV vaccination . RemicheTo the best of our knowledge, this is the first case reporting the comorbidity of NA after HPV vaccination and underlying HNPP. HPV vaccination may potentially cause NA in patients with pre-existing HNPP due to an immune reaction. The asymptomatic HNPP might be vulnerable to the occurrence of an NA as the cause of a dropped shoulder. Our case report demonstrates a possible association between the NA and HNPP. The observation of potential factors that might suggest HNPP in patients with NA by comparing the differences between the reported cases will be of great importance and worth examining in future studies. This study highlights the importance of assessing clinical, electrodiagnostic, and genetic findings to make an accurate diagnosis of NA after HPV vaccination in a patient with pre-existing HNPP. Clinicians should consider hereditary neuropathy as a possible predisposing disease for the development of immune-mediated neuropathy. There may be genetic and immunological associations between HNPP and NA, which require further investigation.


Defending against future pandemics may require vaccine platforms that protect across a range of related pathogens. The presentation of multiple receptor-binding domains (RBDs) from evolutionarily-related viruses on a nanoparticle scaffold elicits a strong antibody response to conserved regions. Here we produce quartets of tandemly-linked RBDs from SARS-like betacoronaviruses coupled to the mi3 nanocage through a SpyTag/SpyCatcher spontaneous reaction. These Quartet Nanocages induce a high level of neutralizing antibodies against several different coronaviruses, including against viruses not represented on the vaccine. In animals primed with SARS-CoV-2 Spike, boost immunizations with Quartet Nanocages increased the strength and breadth of an otherwise narrow immune response. Quartet Nanocages are a strategy with potential to confer heterotypic protection against emergent zoonotic coronavirus pathogens and facilitate proactive pandemic protection. A vaccine candidate with polyprotein antigens displayed on nanocages induces neutralizing antibodies to multiple SARS-like coronaviruses. SARS-CoV-2 (SARS2) has caused at least 6 million deaths and new variants continue to emerge . DespiteAntigen resurfacing and masking of non-protective regions with glycosylation have been attempted to focus antibody responses on regions of low variability and produce more broadly effective vaccines. However, these strategies can lead to overly specific immune responses susceptible to pathogen escape and have not reliably increased neutralization efficacy , 8. BothIn a recently introduced approach, VLPs display a panel of protein variants to favor expansion of B cells recognizing common features of the different antigens. For example, a mosaic of different hemagglutinin heads on ferritin nanoparticles elicited cross-reactive antibodies against diverse influenza strains within the H1 subtype . This apHere we establish the production of a multiviral Quartet Nanocage . InitialRhinolophus affinis) and shares 90% sequence identity for its RBD with SARS2  , 32, an Priming with SARS2 Spike raised the expected narrow strain-specific response against SARS2 RBD  and neglOverall, we have established that RBDs from multiple sarbecoviruses can be efficiently expressed as a tandem construct for assembly onto nanocages, creating a dendritic nanoparticle that elicits neutralizing antibodies against SARS2 variants and diverse other sarbecoviruses. Quartet Nanocage enhanced immune response to antigens present on the nanocage, as well as inducing a high level of antibodies to sarbecovirus antigens absent from the particles. Sequential antigen repeats have mostly been explored for strings of T cell epitopes, where there is no folding to a 3D structure or induction of conformation-sensitive antibodies . RepeatsWe were surprised to discover no substantial difference in antibody response to antigens at the start or end of the Quartet. Crystallography or cryoelectron microscopy structures do not allow clear visualization of nanostructures with multiple flexible regions such as the Quartet Nanocage . Even SpFor many diseases, notably malaria and influenza, vaccines face the challenge of inducing novel protective immunity in people with pre-existing immune responses , 49. AftLimitations of this study are that we immunized only in mice and that expression of tandem antigens was aided by a robust, monomeric antigen; additional optimization would be required for constructing tandem oligomers of obligate trimeric antigens . There aWe detected antibody induction against the nanocage, but data on VLPs decorated using SpyCatcher or genetic fusion indicate that anti-platform antibodies do not impair responses against the target antigen , 52. VLPSARS-CoV-2 had a devastating medical and societal impact, despite the rapid generation of effective vaccines. Therefore, it is important that vaccinology possesses further improved tools before the next major viral outbreak , 56. TheSupplement 1


