Pulmonary Artery Pseudoaneurysm (PAP) is a rare but potentially fatal cause of haemoptysis, which often remains unsuspected by both clinicians and radiologists.Traditionally, infections like tuberculosis and bacterial endocarditis have been associated with the development of PAPs. However, additional causative factors like trauma, neoplasia, pulmonary hypertension and vasculitis are also to be considered.With the advent of the novel Coronavirus (COVID-19), attempts have been undertaken to study its multisystem implications. Also, a strong correlation has also been established between COVID-19 and fungal infestation of the paranasal sinuses and lung parenchyma. Hence, PAP should be suspected in post-COVID patients who develop new-onset haemoptysis or new focal consolidation on imaging.Imaging investigations like chest radiograph, CT chest, and CT Pulmonary Angiography help in the establishment of a diagnosis and assessment of the relevant anatomy, which aid in the classification of the PAP. Management strategies include endovascular treatment, surgical resection or conservative approach in form of prolonged antimicrobial therapy. Interventional radiological procedures like endovascular embolisation are especially useful in vitally unstable cases of massive haemoptysis who are poor surgical candidates.Our case highlights the unique presentation of pulmonary arterial pseudoaneurysm induced by a post-COVID-19 fungal infection. A 30-year-old male with a history of COVID-19 pneumonia two months back, presented with a new onset cough with haemoptysis since two weeks. He initially had streaky intermittent haemoptysis. The patient then developed progressive breathlessness and had five episodes of massive haemoptysis.A frontal chest radiograph was performed  which shHigh-Resolution Computed Tomography (HRCT) Chest  performeIn view of imaging findings of a lower lobe cavity in a setting of post-infective sequelae, fungal infection was suspected, hence Serum galactomannan was done that turned out to be positive.Based on imaging and laboratory correlation, a diagnosis of post-covid fungal infection was made and Amphotericin therapy was initiated.A repeat HRCT chest was performed 20 days later, after the patient had multiple episodes of massive haemoptysis. It showed partial resolution of the previously seen cavity  and the A contrast-enhanced CT (CECT) chest with Computed Tomography Pulmonary Angiography (CTPA) was performed for diagnostic confirmation .It shows the presence of a focal well-defined thin-walled contrast-filled outpouching arising from the left upper lobe branch of the pulmonary artery measuring 2.2 × 2 × 2 cm  suggestive of pseudoaneurysm. There were no other pseudoaneurysms. In such patients, the appearance of a new focal consolidation should prompt the radiologist to consider the following differential diagnosis:Persistence of respiratory symptoms or development of new respiratory symptoms has been observed in half of the patients, which had a history of COVID-19, especially those who required oxygen therapy.1. Pulmonary thromboembolismCT Pulmonary angiography with routine HRCT chest should be considered when there is clinical suspicion for PE or when Well’s score is high (>6). Imaging findings include consolidation, bronchial dilatation within involved portions of the lungs, and a filling defect involving a segmental or main trunk of the pulmonary arteries.2. Superimposed pneumoniaSuperimposed pneumonia is seen in 10% of hospitalized patients with post-covid status. Patients with COVID-19 and ARDS may die owing to superimposed bacterial or fungal infection. Hence, chest imaging and lower respiratory cultures should be considered whenever secondary respiratory worsening occurs in a post-Covid patient. Lobar consolidation at chest imaging may reflect superimposed bacterial pneumonia.3. Post covid fibrosis Tinted sign that has been described as a decrease in the density and increase in the extent of ground-glass opacification is seen in a few patients with fibrotic nodules. It is usually seen three to four weeks after the acute phase and is related to broncho-vascular bundle distortion.The most common findings are parenchymal bands, irregular interfaces, coarse reticular pattern and bronchial dilation.4. Arterial pseudoaneurysm Imaging findings include new-onset consolidation near previous areas of consolidation or a vessel seen reaching up to an area of consolidation. In all cases of suspected pseudoaneurysm, CT pulmonary angiography should be performed to identify and localise the bleeding sites amongst the pulmonary, bronchial and non-bronchial collateral circulations.Although uncommon, as in our case, pulmonary artery pseudoaneurysm is an important cause of haemoptysis. The mortality rate associated with the rupture of a PAP is as high as 50%; death is secondary to aspiration and asphyxia after intrapulmonary haemorrhage.Using all aseptic precautions and under local anaesthesia, Right IJV access was obtained using a 6F Balkin sheath. Pulmonary angiography was performed with a pigtail catheter positioned at the bifurcation, which revealed a left upper lobe pulmonary artery pseudoaneurysm. Super-sePost-procedure repeat angiogram revealed complete occlusion of the aneurysm.After the endovascular therapy, the patient had a resolution of cough and breathlessness. He did not have any further episodes of massive haemoptysis. He had a single episode of streaky haemoptysis on Day 3 post-procedure; however, the rest of his hospital stay was uneventful.The patient came for a follow-up three months after the procedure. He did not have any haemoptysis episodes during this period. Although bronchial arteries and non-bronchial systemic collaterals are more common causes, pulmonary artery as an aetiology is seen in upto 10% of cases of massive haemoptysis. Pseudoaneurysm involving the pulmonary artery occurs when there is a contained rupture of the pulmonary artery and is seen in 5–11% of patients who underwent bronchial or pulmonary angiography. Early diagnosis is imperative to prevent life-threatening haemoptysis for which CT Pulmonary Angiography has become the diagnostic method of choice. CT Pulmonary Angiography is also essential in differentiating it from other causes of focal consolidation like nodular masses of endobronchial origin and hence prevents unnecessary biopsies or surgeries.Massive haemoptysis is defined as pulmonary haemorrhage with expectoration of a volume greater than 300 ml during a 24-h period. The mortality is more than 50% in untreated cases. A similar mechanism of pathogenesis is seen in cases of bacterial pneumonia. In cases of PAP developing after COVID-19, pulmonary vasculitis and severe inflammation are considered the most accepted mechanism. This occurs mainly due to upregulation of pro-inflammatory cytokines, complement activation, endothelial damage/dysfunction. Other postulated mechanisms for small vessel damage is the formation of immune-thrombotic clots. This phenomenon is triggered by the viral RNA molecules and leads to immune cell infiltration into the pulmonary vasculature. These immune cells along with tissue factor and inflammatory cytokines lead to immunothrombus formation which further weakens the vessel wall.The most common cause of acquired PAPs is infection. The PAPs associated with tuberculosis  is due to contiguous spread from the tuberculous cavity. There is the destruction of the outer vessel wall caused by the tissue destruction from the expanding cavity which finally weakens the vessel wall and leads to pseudoaneurysm formation.PAPs that are not directly related to lung consolidation may occur due to causes like septic emboli. Here, the destruction of the vessel wall starts in the lumen (due to endovascular seeding) and then progresses to the outer wall.Another major cause of PAPs is a traumatic injury to the pulmonary vasculature by iatrogenic  or non-iatrogenic causes. An acute injury is more likely to result in haemorrhage surrounding the area of consolidation.Pulmonary embolism, lung cancers and metastases may cause local pulmonary arterial wall injury and rarely may cause pseudoaneurysm formation. As infectious pseudoaneurysms can be simultaneously perfused by systemic and pulmonary circulation, their endovascular treatment includes embolisation of any bronchial, non-bronchial systemic collateral artery, or pulmonary artery feeder branch, which is according to the pattern of the blood supply.Endovascular treatment is a standard technique for infection-related PAP as an emergency open thoracic procedure is associated with mortality rates as high as 43%.Different endovascular embolisation techniques used for PAPs include vascular occlusion devices, coils, polyvinyl alcohol particles, or absorbable gelatin particles. However, particle embolic agents are not ideal for feeding artery embolisation of PAPs because increasing pressure during the infusion of a particulate agent can cause a pseudoaneurysm to rupture. Micro-coils are the most normally employed and preferred embolic materials for feeding-branch embolisation of PAPs. According to the pattern of the blood supply from the pulmonary artery, bronchial and non-bronchial systemic collateral arteries, PAPs were classified into four groups.The appearance of a new focal consolidation in a post covid patient with haemoptysis should raise the suspicion of a PAP and a CT pulmonary angiogram should be performed.Once identified a CT angiography should be done to identify the bleeding sites and bleeding vessels, including bronchial non-bronchial systemic collateral arteries, and pulmonary arteries.Angiographic classification of the type of pseudoaneurysm helps in guiding further endovascular treatment.


Choices between smaller certain reward and larger riskier reward are referred to as risky decision making. Numerous functional magnetic resonance imaging (fMRI) studies have investigated the neural substrates of risky decision making via conventional univariate analytical approaches, revealing dissociable activation of decisions involving certain rewards and risky rewards. However, it is still unclear how the patterns of brain activity predict the choice that the individual will make. With the help of multi-voxel pattern analyses, which is more sensitive for evaluating information encoded in spatially distributed patterns, we showed that fMRI activity patterns represent viable signatures of certain and risky choice and individual differences. Notably, the regions involved in representation of value and risk and cognitive control play prominent roles in differentiating certain and risky choices as well as individuals with distinct risk preference. These results deepen our understanding of the neural correlates of risky decision making as well as emphasize the important roles of regions involved in representation of value and risk cognitive control in predicting risky decision making and individual differences. Decision making under risk occurs on a regular basis in our daily lives. Although certain degree of risk-taking behavior is beneficial and necessary for the survival and evolution of humanity, excessive risk-taking may cause serious social and health issues, such as pathological gambling  and subsFor decades, researchers have studied the neurobiological mechanisms supporting risk-taking behavior from the perspectives of neuroanatomy and neuron activation pattern ,8,9. WitLinear Support Vector Machine (SVM), a multi-variate algorithm, is often applied in the field of neural signal-based prediction ,19,20,21In this study, we combined fMRI with multivariate analysis techniques in a relatively large sample to measure spatial ensemble coding of different certain and risky choices. Moreover, risk preference varies greatly among individuals, on which different preferences are often exhibited even under similar scenarios. And individual differences in risk preference are associated with health behaviors  and suscData used in this study were obtained from the OpenNeuro database with accession number of ds002843. The data set contains behavioral and brain imaging data from 166 healthy adults. More information about participant and study procedures can be found in the corresponding data paper [After removing participants with missing files, extreme choice behavior  and large head motions (>3 mm), fMRI data from a total of 133 healthy participants  were used in the final analysis. All participants gave written informed consent following procedures approved by the University of Pennsylvania Institutional Review Board.The detailed description of the risk task has been provided elsewhere. In brief, participants had to choose between a fixed small certain reward (100% chance of 20 dollars) and a larger riskier reward , whose magnitude and probability varied from trial to trial. After a choice was made, choice feedback (1 s) was given to the participants. Participants completed a total of 120 choices inside the scanner.Functional MRI scanning were acquired with a 3.0-T Siemens scanner. Functional scans recorded using a standard echo-planar imaging (EPI) sequence of 53 axial slices . T1-weighted scans were acquired using a standard Magnetization Prepared Rapid Acquisition Gradient Echo (MPRAGE) sequence . Additionally, a B0 field map was acquired  to support the off-line estimation of geometric distortion in the functional data.https://www.fil.ion.ucl.ac.uk/spm12/; accessed on 1 March 2022). Functional images were slice-timing corrected and then realigned for motion corrections and unwarped using the gradient echo field maps. Realigned functional images were spatially normalized to the MNI template, and then smoothed with a 6mm full-width half-maximum Gaussian kernel.Imaging preprocessing and statistical analyses were performed using SPM12  whereas those in the bottom 27% to the low-risk preference group .Risk preference (α) in this experiment were estimated by fitting the following function:A general-linear model (GLM) was used to estimate task effects for each participant. The GLM had the following two regressors of interest: (1) trials in which the certain choice was chosen (certain choice); (2) trials in which the risky choice was chosen (risky choice). Task regressors were convolved using the canonical hemodynamic response function. The 6 head motion parameters (3 translation and 3 rotation parameters) were also included in the model as regressors of no interest. Data were high-pass filtered with a cutoff period of 128 s to remove low frequency signal drift. We computed first-level contrasts for the following: (1) certain choice, (2) risky choice, (3) risky choice–certain choice. The contrast maps were used in the following multi-voxel pattern analyses.A leave one-subject-out cross validation procedure  was used to estimate the predictive capability of neural encoding patterns on risky decision making.https://www.csie.ntu.edu.tw/cjlin/libsvm/; model setting: “-s 0 -t 0”; accessed on 1 March 2022) with default parameter (c = 1 [n = 72), the second classifier was used to evaluate the difference of the neural representation between high and low risk preference participants in the contrast between certain choice and risky choice, which utilized contrast image of certain choice vs risky choice, resulting in one image per participant. For each classifier, a leave one-subject-out cross validation procedure  was performed to estimate the predictive capability of neural encoding patterns on risky decision making. To facilitate classification across participants, each feature  was normalized across the training set, and the normalization parameters were applied for normalizing the test set. The classifier was trained in the training set and then applied to the test set to obtain the category labels of untested participant. After completing all rounds of cross-validation, the average classification accuracy was calculated to quantify the performance of the classifier. To determine whether the accuracy was significantly higher than random level , we performed a permutation test by randomly shuffling the task labels 1000 times and running the above prediction pipeline for each time. Based on a null distribution of the accuracy, we estimated the significance by dividing the number of permutations that showed a higher value than the actual accuracy by the total number of permutations.We conducted two classifiers which used the linear support vector machines . Using In addition, in order to identify the brain regions made most prominent contribution in the classifier, we trained a model using images from all participants  to obtain the regression coefficient  for each voxel ,31,32. Ap < 0.001, 1000 permutation tests). The top 1% high weighted voxels located in the bilateral striatum , ventromedial prefrontal cortex , anterior cingulate cortex , mid-cingulate cortex , bilateral superior parietal lobe , and left dorsolateral prefrontal cortex   , indicatn = 36) whereas those in the bottom 27% to the low-risk preference group (n = 36). We then performed second classification to discriminate the same contrast images (certain choice vs. risky choice) from high and low risk preference individuals. The results showed that albeit the decision contrasts were held invariant, the classifier can robustly classify the contrast image into the relevant groups . The top 1% high weighted voxels situated in the bilateral insula , bilateral SPL , bilateral dlPFC  and ACC  (ps < 0.015) with high accuracies , the risk preference in the top 27% of the distribution were assigned to the high-risk preference group  . SpecifiUsing multi-voxel pattern analysis, the present study found that the spatially distributed information of neural activity in human brain can not only robustly predict one’s decision choice in risky decision making, but also successfully differentiate high and low risk preference participants with high accuracies. These findings provide strong evidence to confirm the predictive role of the general neural encoding patterns for individual risky decisions in the content of the brain-behavior domain.Although previous researches have extensively studied the dissociable neural mechanisms between different choices processes in risky decision making ,35,36,37The classifier showed that neural representation could distinguish the certain and risky choices with high classification accuracy at the whole brain level. This result suggests that despite that the physical inputs were the same, different choices were accompanied with decodable neural representation patterns. Specially, by quantifying feature weight for each voxel, we found that several regions of cortico-striatal network with high weights play a vital role in the classification, such as the vmPFC, striatum, SPL, ACC, MCC and dlPFC. The high weight region in the classification reflects the effectiveness of encoding and representation of decision choices information in this region. Noticeably, the value and risk of an option along with the agent’s risk aversion are the basic factors implicated in the risky decision behavior . These rConsiderable individual differences have been repeatedly described in risky decision making ,8,37. BrThe current results have a number of limitations that should be noted. First, the risk-reward probability of each trial is certain, but the risk taking in real life involves multiple components, such as unknown risks, loss aversion and learning of implicit probability structures . Future In summary, this study adopted multi-voxel pattern analysis approach in a relatively large sample data to explore the underlying neural substrates of risky decision making. At the global level, the classifier built with global activation pattern not only successfully distinguished the certain and risky choices, but also effectively distinguished the high- and low-risk preference participants. Furthermore, the results underline the regions in representation of value and risk of options and cognitive control as critical components of these neural signatures. These results deepen our understanding of the neural correlates of risky decision making as well as emphasize the utility of pattern analysis in predicting risky decision making and individual differences.


Vaccines remain the best approach for the prevention of infectious diseases. Protein subunit vaccines are safe compared to live-attenuated whole cell vaccines but often show reduced immunogenicity. Subunit vaccines in particulate format show improved vaccine efficacy by inducing strong immune responses leading to protective immunity against the respective pathogens. Antigens with proper conformation and function are often required to induce functional immune responses. Production of such antigens requiring post-translational modifications and/or composed of multiple complex domains in bacterial hosts remains challenging. Here, we discuss strategies to overcome these limitations toward the development of particulate vaccines eliciting desired humoral and cellular immune responses. We also describe innovative concepts of assembling particulate vaccine candidates with complex antigens bearing multiple post-translational modifications. The approaches include non-covalent attachments (e.g. biotin-avidin affinity) and covalent attachments (e.g. SpyCatcher-SpyTag) to attach post-translationally modified antigens to particles. Subunit vaccines contain selected immunogenic components of the pathogen to elicit an immune response , 2. Partvia endocytosis  are nanostructures made up of self-assembled virus proteins. VLPs do not contain viral genomes and thus they do not have the capacity of infecting the host cell . VLPs ca+ helper T cells and cytotoxic CD8+ T cells via MHC class II and MHC class I molecules, respectively  vaccines have already been found highly effective against various infectious diseases , 60. Thevia MHC class I or II to cytotoxic CD8+ T cells or CD4+ T cells, which ultimately results in the activation of cell-mediated and humoral immune responses  have been identified as biocompatible and biodegradable biopolymers and that are produced by a range of bacteria serving as energy and carbon storage materials . PHAs havia efficient assembly inside engineered endotoxin-free Escherichia coli. These particles were ambient-temperature stable and were precision engineered to serve as vaccine candidates that induce protective immunity against SARS-CoV-2, Mycobacterium tuberculosis and group A Streptococcus, respectively. The study demonstrated the utility and versatility of engineering immunogenic carrier proteins, that have been approved in vaccine formulation, into a synthetic particulate vaccine for induction of functional humoral and T cell-mediated immune responses  was engineered for the assembly of antigen-containing submicron-sized particles . Chen etesponses .via costimulatory receptors on T cells. Both signals are provided by APCs that encounter pathogens  regulate function of proteins including antigens and contribute to their immunological properties and stability . A studyfication . As a rellenging .E. coli expression system is commonly used to produce recombinant protein vaccines, mammalian or insect cells should be considered for antigens that require high levels of PTMs that are required for vaccine purposes  attaches biotin to the 15 amino acid avidin tag (AviTag) peptide yielding a homogeneous product with a high yield  in seconds  or sheare design .+ and CD4+ T cells. Particulate vaccines are versatile as they can be formulated with adjuvants and/or bioengineered for the co-delivery of antigens with PRR ligands, CPPs, and DCpep for induction of protective immunity. Immobilizing antigens to particulate carriers significantly enhances their stability such as enabling the generation of ambient-temperature stable vaccine formulations. Bacterial production hosts are unable to produce complex antigens with high levels of PTMs. This review highlighted the advances of using various technologies via covalent and non-covalent attachments to incorporate antigens with PTMs on particles. Although particle vaccines possess a great promise to combat infectious diseases, there are still a number of unknowns. These include a profound understanding of how particle size, charge, and structure influence the induction of immune responses. Safety concerns, such as severe anaphylaxis and myocarditis, have also been raised due to the extensive use of some new nanoparticle vaccines, such as mRNA-LNP. Understanding the underlying mechanisms of nanoparticle vaccine properties and potential toxicity could significantly advance the rational design of prophylactic and therapeutic nanoparticle vaccines.Antigens delivered in particulate form show superior immunological properties when compared to corresponding antigens in soluble forms. APCs, such as DCs, can cross-present antigens taken up in particulate form to potently activate both cytotoxic CD8All authors contributed to the manuscript. SC and BR conceived and revised the manuscript. All authors contributed to the article and approved the submitted version.