Circular RNAs (circRNAs) as novel regulatory molecules have been recognized in diverse species, including viruses. The virus-derived circRNAs play various roles in the host biological process and the life cycle of the viruses. This review summarized the circRNAs from the DNA and RNA viruses and discussed the biogenesis of viral and host circRNAs, the potential roles of viral circRNAs, and their future perspective. This review will elaborate on new insights gained on viruses encoded circRNAs during virus infection. Viruses are a major class of intracellular parasites that use the transcription and translation machinery of the host to produce nucleic acids and proteins for their life cycle and reproduction. Virally infected hosts suffer immunosuppression, development disorder, and loss of energy and nutrients, causing diseases. Another subset of viruses can mutually benefit the hosts that will not cause disease . These vCircular RNA (circRNA) is a recently discovered functional non-coding RNA molecule, covalently closed circular single-stranded RNA molecules without a 5’-terminal cap structure and a 3’-terminal polyadenylate , 9. circThis review will concentrate on circRNAs in viruses, focusing on classes and features of virally circRNAs, the potential functions of virally circRNAs, and possible biogenesis mechanisms, providing clues to explore better the roles in the interplay between viruses and hosts.DNA viruses with a relatively larger and more stable DNA genome mainly include three categories according to the types of their genome: double-stranded DNA viruses, single-stranded DNA viruses, and pararetroviruses . Genomesvia the pre-mRNA back-splicing of E6E7 , which widespread induces T-cell lymphomagenesis in the domestic chicken. A large variety of MDV circRNAs was identified through RNA-sequencing, and the hot spots of circRNAs expression occurred on the major viral oncogenes in herpesviruses. Moreover, many noncanonical junction sites were observed in viral circRNAs compatible with the U2-dependent splicing machinery .LMP-2 gene could be universally detected in EBV-positive cell lines. The expression pattern of circLMP-2_e5 was consistent with its linear parental transcript following EBV lytic reactivation. circLMP-2_e5 may be generated by exon skipping because none of the cis-elements were found in the short flanking introns , nasopharyngeal carcinoma (NPC), and several lymphomas. CircBART2.2 derived from EBV could increase the expression level of PDL-1 in NPC and dysregulate the function of T-cells, leading to the tumor immune escape by multiple biological processes . EBV cir introns . EBV cir introns . EBV-der introns . EBV cirMS1 gene . CircRPMMS1 gene .Kaposi’s sarcoma-associated herpesvirus (KSHV) is an oncogenic γ2 herpesvirus, also called human herpesvirus-8 (HHV-8) . It is cTrichodysplasia spinulosa polyomavirus (TSPyV) also encoded a circALTO, which existed in the virally infected tissues and cell lines  were encoded by Merkel Cell Polyomavirus (MCPyV), and they could also be detected in the virus-positive cells and patients’ tissues. In addition, the related ll lines . MCPyV ell lines . Viral cRNA viruses are normally recognized as very simple entities with small genomes, and the size of the length is from less than 2 to 32 kb. A relatively small genome of these RNA viruses has been confirmed with limited coding capacity. They are obligate intracellular parasites like DNA viruses. Host cells provide the energy, ribosome, deoxyribonucleotides, transcription and translation machinery, and other components that play important roles in assembling and releasing progeny virus . The genBombyx mori cytoplasmic polyhedrosis virus (BmCPV) is one of the most serious pathogens in the sericulture and bright huge economic loss to the farmers. This virus with 10 segmented dsRNA genome can specifically infect the midgut of the silkworm. Until now, the interaction between BmCPV and silkworm are poorly understood. circRNAs was considered a novel type of regulators that can regulate multiple biological processes of viruses or host. BmCPV derived circRNA-vSP27 have translation activity, and its translation production vSP27 small peptide suppressed viral replication via ROS-NF-κB signaling pathway, and was recruited with nuclear factor Akirin for activating NF-κB signaling pathway  have brought huge threating to our life and cause enormous morbidity and mortality to humans . MERS-CoBased on the biogenesis of circRNAs in a eukaryote, the formation of circRNAs is classified into six categories: exonic circRNAs (EcircRNAs), circular intronic cirRNAs (CiRNAs), exon-intron circRNAs (EIcircRNAs), fusion circRNAs (f-circRNAs), read-through circRNAs (rt-circRNAs) and noncanonical circRNAs like tricRNAs Figure 2Several RNA viruses have been confirmed with the RNA circularization in the virally infected cells. Most RNA viruses derived circRNAs were produced with the noncanonical mechanism. The circularization events of viral RNAs found in the BmCPV and GCRV showed that the splicing signals flanking the junction sites of vcricRNAs differed from the reported circRNAs formation in animals and some DNA viruses , 52, 53.Increasing potential roles of circRNAs of hosts were reported, and several data showed that virally circRNAs with similar structures might have similar regulatory roles in various biological processes. The mainly reported roles of circRNAs acted as microRNAs –71/RNA bInnate immunity acts as the first line of hosts to defend against pathogen invasion. During interactions and coevolution between the viruses and their hosts, the host’s immune system evolved various antiviral mechanisms, such as RNA interference, interferon, NF-κB-mediated, immune deficiency, stimulator interferon gene pathways, and Janus kinase/signal transducer and activator of transcription pathway. The generation of these antiviral signaling pathways restricts the process and speed of virus infection