The collection of caterpillar fungus accounts for 50–70% of the household income of thousands of Himalayan communities and has an estimated market value of $5–11 billion across Asia. However, Himalayan collectors are at multiple economic disadvantages compared with collectors on the Tibetan Plateau because their product is not legally recognized. Using a customized hybrid-enrichment probe set and market-grade caterpillar fungus (with samples up to 30 years old) from 94 production zones across Asia, we uncovered clear geography-based signatures of historical dispersal and significant isolation-by-distance among caterpillar fungus hosts. This high-throughput approach can readily distinguish samples from major production zones with definitive geographical resolution, especially for samples from the Himalayan region that form monophyletic clades in our analysis. Based on these results, we propose a two-step procedure to help local communities authenticate their produce and improve this multi-national trade-route without creating opportunities for illegal exports and other forms of economic exploitation. We argue that policymakers and conservation practitioners must encourage the fair trade of caterpillar fungus in addition to sustainable harvesting to support a trans-boundary conservation effort that is much needed for this natural commodity in the Himalayan region. Ophiocordyceps sinensis parasitizes soil-boring Thitarodes larvae: the fungal mycelium proliferates throughout the larval tissues and extrudes a stroma through the head capsule of its host, out of the soil surface to release ascospores. The whole complex hardens into a mummified, caterpillar-shaped bundle of fungal mycelium and stroma commonly referred to as ‘caterpillar fungus’.The entomopathogenic fungus This moth–fungus symbiont was first described in the 15th century by Tibetan scholars and has since been avidly collected in its endemic range by Chinese and Tibetans as an ethnomedicine ,3. PreseAlthough caterpillar fungus was traditionally collected only within the Chinese border of the Tibet Autonomous Region (TAR) and the provinces of Qinghai, Gansu, Sichuan and Yunnan, the past decade has seen nations on the southern slope of the Himalaya  lured into this lucrative supply chain –17. For The current pattern of Himalayan caterpillar fungus trade operates in a ‘licit but illegal’ grey zone and can be summarized as (1) a cross-border legalization process from India to Nepal, followed by (2) a post-export de-origination process upon entering the Chinese border from Nepal. This provides ample opportunity for both state-actor corruption and non-state-actor exploitation that ultimately is detrimental to the economies of local communities and thwarts conservation action for the long-term persistence of caterpillar fungus populations.https://www.fra.org.in).Top-down policies continue to adapt and find the best practice of sustainable caterpillar fungus harvest in each region ,22,24–27Through these institutions, communities could then prepare biodiversity registers that would make a catalogue of natural resources such as the caterpillar fungus found on community lands. This framework for local product origin authentication, as has been applied in authenticating agricultural food products (reviewed in ), might O. sinensis fungal strains that parasitize them show comparatively less genetic differentiation  from caterpillar fungus using traditional Sanger sequencing has succeeded in obtaining a maximum of three genetic loci per sample [DNA-based origin authentication relies on molecular techniques to obtain genetic material from samples so that they can be assigned to geographical genetic clusters with which they are most similar. In the context of the wildlife trade, these techniques have been successfully applied to trace geographical origins of ivory , shark fles, see ). Nevertr sample –46, mostThitarodes hosts are highly distinctive across regions, a robust host phylogeny can serve, and be iteratively improved, as a shared molecular reference ‘library’ for caterpillar fungus host origin authentication, especially for samples collected in the Himalayan regions. Based on these results, we propose a two-step procedure to help local communities authenticate their product using this hybrid enrichment probe kit, and provide suggestions for policymakers and conservation practitioners for improving this multi-nation trade route without creating opportunities for illegal export and other forms of economic exploitation. We suggest that maintaining sustainable harvest as well as the fair trade of caterpillar fungus will support the trans-boundary conservation efforts needed in the Himalayan region [Here, we customized a commercially available hybrid-enrichment probe set originally designed for butterfly phylogenomics  to buildn region ,11,51,52. 2See electronic supplementary material, Methods, for detailed descriptions. (a)Thitarodes mitogenomes deposited in GenBank to maximize our loci overlap with existing phylogenies. We collected 94 caterpillar fungus samples from across its recorded distribution range, with 34 of these samples originating from the Himalayan regions of TAR, Nepal, Bhutan and India (O. sinensis and host DNA) was extracted using Qiagen DNeasy Blood and Tissue Kits. To sequence hosts, quantified DNA extracts were submitted to RAPiD Genomics  for hybrid enrichment and sequencing following the procedure described in Espeland et al. [O. sinensis) using the nrDNA internal transcribed spacer (ITS) region and the Sanger sequencing protocols of Zhang et al. [We used a 13-locus target capture probe set  that incd et al. . The samg et al. .Figure  (b)We used an ultra-fast all-in-one FASTQ preprocessor  to merge (c)We visualized the increase in phylogenetic resolution using markers from additional loci by bootstrapping possible sequence alignments generated using less than 14 loci. We then assessed the likelihood of correctly identifying a caterpillar fungus from the Himalayan region using both a phylogenetic placement approach and a maximum-likelihood approach: first, we applied a parallel evolutionary placement algorithm  to quer (d)We used BioGeoBEARS  to inferThitarodes hosts and their Ophiocordyceps parasites. A fungal phylogeny was constructed in IQ-TREE using ITS sequences from each sample, with the multi-locus fungal phylogeny of [We used the ParaFit test  and the ogeny of  as a topogeny of . Similarogeny of ), we conogeny of ) and (3)ogeny of  and compWe further investigated the geographical ‘width’ and phylogenetic ‘depth’ of any detected IBD and cophylogenetic signals to gauge whether relationships are stronger at regional or global levels, and at historical or contemporary timescales. To do this, we first conducted a hierarchical clustering  of our s. 3Our 94 samples obtained on average 496 k reads per sample (s.d. = 451 k), 29.9% of which hit the targeted regions (s.d. = 0.16). An average sample yielded 13.2 out of the 14 genes (94% success rate), with dried samples collected as long ago as 1993 successfully yielding all 14 genes . The only significant predictor of enrichment success rate was the year in which a sample was collected . However, PCR and Sanger sequencing of the fungal ITS region only recovered 58 fragments out of 94 samples due to DNA degradation.a). The delimitations reveal at least 20 valid species of Thitarodes as caterpillar fungus hosts, some of which are still being taxonomically identified and described (e.g. [figure 2a ‘widespread species complex’), most endemic monophyletic clusters are still highly supported.A total of 90 out of the 94 samples achieved complete 14-loci target recovery and were used in ML tree reconstruction. IQ-TREE yielded a well-supported tree that is consistent with the coalescent-based species tree obtained using ASTRAL . Results from the PTP and GMYC species delimitation models were consistent  and recovered a wide-ranging species complex from the Himalaya to the Qinghai–Tibet Plateau a. The deed (e.g. ). HimalaOur simulated alignment datasets show that increasing the number of loci used for phylogenetic reconstruction significantly increased the resolution of the molecular phylogeny . The phylogenetic placement test that simulates the origin-authentication of already-catalogued caterpillar fungus samples indicated that they can be identified with close to 100% certainty when the reference molecular phylogeny is constructed from more than seven loci . With 14 loci per sample in the phylogeny, once a region's sample has been genetically catalogued, we can correctly place samples with those from the same region.a). However, one out of 10 known non-Himalayan samples was misplaced within Himalayan clusters .In simulating the identification of Himalayan caterpillar fungi that have not already been catalogued in a molecular phylogeny, all six cytochrome oxidase I (COI) haplotypes from GenBank were correctly placed within the Himalayan monophylies a. Howeveb and electronic supplementary material, figure S7).Our best model identified the ancestral caterpillar fungus host in the Hengduan Mountains ; all models incorporating parameters of founder event speciation (+J parameters) obtained higher likelihood compared with their counterparts without this parameter . Species-level biogeographical stochastic mapping (BioGeoBears) shows high levels of dispersal between adjacent geographical regions . The same pattern was recapitulated in sample-level stochastic mapping . Monophyletic Himalayan hosts do not correspond to monophyletic groups of fungal parasites  but DNA distances among hosts are highly correlated with those among parasites . Among hosts, IBD was best explained by landscape resistance distance  rather than climatic differences or Euclidean geographical distances among hosts . Across hierarchical distance clusters, the greatest signal of IBD was observed in samples within 500 km of each other , and not traceable to more ancient lineages . Signals of cophylogeny were best conserved within samples approximately 1000 km of each other  and were more prominent in ancient lineages .We detected significant signals of co-cladogenesis between hosts and fungal parasites , although the strongest signals come from Hengduan Mountain samples that occupy less derived branches Thitarodes hosts using phylogenetic data from samples representing all major caterpillar fungus collection regions. In this study, only 94 out of the 400 caterpillar fungus collection regions tallied in Hopping et al. [b), as well as significant isolation-by-distance across all landscape scales (b) of caterpillar fungus hosts means samples from major production zones can be readily distinguished from one another. This is especially true for samples from the Himalayan region, which have likely undergone multiple, independent dispersal events from the Hengduan Mountains .First, we suggest building a molecular reference library of e scales b of cateThitarodes host species from each region by engaging with local scientists. There is a major disconnect between caterpillar fungus-derived Thitarodes phylogeny and descriptions of adult forms deposited in museums  rather than a lack of species diversity [At the same time, we advocate creating a molecular library of adult iewed in ). Our apin Nepal , two in in Nepal  and one in Nepal . Even iniversity . (b)Thitarodes expands, conservation practitioners (or regulatory agencies) can use it to trace sample origin and authenticity in the market with as little as a single COI fragment. This ensures communities with authentic products are recognized in the market and given proper economic compensation through market consumer choice . Once a shared library is in place (see 4.1), the cost of authenticating a sample's origin using Sanger-based genetic fragments is relatively small.Secondly, as the molecular reference library of origin-authenticated ’ model, ). Phylog’ model, . Now wit (c)The two proposed steps form a positive feedback loop between the market and communities. Origin-authenticated products allow the community to assert their fair economic contribution and enable regulators to detect smuggling. These increased economic incentives would encourage more communities to sequence their products, thereby increasing the coverage and robustness of the shared library. Cataloguing regional caterpillar fungus hosts (step 4.1) and identifying market samples (step 4.2) require operational molecular laboratories that have the capacity to conduct NGS sequencing (in the former case) or Sanger sequencing and PCR (in the latter case). Such facilities are readily available in major cities in India and China, and to a certain extent, in Nepal. Although these facilities are not located within the communities that would benefit from them, caterpillar fungi are easily transportable from the field to the lab. Multiple national agencies will need to work together to ensure caterpillar fungus authenticity for the benefit of their stakeholders, which involves sharing research facilities, standardizing sequencing pipeline and making results transparent. Our concern is that if the caterpillar fungus trade, especially in the Himalayan region, continues to operate in a legal grey zone, hundreds of local communities risk vulnerability to economic exploitation.et al. [O. sinensis are also plant endophytic fungi that are highly reliant on alpine vegetation. Thus, sustainable harvest of caterpillar fungus also ensures preservation of alpine habitats that are extraordinarily rich in biodiversity and are situated near the source of Asia's largest rivers. Running through these habitats are international borders and sites of armed conflicts rooted in cultural misunderstanding. These habitats must be sustained for the benefit of their wild species and the many people in some of Asia's largest countries whose livelihoods depend upon them [Caterpillar fungus trade is an economic tie that connects tens of thousands of stakeholders across international boundaries. The methods outlined here offer policymakers and conservationists a means to promote trans-boundary conservation ,11,82. Wet al.  have shopon them ,52.


We report the case of a patient who developed asymptomatic bilateral papillitis after coronavirus disease 2019 (COVID-19) vaccination.A 61-year-old man presented to our tertiary clinic with bilateral optic disc edema, which was incidentally detected during his visit to a primary ophthalmology clinic. He had received an adenovirus-vectored COVID-19 vaccine 2 weeks before the optic disc edema was detected and had experienced no ocular discomfort, except for a floater in his right eye. Although his visual acuity was normal and he had no color vision deficiencies or marked visual field defects, the optic disc edema worsened over several days. Orbital magnetic resonance imaging showed no optic tract enhancement, and lumbar puncture revealed normal cerebrospinal fluid pressure. The patient tested negative for aquaporin-4 and myelin oligodendrocyte glycoprotein antibodies and Leber hereditary optic neuropathy-associated gene mutations.The patient was diagnosed with bilateral papillitis, possibly induced by the COVID-19 vaccination.The patient received steroid pulse therapy with methylprednisolone (500 mg/day) for 3 days followed by an oral prednisolone taper for 3 weeks.The patient’s papillitis started to subside 3 weeks after he received systemic steroid therapy and completely resolved without any sequelae 2 months later. A year after the diagnosis, the fundus remained stable without disease recurrence or optic disc atrophy.Healthy individuals receiving COVID-19 vaccines may present with various manifestations of optic neuritis. In the present case, the patient presented with asymptomatic progressive bilateral optic disc edema and had a favorable long-term course after receiving steroid therapy. Neuro-ophthalmic complications include eye disorders such as neuroretinitis, optic neuritis, nonarteritic anterior ischemic optic neuropathy, and retinal vessel occlusion and eye disorders concomitant with brain lesions such as paralytic strabismus and papilledema after thrombotic events or autoimmunological inflammation.–5Since the coronavirus disease 2019 (COVID-19) vaccine was first approved for use in Western countries in December 2020,,6,7 and the causes of these disorders were confirmed; lesion localization in brain imaging or positive biomarkers in laboratory test.,8,9 However, a case with asymptomatic bilateral optic disc edema, which was followed for a long period of one year is rare. Herein, we present the case of a patient who developed silent progressive bilateral papillitis after receiving an adenovirus-vectored COVID-19 vaccine. The patient has provided informed consent for the publication of the case.In most of the reported studies, patients presented with prominent visual dysfunctions such as decreased visual acuity, diplopia, and visual field defects,A 61-year-old man without any systemic diseases presented to our hospital with a floater in his right eye, which had appeared 2 days prior to presentation. He was well-being appearance without eye pain or headache. He had a history for receiving his second dose of an adenovirus-vectored COVID-19 vaccine  2 weeks before presentation. Five days after vaccination, he was admitted to a different clinic owing to fever of unknown origin, and he recovered with conservative treatment. He reported that the floater appeared after the fever subsided.On his first visit to our hospital, he had a best-corrected visual acuity of 20/20 in both eyes and normal intraocular pressure. His Ishihara test results for color perception were normal and extraocular muscle movements were full. Pupillary light reflex examination showed that his pupils were equal and reactive with no afferent pupillary defect. Slit-lamp examination revealed no cells in the anterior chamber or vitreous. Fundus examination revealed bilateral optic disc edema, which was more severe in the right eye Fig. A compari2O. There was no evidence of infection and inflammation in blood test. Screening for autoimmune optic neuritis including testing for anti-myelin oligodendrocyte glycoprotein and aquaporin-4 antibodies and analysis of mitochondrial DNA mutations associated with Leber hereditary optic neuropathy yielded unremarkable results. Polymerase chain reaction test results of the patient were negative for COVID-19.Under the impression of papilledema, considering Considering that visual function was maintained, the which did not correspond with the severe disc edema, spinal tapping was therefore recommended for measuring cerebrospinal fluid pressure, but the patient refused to undergo the examination. Therefore, regular follow-up without treatment was performed at the clinic. After 2 days, the patient reported that the floater in his right eye had spontaneously disappeared and he experienced no further visual discomfort. However, fundus examination showed that the disc edema had increased, which did not correspond with the reported symptom relief. And the degree of edema was more severe in the right eye  with glycemic monitoring for 3 days followed by an oral prednisolone taper for 3 weeks. During the treatment period, the disc edema was consistent and did not improve. Mild enlargement of the physiological blind spot in his right eye was noted in the visual field test, but his visual acuity and color perception remained normal. Three weeks after his first visit to our hospital, the disc edema started to subside, and the peripapillary RNFL thickness decreased. Two months later, superior peripapillary RNFL thinning was observed on optical coherence tomography, but optic disc atrophy in both the right Fig. C and theStudies on optic neuropathy associated with COVID-19 vaccination have reported various visual outcomes from visual function improvement in some patients to permanent visual loss in others. In the present study, the patient reported few deficits in visual function at the first presentation, and disc edema was detected only on fundus examination. However, because his cerebrospinal fluid opening pressure was normal, papilledema and idiopathic intracranial hypertension were no longer considered. Moreover, nonarteritic anterior ischemic optic neuropathy, which is the most common acute optic neuropathy in the elderly population, was ruled out because no ischemic lesions in the peripapillary region and no definite altitudinal field defects were found on optical coherence tomography angiography and visual field, respectively. Furthermore, because there was no infection evidence in blood test and no enhancement in orbital MRI, the patient was finally diagnosed with bilateral papillitis, which was regarded as an exclusion diagnosis.Considering that the patient had normal visual function despite severe bilateral disc edema, he was initially suspected to have papilledema or idiopathic intracranial hypertension.–15 Roy et al reported the case of a 40-year-old man who showed symptoms typical of acute bilateral optic neuritis 12 days after receiving a COVID-19 recombinant messenger RNA vaccine. He experienced vision loss and pain with eye movement, and orbital MRI demonstrated optic nerve enhancement. His best-corrected visual acuity improved after steroid therapy. Helmchen et al reported a case in which a patient with multiple sclerosis developed neuromyelitis optica, an autoimmune disease that distinctly differs from multiple sclerosis, after receiving a vector-based vaccine. The presumptive mechanisms of neuro-ophthalmologic complications associated with COVID-19 vaccination do not differ from those associated with other vaccines. Possible mechanisms include infection with the attenuated pathogen, molecular mimicry resulting in hypersensitivity, and adjuvant-induced inflammation. Furthermore, these are believed to be associated with immune-mediated damage, resulting in demyelination or localized vasculitis. In the present study, bilateral papillitis may have developed owing to an immune response or hypersensitivity in the patient. Moreover, after receiving the vaccine, the patient developed fever of unknown origin, which may have been an adenovirus vector-induced immune response. This may have caused an inflammatory reaction in the optic nerve.There have been several case reports that have described bilateral disc edema after COVID-19 vaccination. previous studies have reported papilledema development associated with thrombosis in patients after vaccination.,19 Qian et al reported the case of a 45-year-old woman who was diagnosed with papilledema secondary to dural sinus thrombosis 8 days after vaccination. Nowak et al reported that a 23-year-old man developed papilledema associated with intracerebral hemorrhage secondary to venous sinus thrombosis 10 days after vaccination. In the present study, the possibility of a microthromboembolic event associated with the adenovirus-vectored vaccine cannot be excluded; however, unlike that reported in the previous studies, our patient did not experience systemic symptoms such as headache or dyspnea that can occur owing to thrombosis in other organs.Meanwhile, regarding thrombotic events specific to adenovirus-vectored COVID-19 vaccines, If he had received the conventional high-dose steroid treatment, he could have shown a dramatic response to the steroids.Regarding the patient’s response to steroid therapy, the reasons for why the patient’s disc edema did not decrease for several weeks after steroid therapy and then slowly subsided thereafter are unclear. We suggest several hypotheses to explain this result. First, the patient’s signs and symptoms were not severe, which may mean that his immune response to COVID-19 vaccination was not strong. Therefore, his responses to steroid therapy for suppressing abnormal immune reactions may have been also slow and not prominent. The second hypothesis is associated with the steroid dosage. Considering his old age and minimal visual function impairment, the patient received therapy with half the standard steroid dose reported in the Optic Neuritis Treatment Trial.Although we have reported only one case of bilateral papillitis associated with COVID-19 vaccination, we believe that more data on the development and characteristics of optic neuritis in patients receiving different types of COVID-19 vaccines would be meaningful.In the present study, we report the results of a 1-year follow-up in a patient who developed asymptomatic bilateral disc edema after COVID-19 vaccination. Contrast-enhanced orbital and brain MRI showed unremarkable results. The results of systemic evaluations including spinal tapping and laboratory tests did not support the possibility of papilledema, infection, or other autoimmune diseases.In addition, because the patient was healthy without any underlying systemic diseases and his disc edema was detected 2 weeks after vaccination, he was diagnosed with bilateral papillitis associated with COVID-19 vaccination. After high-dose intravenous pulse steroid treatment, the disc edema gradually subsided. A year after the diagnosis, the patient’s fundus remained stable without visual sequelae or disease recurrence. This case report demonstrates that atypical asymptomatic papillitis can occur after COVID-19 vaccination.Conceptualization: Donghun Lee.Data curation: Hyeong Seok Park, Donghun Lee.Investigation: Geun Woo Lee, Donghun Lee.Resources: Hyeong Seok Park, Donghun Lee.Writing – original draft: Hyeong Seok Park, Donghun Lee.Writing – review & editing: Donghun Lee.