and the degree of disease in susceptible hosts. Meanwhile, various immune evasion strategies are evolved by viruses –84. Recein vitro and in vivo. Several formation mechanisms for circRNAs in other species, including inverted repeat sequences, exon skipping, RNA-binding proteins, repetitive complementary sequences, or m6A modification in pre-mRNA, may be associated with the production of viral circRNAs from DNA viruses  suppressed aberrant exon inclusion and circularization of transcripts in cells. HNRNPM preferentially interacted with GU-rich elements in the long flanking proximal introns in the mis-spliced linear and circular transcripts . HeterogP35 gene . Long flP35 gene . HeterogP35 gene .in vitro and in vivo via binding in the proximity of intronic Alus in the pre-mRNA of Spinal Muscular Atrophy gene  related to splicing event globally promoted circRNA circularization using the NOVA2 binding sites in both flanking introns of circRNA loci , 93. Canphy gene . Long anphy gene . Nudix Hphy gene . Trans-aphy gene .via binding upstream and downstream of exons (via binding to the flanked intron region of the cognate linear transcript of circ0006916 (Drosophila DExH/D-box helicase Hel25E and human homologs of Hel25E were related to the nuclear accumulation of long circRNAs. UAP56 (DDX39B) and URH49 (DDX39A) controlled the nuclear export of long and short circRNAs . RNA cirof exons . Severalof exons , 94, 102c0006916 . The RNAc0006916 .The back-splicing occurred at m6A-enriched sites in male germ cells, and these circRNAs encompassed the m6A-modified start codons in their junction sites in large ORFs . IncreasThe production of circRNA may be due to the fine regulation of the host cell to the genetic information of the virus so that its smaller genome carries more genetic information and regulates the immune system of the host cell or the life cycle of the virus to achieve mutual “reciprocity”. In the virally infected cells, viral circRNAs may be generated by the host cell machinery for its advantage or recruitment to suppress viral replication. Various viral circRNAs produced in the virus’s infected cells may have two-direction regulatory functions mediating the host or virus itself Figure 5Viruses invade host cells and release genetic material inside the cells. These genetic materials enter the nucleus for replication and proliferation. As the circRNA formation machinery is conservative in the cell, we can observe the existence of circRNA in lower animals to higher animals, which proves that the formation mechanism of circRNA is very conservative. The modification system may covalently modify the viral genetic material entering the nucleus in the host cell, such as m6A modification. Such modification will make the host immune system unable to distinguish whether it is its genetic material or foreign nucleic acid species, thus avoiding recognition by the innate immune system. The modified genetic species can be selectively spliced, recombined, and translated like the host genetic material. Another mechanism may be that foreign substances are circularized in host cells to reduce the levels of linear RNA and corresponding proteins, avoiding the stimulation of the innate immune system. Third, circularization may absorb more viral or host miRNAs that are not conducive to virus proliferation. Forth, the circularization of RNAs in host cells may reduce the immunogenicity of viral nucleic acid. Fifth, the circularization of RNAs may preserve the virus’s genetic material to facilitate reinfection or damage to the host Figure 5As to these novel types of RNA molecules, more questions need to be answered:(1) Whether multiple circRNAs are produced simultaneously or followed with cognate linear RNA transcripts?(2) Can these circularizations of viral RNAs be inherited vertically in virally infected cells as regulatory elements to protect the host from reinfection?(3) Whether viral circRNAs formation strategy will be manipulated by the host to avoid the degradation of viral RNAs?(4) Whether these viral circRNAs are produced under certain circumstances, such as virus infection, different developmental stages, and other stimulates or other stimuli?(5) Whether multiple viral circRNAs produced in the virally cells have a competitive interaction with other RNA transcripts, such as non-coding RNA, small RNAs, and genes between viruses and hosts?(6) Whether the translation of viral circRNAs is the novel, unknown structural, and nonstructural proteins required for the viral life cycle?(7) Whether these circRNAs can form a circRNA subgenome of viruses?(8) Whether circRNAs are recruited by RNA binding proteins to form RNA virus replication regions?(9) Why so small a virus genome can produce so many circRNAs?(10) How do we balance the roles conducted by circRNAs and other non-coding RNAs or genes?(11) Whether some viral circRNAs are pro-virions (immature virions)?(12) Can some viral circRNAs fuse with the host or other viral circRNAs?XZ and ZL wrote the draft. XH and CG reviewed and supervised the manuscript. XZ, ZL, CW, ZS and SS collected the data. All authors contributed to the article and approved the submitted version.This study was supported by the National Natural Science Foundation of China  and the Priority Academic Program of Development of Jiangsu Higher Education Institutions. The funders had no role in study design, data collection, analysis, publishing decisions, or manuscript preparation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.