The ability to maintain normoglycaemia, through glucose-sensitive insulin release, is a key aspect of postnatal beta cell function. However, terminally differentiated beta cell identity does not necessarily imply functional maturity. Beta cell maturation is therefore a continuation of beta cell development, albeit a process that occurs postnatally in mammals. Although many important features have been identified in the study of beta cell maturation, as of yet no unified mechanistic model of beta cell functional maturity exists. Here, we review recent findings about the underlying mechanisms of beta cell functional maturation. These findings include systemic hormonal and nutritional triggers that operate through energy-sensing machinery shifts within beta cells, resulting in primed metabolic states that allow for appropriate glucose trafficking and, ultimately, insulin release. We also draw attention to the expansive synergistic nature of these pathways and emphasise that beta cell maturation is dependent on overlapping regulatory and metabolic networks.The online version contains a slideset of the figures for download, which is available at 10.1007/s00125-022-05672-y. Understanding the mechanisms of beta cell differentiation and maturation is integral to studies of diabetes pathophysiology, regenerative therapies and stem-cell-derived models of beta cell dysfunction and replacement. While the developmental processes that lead to a stable beta cell identity are relatively well known, the mechanisms underlying the functional maturation of beta cells are less clear. In simple terms, beta cell ‘differentiation’ defines the acquisition of a terminally differentiated insulin-positive cell identity throughout in utero development or in vitro stem-cell-based protocols. Conversely, beta cell ‘maturation’ is a measurement of the phenotypic properties of beta cells and their ability to respond to, and control, blood glucose levels through glucose-sensitive insulin secretion (GSIS). Acquisition of this function occurs postnatally in rodents –3 and huThe current understanding of beta cell maturation is that such a process is a spectrum rather than a binary state –10. MatuThis review will primarily focus on the reported multi-faceted mechanisms that drive and maintain beta cell functional maturation within in vivo and in vitro models.The functional maturation of mammalian beta cells is known to occur postnatally, and continues to develop post-weaning , 2. TherThe concept of beneficial mTOR signalling in beta cell differentiation and function is well documented . HoweverAnother intriguing concept is the coupling of beta cell glucose sensing to mTOR activity. It has recently been shown that acute glucose stimulation of mTORC1 activity in beta cells is only partially dependent on mitochondria-derived glucose metabolism . In lineBMAL1  and/or CLOCK deletion within pancreatic lineages  disrupts the functionality of beta cells, resulting in an oxidative-stress-induced state  and SRY-box transcription factor 6 [SOX6] pathways [PDX1 levels in SC-islets [PDK4 and reduced PC and MDH1 expression within the primary islets. The shifting patterns and balance of microRNA family expression is therefore another key component of the onset and maintenance of beta cell maturity.Another intriguing feature of beta cell functional maturation is the regulatory influence of microRNAs. Shifting patterns of microRNA expression have been shown to elicit robust regulatory effects on metabolic gene expression and beta cell functionality in a nutrient-sensitive manner, as well as throughout postnatal maturation –141. TheREST  and SLC1[SLC16A1 . In contic genes . Other mpathways ) and theC-islets  while suC-islets ) are allC-islets , yet theC-islets . This drFinally, epigenetic signatures may help explain particular functional features of mature and immature beta cells. Both DNA methylation and histone modification are mechanisms by which beta cell identity and function are maintained, through tailoring the expression pattern of beta cell-enriched transcription factors, as well as being regulated by the transcription factors themselves , 148. SoIn summary, the concept of tracking beta cell maturation through panels of marker genes is one that should be approached cautiously. While core beta cell identity genes are no doubt important for many facets of beta cell maturation, the upregulation of one particular gene is not necessarily a strong argument for predicting functional maturation. Indeed, much more needs to be uncovered about how signalling pathways fully trigger beta cell maturity and through which mechanisms they operate. Furthermore, interpreting expression levels of particular genes, especially those within core metabolic pathways, should be done carefully so as not to misconstrue what is necessary for specific beta cell function and what is key for basal cellular metabolism. Additionally, overexpression of particular genes within a pathway may not necessarily trigger systemic maturation events. Full understanding of beta cell maturity clearly needs to go beyond simplistic models of gene and protein expression, and the regulation and maintenance of epigenetic signatures in beta cell function and disease must be considered.Beta cell maturation is a multi-faceted process that takes cues from systemic nutritional and hormonal signals and ultimately results in a primed transcriptomic and metabolic beta cell state conducive to drive GSIS Fig. . Recent ESM 1(PPTX 332 kb)


Our objective was to review the latest evidence on resuscitation carefor maternal cardiac arrest (MCA) and gain expert consensus on bestpractices to inform an evidence-based curriculum.We convened a multidisciplinary panel of stakeholders in MCA todevelop an evidence-based simulation training, Obstetric LifeSupport™ (OBLS). To inform the learning objectives, we used a novelthree-step process to achieve consensus on best practices for maternalresuscitation. First, we reaffirmed the evidence process on an existing MCAguideline using the Appraisal of Guidelines for Research and Evaluation(AGREE II). Next, via systematic review, we evaluated the latest evidence onMCA and identified emerging topics since the publication of the MCAguideline. Finally, we applied a modified Research and Development (RAND)technique to gain consensus on emerging topics to include as additionaljust-in-time best practices.The AGREE II survey results demonstrated unanimous consensus onreaffirmation of the 2015 American Heart Association (AHA) MCA guideline forinclusion into the OBLS curriculum. A systematic review with deduplicationresulted in 11,871 articles for review. After categorizing and synthesizingthe relevant literature, we presented twelve additional best practices tothe expert panel using a modified RAND technique. Upon completion, the 2015AHA statement and nine additional just-in-time best practices were affirmedto inform the OBLS curriculum.A novel three-step process including reaffirmation of evidenceprocess, systematic review, and a modified RAND technique resulted inunanimous consensus from experts in MCA resuscitation on existing and newjust-in-time best practices to inform the learning objectives for anevidence-based curriculum. Inone study of maternal cardiovascular deaths in Illinois between 2002–2011, 28% of ScientificStatement on Cardiac Arrest in Pregnancy,[In 2015 the American Heart Association (AHA) published the regnancy,. Despiteregnancy,,11, the A standardized, evidence-based training curriculum for MCA response isurgently required. To address this need, a team of stakeholders are currentlydeveloping a simulation-based training package for in-hospital and out-of-hospitalMCA named Obstetric Life Support™ (OBLS). This article describes aninnovative three-step approach used to identify and achieve consensus on currentbest practices to train resuscitation skills needed during MCA.2.After being awarded a grant from the National Institutes of Health (AHRQ FOAPA16–420) and gaining Baylor College of Medicine Institutional Review Board(IRB) approval (#H-48730), a novel validation process was used to createjust-in-time learning objectives to inform the creation of a new hybrid simulationcurriculum to train emergency medicine services (EMS) providers and in-hospitalpersonnel to manage maternal cardiac arrest (MCA) called OBLS. During the initialphase, an expert panel was formed, comprised of researchers and nationalstakeholders in MCA. The researchers identified stakeholders in pre-hospital andin-hospital MCA across North America  by online searches,reviewing authors for peer-reviewed manuscripts and guidelines, and contactingnational organizations and asking to be referred to relevant staff. Thesestakeholders formed the expert panel and agreed to develop the OBLS simulationcurriculum to train EMS providers and in-hospital personnel to manage MCA.Step 1:The OBLS expert panel was asked to apply an AGREE II assessment tool tothe 2015 AHA guidelines on MCA. The AGREE II tool contains 23 items organizedinto six quality domains that assess the methodological quality andapplicability of guideline recommendations. The six domains are: scope andpurpose; stakeholder involvement; rigor of development; clarity of presentation;applicability; and editorial independence. Using a seven-point scale (1 =strongly disagree to 7 = strongly agree) appraisers independently reviewed andassessed the validity and usefulness of the 2015 AHA Statement.Step 2:A trained medical librarian developed two comprehensive literaturesearches using the Medline and OVIDSP databases. Medical Subject Headings (MeSH)were utilized, and keywords and synonyms . Given thatthe AHA guidelines were published in 2015, the researchers limited the search to2014 -November 2018. The researchers approved the terms, and the librariandeveloped a second search strategy using the same publication date range. Thesearch was then translated to two additional databases: Embase and The CochraneLibrary. Final searches were run on November 29, 2018. In February 2019, theresearchers decided to include the CINAHL Plus with Full Text database into theinitial search to ensure the search captured all relevant articles. Theresearchers updated the search results from the first search initially run inNovember 2018. The search strategy was translated to the CINAHL database onFebruary 7, 2019. The CINAHL search totals were combined with the initial searchresults from the searches  runon November 29, 2018. A deduplication process was performed for the combinedtotals. The updates of the initial searches were also run on Medline OVID,Embase, and the Cochrane Library on February 7, 2019. The updates from theinitial searches were combined and underwent the deduplication process onFebruary 11, 2019. The updated search totals were added to the CINAHL searchresults and deduplicated again. The total 2,249 results of the updates and theCINAHL searches were then delivered to the researchers for review and to undergothe inclusion and exclusion process. The search strategies are available inAdditional File 4.The researchers reviewed the articles for relevance to the project.After categorizing and determining relevance, the researchers developed keyquestions, abstracted, and graded the literature, and defined inclusion andexclusion criteria. Four independent reviewers selected studies to be includedbased on consensus on whether they met the inclusion and exclusion criteria. Anindependent reviewer was available if the researchers could not reach agreementbut was not utilized. A synthesis of the relevant literature for each keyquestion was performed focusing on validity and reliability of admissibleevidence at the individual study level. The researchers developed overallsummary statements regarding specific tasks for managing MCA and extractedliterature into a support summary table for each key question.Step 3:a priori determination ofconsensus to support the summary statements included an average score of 5.0 orgreater; scores <5.0 were automatically reviewed in round two. Theresearchers found new level A evidence supporting the AHA’s 2015statement “We recommend against the routine prehospital cooling ofpatients after return of spontaneous circulation (ROSC) with rapid infusion ofcold intravenous fluids.” Therefore, the researchers asked the expertpanel to reaffirm the statement as written. After completing the first round, anaverage ranking score for each statement was calculated and comments formodifications to the statement were incorporated into the consensusstatements.These overall summary statements were presented to the expert panel(Table 1) using a modified RAND technique. Via REDCap, a secure web platform forsurveys, the researchers invited 24 members of the expert panel to evaluate andrank the statements using a Likert scale (Table 2). Expert panel members who hadexpertise in areas other than obstetrics, anesthesiology, emergency care orresuscitation were not included. An a prioriresult of 4.0 or greater, and >80% consensus was set. After theface-to-face meeting, the statements were evaluated based on ranking andconsensus around inclusion into the curriculum, and the researchers furtherrefined the statements. No further rounds were performed due to significantagreement around statements. The final statements that met criteria were thensent to the expert panel for affirmation.The second round consisted of a face-to-face meeting of the expert panelon January 31 – February 1, 2019, with a consensus discussion for eachrevised statement led by the researchers. The moderated discussion involvedpresentation of the individual statements and summary of evidence to support theupdate. This was followed by an approximately 20-minute discussion, with moretime given for a statement if needed. The discussion focused on statementcontent and wording. Using Poll Everywhere, a live and anonymous audienceparticipation software, the researchers surveyed the expert panel again usingthe same Likert scale. Stakeholder also answered, “Should this statementbe incorporated into the OBLS curriculum?” To be considered foraffirmation and inclusion into the curriculum, an 3.Step 1:Statement of Managing CardiacArrest in Pregnancy via the AGREE II tool .Scores for the domains ranged from a low of 58% (Domain 2. StakeholderInvolvement) indicating that the stakeholders did not think that the guidelinessatisfied the criteria for this domain to a high of 90% (Clarity ofPresentation) indicating the guidelines mostly satisfied the criteria for thisdomain. Scores were >80% for four of the six domains: Scope and Purpose(82%), Rigor of Development (70%), Clarity of Presentation (90%), EditorialIndependence (85%) and for the Overall Assessment (75%). There was unanimousconsensus to recommend the guideline for use in the OBLS curriculum, with eightpanelists responding “Yes” and six responding “Yes withmodifications.” A qualitative synthesis of the recommended modificationsis listed in Table 3.Sixteen expert panelists representing expertise in resuscitation,obstetrics, anesthesiology, and emergency care were invited, and fourteenmembers responded to appraise the 2015 AHA Step 2:Following both searches and the second deduplication process, theresults totaled 9,622 records . An additional 296 records from othersources were combined with this search and deduplicated resulting in 7,152full-text articles for review. Three reviewers  screenedthese 7,152 articles independently and in duplicate, using the same inclusionand exclusion criteria from the search strategy. A total of 5,449 articles wereexcluded because they did not meet focus population, intervention, or outcome.Four reviewers  abstracted 1,703 full-text articles,looking at key questions to appraise their quality. A total of 375 studies wereincluded in the qualitative synthesis and 112 studies for quantitativesynthesis. From this synthesis, the researchers developed 12 statements forexpert panel consideration.Step 3:apriori specified rank of “5” or greater to beconsidered for affirmation. Following the second round, 8 of the 11 statementsmet the a priori rank of “4” of greater foraffirmation. Two statements were voted on as dangerous/inappropriate:“First responders should initiate and maintain bag-mask valve (BMV)techniques until arrival at a hospital with a more experiencedlaryngoscopist” and “EMS should deploy highly specializedparamedics in addition to regular EMS crew in cases of suspected MCA” toless important: “The use of a ketamine-based anesthesia package should beconsidered for patients with ROSC who have undergone PMCD in settings withoutimmediate anesthesia availability”. These three statements were removedfrom further consideration as they all received a lower score following theface-to-face discussion compared to the first round. Because there was consensusfor all remaining statements, further rounds were not performed. The teamrefined the remaining nine statements and sent them to the expert panel. Allnine statements were affirmed for inclusion into the curriculum (Table 5).During the first round, 23 expert panel members were surveyed on theupdated AHA statements. Descriptive statistics were performed (Table 4). Afterthe first round, the experts all agreed to reaffirm the AHA 2015 statement:“We recommend against the routine pre-hospital cooling of patients afterROSC with rapid infusion of cold intravenous fluids.” There was also avery high level of consensus (“5” or greater) on only one summarystatement: “Training emergency room physicians in perimortem cesareandelivery (PMCD) is recommended so that PMCD can be immediately performed uponarrival to the hospital for out-of-hospital maternal cardiac arrest (MCA)without ROSC.” The remainder of the statements had a “high”or “moderate” level of consensus but did not meet the 4.process composite performance measures of in-hospital cardiacarrest care quality are associated with patient outcomes. The authors state:“After adjustment, each 10% increase in a hospital’s process compositeperformance was associated with 22% higher odds of survival . Hospital process composite qualityperformance was also associated with favorable neurologic status at discharge (P =.004)”[maternal cardiac arrest simulation training  are instituted throughout the medical sector.National OB training platforms that are currently employed by specialtyorganizations dedicate very small portions of their courses, if any, to teaching howto manage MCA. The programs that do exist are narrowly focused on OB and familypractice physicians and nurses, limiting broad application to other specialists, andemergency medical technicians. Additionally, they do not require summativeMCA-simulation-testing as a course completion requirement. Evidence suggests,however, that continually improving cardiac-response processes  manifests in improved patient outcomes. Andersen et al.published an article in the Journal of the American Medical Association (JAMA) in2016  which ev =.004)”, demonstThe OBLS expert panel utilized a novel three-step process to reaffirm the2015 scientific statement, review the evidence to update the 2015 AHA guidelines,and achieve consensus around the proposed statements to arrive at just-in-time bestpractices to supplement the 2015 AHA scientific statement on managing cardiac arrestin pregnancy. The Agency for Healthcare and Research Quality U.S. PreventiveServices Task Force Procedure Manual has previously described the reaffirmationevidence process of clinical practice guidelines . An AGREWith these limitations in mind, the second step involved performing asystematic review limited to the evidence since the 2015 AHA guidelines on CardiacArrest in Pregnancy. Prior systematic reviews in this topic area are notable for thelack of level A evidence . In lighThe OBLS expert panel then utilized a modified RAND technique to arrive atconsensus on the summary of evidence for the 2015 AHA guidelines. Nominal consensustechnique such as the RAND technique have been previously described , 15. BecOur results demonstrated enthusiastic affirmation of several updates to the2015 AHA statement, consistent with the current 2–5-year timeline forupdating guidelines described in the literature –18. Addia priori definition of consensus was readily achieved by thegroup after three rounds, and therefore statistical analysis of individual responsesto determine further rounds was unnecessary. Another limitation was that experts hadto self-select “0” if they did not feel qualified to rank a statement.This may have resulted in some experts answering questions that they were not fullyqualified to answer. However, the high degree of consensus following the third roundsuggests this self-selection was not likely to significantly bias the consensusprocess.Limitations of our methodology included the inability to calculate analyticstatistics of individual responses during the consensus rounds. Fortunately, theDespite these limitations, this novel process was systematic and thoroughand brought together a multidisciplinary panel of experts from all regions of NorthAmerica, including both pre and in-hospital settings. We believe this is the mostdiverse group of experts convened around this topic area which permitted a robustdiscussion on the newest evidence to update the 2015 AHA scientific statement.Existing and new just-in-time best practices will inform the learning objectives foran evidence-based simulation training package relevant for a wide range of medicaldisciplines to improve the care of maternal cardiac arrest.Additional file


Plant diversity may enhance stability of ecosystem function and its satellite-derived indicators. However, its potential to stabilize phenology, or seasonal changes in plant function, is little understood, especially in understudied systems with high biodiversity potential such as wetlands. Using a large sample of U.S. wetlands and a new satellite-based indicator of phenological stability, we found that plant diversity was negatively associated with interannual phenological variability after controlling for covariates representing climate, site conditions, and spectral fluctuations. Furthermore, plant diversity and covariates better explained phenological variability than stability in annually summarized satellite-based biomass indicators used by earlier studies. Last, a subsequent path analysis indicated that phenological variability could mediate plant diversity relationship with the latter stability. Our results suggest that contributions of plant diversity to seasonality of ecosystems may have a stabilizing role in their functioning and offer a new basis for assessing biodiversity-stability relationships across broad geographic extents. Wetland plant diversity stabilizes satellite-based indicators of biomass and the timing of ecosystem functions. Biodiversity contributions to long-term stability of ecosystem functioning  across the conterminous United States (table S1) , represec)  and native (NatSpecies_S) species richness, family richness (Family_S), and Shannon-Wiener diversity index for all (TotSpecies_H) and native (NatSpecies_H) species; table S1] were included in the highest-support regression models (c) ; howeverP < 0.05 for all; c models; however, it strongly and positively correlated with its SD . Wetland type determined by NWCA hydrological status and vegetation  were included less often and not significantly related to phenological variability in the highest-support models . Most of these hot spots were in coastal regions (fig. S3F).In contrast, SD in annual temperature , soil pH (Soil_pH), indicator of the cyclicality in greenness , and presence of agricultural stressors based on wetland adjacency to agricultural areas  positively correlated with phenological variability . Shannon-Wiener diversity (TotSpecies_H) showed a negative and significant but weaker association with phenological variability . Similar effects were observed also in the highest-support SEMs for family richness and for Shannon-Wiener diversity of native species (table S6). However, in models with native species richness, diversity also had a significant, although weak, direct negative relationship with phenological variability .Path analysis with SEMs found that in the highest-support models, plant species richness (TotSpecies_S) was negatively related to phenological variability , SEMs using stability of annual maximum NDVI to test similar hypotheses were not sufficiently supported (showing the ratio of chi-square to degrees of freedom greater than 3). Together, these outcomes suggest that interannual phenological variability may be a mediator in plant diversity relationships with stability of biomass when the latter is indicated by the annually averaged greenness.r = −0.28 and −0.21, respectively, P < 0.001 for each; r = 0.20, P < 0.001). However, the associations of mean atmospheric temperature and mean annual precipitation with stability of greenness were also negative and significant but weaker than those for phenological variability , suggesting lower variation in greenness phenology in more acidic wetlands. Last, Max_PSD, related to magnitude of the main cycles in greenness fluctuations, showed a very strong positive effect on phenological variability  and a somewhat weaker but significant positive effect on stability of greenness . This evidence suggests that wetlands with greater magnitude of greenness fluctuations may exhibit both less stable seasonality and less stable interannual biomass.Among other factors, soil pH had a strong positive effect on phenological variability , phenology has long been discussed as one of the essential biodiversity variables that could be monitored with the help of remote sensing data  suggests that future efforts should consider other covariates of phenological variability not captured by our data. Of particular importance can be variables representing hydrological connectivity among wetland sites, which may influence synchronies of their ecological processes (2 plots within a ~0.5-ha (40 m radius) assessment area  on phenological variability estimation and more reliably characterize the latter in terms of vegetation contributions. Note that in  or a low baseline  and sites where equivalent 8-day time blocks may differ in their potential magnitudes of greenness change . For the subsequent regression analyses, phenological variability estimated using   were conducted in MATLAB software v.2022a (MathWorks Inc.) using the function fitlm. The models were subsequently ranked using a form of the AICc . We then conducted similar regression model comparisons to test the associations of plant diversity and covariates with each of the 14 alternative measures of stability (table S3).We assessed the association between phenological variability and plant diversity of NWCA wetland sites using generalized linear regression modeling with phenological variability (PhenoVariability) as a response variable, plant diversity as the main predictor variable, and several covariates  described below. The main goal of this analysis was to examine the importance of diversity at the broad scale of NWCA data after adjusting for the relevant covariates identified through the most parsimonious models as discussed below. We tested regression models with different combinations of plant diversity, and covariates . These included proxies of climate, local soil properties, cyclical variability in the greenness time series, wetland hydrological type, prevalence of medium-tall vegetation, NWCA-determined disturbance status, and severity of agricultural stressors in the wetland buffer area (table S2).Climate covariates were included to adjust for climate-induced variability in phenological timing of changes in greenness  computed from MOD11A2v.6 LST product at 1-km spatial resolution. To address the key challenge of temporal gaps in 1-km LST due to atmospheric effects, we developed a specialized gap filling approach. For each wetland site, we first identified missing values and assessed whether they formed consecutive sequences and of which length. Given the uncertainty associated with filling very large gaps, we applied gap filling only to sequences of no more than four consecutive missing values; sequences of five and more consecutive missing values were left as missing data. For portions of wetland time series that contained missing values and qualified for gap filling based on these criteria, we used MATLAB function fillmissing with the space-preserving piecewise cubic spline interpolation (“pchip” fill method of this function).i,j is the LST value for a given seasonal 8-day block i and year j in the time series and Nvalid is the count of seasonal 8-day blocks containing valid data .Next, we computed variability in LST as the average deviation in LST of the satellite pixel overlapping a wetland site from the mean value of its respective 8-day block during 2002–2019, corrected for the number of 8-day blocks that could not be robustly gap filledWe expected that greater variability in LST would be associated with greater phenological variability of greenness due to the variation in microclimate-related triggers of phenological events such as snowmelt . Such cyclical variability results from seasonal changes in vegetation biomass and flooding attenuation, which varies with plant height and cover .To perform periodogram analysis, the NDVI time series of each site were first differenced (using MATLAB diff function) to remove potential nonstationarity before periodogram estimation. Next, for each site, we computed periodogram as PSD associated with different frequencies of the signal using Welch’s method (MATLAB pwelch function)   maximum PSD across all possible signal frequencies (Max_PSD), related to the magnitude of NDVI change within the dominant greenness cycle of a wetland, and (ii) total number of clusters with significant PSD representing the total number of the most pronounced periodic cycles in the time series (NumPeaksPSD). We expected that wetlands with greater Max_PSD would show greater variation in phenological timing year to year due to a greater amount of greenness change associated with such a cycle. We further expected that temporary flooded conditions may affect Max_PSD by increasing the difference in NDVI between high-biomass stages with little attenuation and flooded conditions with low NDVI representative of water. Relatedly, frequent flooding could reduce the amplitude of greenness fluctuations by reducing the probability of remote observations of water-free plant biomass. We further expected that sites showing both lower Max_PSD and greater NumPeaksPSD would exhibit greater overall phenological variability due to more complex time series, such as in hydrologically variable sites.We also included the combined frequency of medium and tall vegetation summarized at the NWCA site level . This covariate was used to account for a potentially greater contribution of tall species (particularly woody plants) to site greenness, given a somewhat coarse 250-m spatial resolution of MODIS input data and the potential to obstruct the reflectance from herbaceous vegetation in their understory , both of which were expected to increase phenological variability but for somewhat different reasons (P > 0.05) paths to select the models where all path coefficients were significantly different from 0. We computed the standardized regression weight coefficients (r) to compare model effects and evaluated the fit of the models to hypotheses using (i) the chi-square test , (ii) the ratio of chi-square to degrees of freedom expected to be <3, and (iii) criteria of fit such as comparative fit index expected to be >0.90 for a reasonably good fit. Models not meeting these criteria were not analyzed further  and models in which the diversity variable’s regression β coefficient was not significantly different from the most negative coefficient value, indicating a higher-magnitude stabilizing effect of diversity based on the coefficient 95% confidence intervals.Last, to help interpret the statistical effects of diversity in the presence of covariates, we also compared the regression coefficients of diversity metrics between models with the highest statistical support (within 2 units of AIC


Consistent with previous observations, we found significant phenotypic correlation between the various components of MetS and PTSD severity scores. To examine if this observed symptom correlations stem from a shared genetic background, we conducted genetic correlation analysis using summary statistics data from large-scale genetic studies. Our results show robust positive genetic correlation between PTSD and MetS , and obesity-related components of MetS . Prioritizing genomic regions with larger local genetic correlation implicate three significant loci. Overall, these findings show significant genetic overlap between PTSD and MetS, which may in part account for the markedly increased occurrence of MetS among PTSD patients.Post-traumatic stress disorder (PTSD) is a highly debilitating psychiatric disorder that can be triggered by exposure to extreme trauma. Even if PTSD is primarily a psychiatric condition, it is also characterized by adverse somatic comorbidities. One illness commonly co-occurring with PTSD is Metabolic syndrome (MetS), which is defined by a set of health risk/resilience factors including obesity, elevated blood pressure, lower high-density lipoprotein cholesterol, higher low-density lipoprotein cholesterol, higher triglycerides, higher fasting blood glucose and insulin resistance. Here, phenotypic association between PTSD and components of MetS are tested on a military veteran cohort comprising chronic PTSD presentation ( Post-traumatic stress disorder (PTSD) is a highly debilitating psychiatric disorder that can develop after experiencing extreme traumatic event ,2. BesidWhile PTSD is classified as a mental disorder, chronic PTSD is characterized by somatic comorbidities that affect the whole-body system besides the brain ,9. One oBesides the higher co-occurrence with PTSD, another intriguing fact is the significant phenotypic and genetic association of MetS with other stress-related psychiatric disorders including major depressive disorder (MDD). MDD is a mood disorder that shares a lot of symptomatology with PTSD. In addition to the substantial symptom overlaps, PTSD and MDD also have high genetic overlap ,14. VariMost studies pertaining to understanding the relationship between PTSD and MetS are limited to showing their epidemiologic co-occurrence. Fundamental questions as to the nature of this commonly observed comorbidity are yet to be addressed. What is the relationship between PTSD severity and level of metabolic dysregulation? How much of observed association between PTSD phenotypes and MetS as a whole and its components stem from genetic underpinning? What is the direction of causality, if there is any, between these associations? Owing to the high prevalence and the detrimental consequences of these disorders, answers to these questions have important practical implications. These include how to judiciously prioritize treatments targeting a particular illness from among a set of comorbidities so as to maximize benefit in terms of the overall health of an individual. For example, in the absence of causal influences between co-occurring disorders, targeting one condition will not have a direct impact on reducing risk for the other. Genetic studies of the psychiatric and metabolic traits have recently witnessed analysis with large-scale sample sizes ,19,20,21In this study, we aim to enhance our understanding of the link between PTSD and MetS as well as its components. First, we test the phenotypic association between PTSD phenotypes (PTSD status and symptom severity scores) and multiple metabolic traits using data from the PTSD Systems Biology Consortium (SBC) cohort, a well-characterized cohort comprising US veterans of the Iraq and Afghanistan wars. Then, we estimate genetic correlations between PTSD and metabolic traits using data from large-scale GWAS summary statistics. We also identified pleiotropic genetic regions contributing to the shared genetics between PTSD and MetS. Finally, in order to gain insight into the presence and direction of causal influences between Mets and psychiatric disorders, we conduct Mendelian randomization analysis. p = 1.7E-05 and CAPS . The co-occurrence between PTSD and MetS has been reported in multiple studies including in meta-analysis ,22. BesiOwing to the inclusion criteria of the study recruitment, the distribution of the PTSD symptom severity scores seems to have a bimodal distribution . To probe the effect of this distribution on the observed association, we performed additional tests using the non-parametric Spearman rank correlation test. Results from Spearman rank correlation test also showed significant association between PTSD severity scores and the various components of MetS . Analysin = 1134), we did not find a similar pattern of association between the same MetS components and PCL score . In order to determine whether these phenotypic associations stem from a shared genetic underpinning, we estimated pairwise genetic correlations between PTSD and MetS as well as the individual components of MetS. Based on GWAS summary statistics from recent large-scale studies on MetS-related traits with European-ancestry participants, SNP-array based heritability estimates were computed to ensure they are sufficiently powered and large enough proportion of the phenotype variance is explained. All summary statistics used for further analysis have SNP heritability estimates of more than 5%. Using estimates from LD score regression (LDSC), there is evidence for a statistically significant genetic correlation between PTSD diagnosis and MetS . Despite the strong phenotypic correlation between PTSD and sugar-related traits, the current study did not find corresponding statistically significant genetic correlation. This can be due to the fact that the GWAS summary statistics for these two traits are much less powered  compared to the other traits. Details of genetic correlation estimates between PTSD and various metabolic traits are listed in Obesity-related components (BMI and WHR) also show statistically significant genetic correlations. On the other hand, the remaining components of MetS in which we investigated genetic correlation estimates did not pass Bonferroni multiple-testing corrected Some previous studies reported significant genetic correlation between MetS and depression phenotypes ,23. To cg,local = 0.707, p= 3.30 E-05), (ii) chromosome 20:43.01–44.07 Mb , and (iii) chromosome 4:102.54–104.38 Mb . These regions contain genes previously implicated in genetic studies of relevant traits including SLC39A8 and HNF4A  chromosome 13:111.62–112.32 Mb (rnd HNF4A . Notablyp < 1E-08) and LD independent (pruning with r2 threshold of 0.1 and window of 10 Mb) SNP’s as genetic instruments. Testing the causal hypothesis that PTSD results in MetS using the inverse variance weighted (IVW) Mendelian randomization method did not result in a statistically significant estimate . Similarly, using 146 genome-wide significant and independent SNP’s in the MetS summary statistics, a test of the effect of MetS on PTSD also did not pass a significant threshold .Since the metabolic traits are correlated with chronic but not short-duration PTSD, we hypothesized the direction of causal influence might be from PTSD to metabolic dysregulation, but not the reverse. To test this hypothesis, we first selected 16 genome-wide significant (p = 1.3E-04) rather than from MetS to MDD . This comports with previous reports of the effect of depression phenotypes on metabolic dysregulation [Next, since we could not determine the direction of influence between PTSD and MetS despite the significant genetic correlation, we sought to assess the direction of influence with MDD, which is another stress-related psychiatric disorder with large-scale well-powered genetic study for Mendelian randomization analysis. A similar IVW analysis suggest the direction of influence is from MDD to MetS  and physical ailments  ,25. UndeSome clinical implications of the results of the present study are worth mentioning. First, it is important to acknowledge that the relationship between PTSD and MetS is not limited to increased preponderance in binary case–control comparison. Higher PTSD symptom severity scores are also associated with elevated level of metabolic dysfunction. Second, the epidemiologic link between PTSD and metabolic syndrome may arise from a shared genetic underpinning. Future risk stratification and management strategies can benefit from incorporating this insight. Third, the level of genetic overlap between metabolic traits with PTSD is comparable to that of major depression. Fourth, the direction of causal influence is likely from the psychiatric illnesses leading to metabolic dysfunction, but may not be the other way around. Therefore, interventions that target the psychiatric disorders may also help reduce metabolic-related disease risk, which are some of the leading causes of mortality in the general public. In fact, the high comorbidity with MetS and its components is thought to be a major factor responsible for the markedly high (2 to 3 times higher) mortality rate among PTSD patients ,27. In oMetS is a major risk factor for adverse cardiovascular events, diabetes and all-cause mortality ,29. Its Besides the overall MetS diagnosis, the MetS-related metabolic traits have previously been reported to be associated with PTSD phenotypes. PTSD is reported to be significantly associated with higher BMI, and particularly with central obesity ,34. MultThis study involved estimating the level of genome-wide correlations. Future studies that can identify specific polymorphisms, genes, pathways and metabolites involved in the common pathophysiology of PTSD and metabolic dysfunction are needed. In particular, abundance of many metabolites  is shown to be highly genetically influenced ,41, makiThe findings of the present study should be interpreted in light of its strengths and limitations. Most previous studies focused on comparing the presence and prevalence of MetS and associated metabolic traits between PTSD patients with healthy controls. Here, the phenotypic associations with PTSD were assessed using two quantitative scores of PTSD symptom severity. This approach can capture the effect of disease severity in addition to a binary disease onset. Another strength of the study is that the genetic correlation estimates are obtained from large-scale genetic analysis results. To ensure this summary statistics are well-powered, SNP heritability of the summary statistics data are computed and only those with sufficient minimum threshold are used, resulting in a more reliable genetic correlation estimate. The main limitations of the study are the following. First, to avoid population stratification effects, only genetic studies with European-ancestry participants are collected and analyzed. Therefore, the results with this summary data may not necessarily generalize on other ancestral groups. Second, genetic correlations between psychiatric conditions and metabolic traits are reported to be gender and age dependent . In the PTSD, MetS and its components are heritable traits with large-scale publicly available GWAS summary statistics data, enabling application of modern genetic analysis tools to interrogate the mechanism of influence among them ,46. In tFuture studies need to further investigate many aspects of the pathophysiology of the co-occurrence of PTSD and MetS. These include (i) replicating and refining the current findings with additional datasets as results from new larger cross-ancestry genetic studies become available, (ii) identifying metabolites and other small molecule biochemicals that mediate the effect of genetics on PTSD/MDD, (iii) uncovering specific genes and pathways underpinning the genetic correlations between PTSD/MDD and metabolic dysregulation, and (iv) identifying potential pleiotropic genetic variants that are shared between PTSD and metabolite genetics.The current study involves examining the relationship between PTSD and metabolic dysregulation at genetic and phenotypic levels. These two aspects are done in parallel on independent datasets .The SBC (Systems Biology Cohort) consists of participants from US military veterans who served in OEF (Operation Enduring Freedom) and/or OIF (Operation Iraqi Freedom) ,48. All n = 1134) of the cohort, only PCL is available to assess PTSD symptoms. Metabolic traits  are also measured in the same manner as the SBC dataset. Written informed consent was obtained from all participants in both cohorts and approvals were obtained from all appropriate Institutional Review Boards.The FCC (Fort Campbell Cohort) participants comprises active-duty service members in the US Army with recent PTSD symptom presentation from recent trauma exposure (within 90–180 days of return from deployment) . Given tSeveral large-scale GWAS summary statistics pertaining to MetS or its components as well as PTSD and depression are obtained from public repositories. The PTSD GWAS summary statistics is from the Psychiatric Genomic Consortium (PGC) freeze-2 study of the European-ancestry participants . The stuPreprocessing and quality-control step is done on each of the summary statistics individually as follows. Rare variants  are filtered out. If z-statistics is not given, it is computed from the effect size (regression coefficient or odds-ratios) of the univariate tests (Z = beta/SE or Z = log(OR)/SE). If rsID’s of genetic variants are not provided in the original summary statistics, its rsID is looked up from dbSNP database and inserted as an additional column. After computing SNP array heritability on the given summary statistics, if it does not explain a significant variance of the phenotype (g). Its estimate is obtained from GWAS summary statistics data using cross-trait LD score regression (LDSC) [The proportion of variance of the association between two genetically influenced traits that is attributable to genetic background is known as genetic correlation (rn (LDSC) . A Python (LDSC) .p < 1E-05) associations with PTSD are selected, resulting in 50 independent regions for further analysis. Univariate local heritability analysis on these 50 genomic regions was conducted for PTSD susceptibility. A total of 43 regions with Bonferroni corrected significance (p < 0.05/50 = 0.001) are selected for further bivariate local genetic correlations. Local genetic correlation estimates between PTSD and MetS are analyzed on these 43 genomic regions. Both univariate local heritability and bivariate local genetic correlation analysis are conducted with LAVA  [A predefined LD blocks that was defined using European European-ancestry 1000-genome data is obtained . The whociation) . Regionaciation) . All genp < 5E-08) are selected. To enforce independence among genetic instruments, LD clumping procedure with window distance of 10 Mb and r2 threshold of 0.1 is conducted. For each instrumental variable, the corresponding SNP-outcome association statistics is obtained from the three summary statistics. After ensuring the same effect allele is used in the exposure and outcome summary statistics, palindromic SNP pairs  are removed.Genetic instrumental variables are selected based on association statistics on the exposure phenotype summary statistics  Mendelian randomization analysis is performed using the inverse variance weighted (IVW) method . Briefly