Vibrio cholerae (NOVC) is rare, though bacteremia and hepatobiliary manifestations have been reported. Reduced stomach acid, or hypochlorhydria, can increase risk of V. cholerae infection. We describe a 42-year-old woman with hypochlorhydria due to untreated Helicobacter pylori infection, gastric-bypass surgery, and chronic proton pump inhibitors (PPI) exposure, who developed acute diarrhoea following raw oyster consumption. Her symptoms were attributed to rapid gastric emptying (dumping syndrome) after a negative limited stool work-up. She had persistent diarrhoea, weight loss, and after 5 months was admitted with acute cholecystitis and NOVC bacteremia, requiring cholecystectomy. This is the first reported case of NOVC bacteremia and cholecystitis in a patient with gastric bypass. This case highlights the potential for NOVC biliary carriage, the role of hypochlorhydria as a risk factor for Vibrio infection, and the importance of excluding infectious diarrhoea in patients with new onset of symptoms compatible with dumping syndrome and a relevant travel history.Extra-intestinal infection with non-O1/non-O139 strains of  The datasets generated and/or analysed during the current study are available in the NCBI repository (SAMN27723935).Vibrio cholerae, including the O1 and O139 subtypes, are typically associated with poor drinking water access and suboptimal sanitation. These strains encode the ctx (cholera toxin) and tcpA (toxin-coregulated pilus) genes which are known to cause severe acute diarrhoea and volume depletion .To our knowledge this is the first reported case of NOVC cholecystitis and bacteremia in a patient with prior gastric bypass surgery. Though not immunocompromised, this patient’s primary risk factor for systemic infection was her recent gastric bypass procedure and the resultant hypochlorhydria. Vibrio testing through expanded gastrointestinal multiplex PCR panels or through clinician-directed requests for Vibrio cultures. Clinicians should be aware of their institutional protocols for stool culture workup, as Vibrio is often not routinely assessed. We highlight gastric bypass surgery as a risk factor for V. cholerae infection. Further studies are needed to understand the role of gallbladder carriage in V. cholerae.This case highlights the need for appropriate microbiological testing based on patients’ exposure history and the clinical importance of excluding infectious diarrhoea in patients with new onset of symptoms or ongoing symptoms compatible with dumping syndrome and a relevant travel history. Clinical microbiology labs may offer


Esophageal stenosis is a common complication after endoscopic submucosal dissection (ESD) for early esophageal cancerA 77-year-old patient with esophageal stricture after ESD for early esophageal cancer underwent three endoscopic esophageal stricture expansion procedures over 6 months. Endoscopic examination showed that the patient had irregular stenosis in the middle esophagus, which the gastroscope could not pass. Under white-light and narrow-band imaging , the apEndoscopic cicatricotomy of the esophagus, assisted by submucosal injection.Video 1The esophagus that has undergone multiple expansions will have multiple complex fibrotic areas and severe submucosal adhesions. Submucosal injection-assisted cicatricotomy can aid visualization of the scar and submucosa during the operation, allowing the endoscopists to accurately control the incision site and depth, minimize the damage to normal mucosa, and successfully reduce the risk of perforation and bleeding.Endoscopy_UCTN_Code_TTT_1AO_2AH


Survivin (BIRC5) is a tumor-associated antigen (TAA) overexpressed in various tumors but present at low to undetectable levels in normal tissue. Survivin is known to have a high expression in breast cancer  and triple negative breast cancer). Previous studies have not compared survivin expression levels in DCIS tumor samples to levels in adjacent, normal breast tissue from the same patient. To ensure the effective use of survivin as a target for T cell immunotherapy of breast cancer, it is essential to ascertain the varying levels of survivin expression between DCIS tumor tissue samples and the adjacent normal breast tissue taken from the same patient simultaneously. Next-generation sequencing of RNA (RNA-seq) in normal breast tissue and tumor breast tissue from five women presenting with DCIS for lumpectomy was used to identify sequence variation and expression levels of survivin. The identity of both tumor and adjacent normal tissue samples were corroborated by histopathology. Survivin was overexpressed in human breast tissue tumor samples relative to the corresponding adjacent human normal breast tissue. Wild-type survivin transcripts were the predominant species identified in all tumor tissue sequenced. This study demonstrates upregulated expression of wild type survivin in DCIS tumor tissue versus normal breast tissue taken from the same patient at the same time, and provides evidence that developing selective cytotoxic T lymphocyte (CTL) immunotherapy for DCIS targeting survivin warrants further study. Surgical procedures for the removal of breast cancer tumors are commonly combined with pharmaceutical or radiation therapies to kill the remaining tumor cells in the adjacent tissue and/or metastases . While sImmunotherapy designed to expand cytotoxic T lymphocytes (CTLs) that recognize Major Histocompatibility Class I molecule (MHCI)-presented tumor antigens on tumor cells, including survivin, have shown encouraging results in small clinical trials ,7,8,9. SNormal tissues adjacent to tumors exhibit inflammation and alterations in the extracellular matrix, thereby influencing RNA and protein expression ,15. ExamAll patients in this study had luminal breast cancer tumors, characterized as estrogen receptor-positive, progesterone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative, and low levels of KI-67 expression . Survivi5 mRNA molecules per cell [The survivin transcript levels were higher than those observed in the respective pair-matched normal tissue samples. Given that typical breast cancer cells contain approximately 3–5 × 10per cell , a TPM lper cell . This haper cell . Table 1Tissue sections for pathological analysis of tumor purity were obtained as close as possible to the sample used for sequencing for optimal comparison. These purity calculations were repeated four times before averaging, with all repetitions producing values within 10% of one another. Two of the five patient samples were less than 90% pure; however, these samples still expressed survivin at TPM levels significantly higher than normal tissue without correction based on purity. Further immunohistochemical results are provided in https://www.cancer.gov/tcga, accessed on 1 January 2022). The database creators categorized samples by cancer type, as determined by the immunohistochemical (IHC) assay [The NIH Cancer Genome Atlas Breast Invasive Carcinoma (TCGA-BRCA) database contains nearly 1100 patients with different forms of breast cancer over the past 10 years (C) assay . As illuThis may make survivin a particularly promising target for triple-negative breast cancer, which has few therapeutic options available to significantly improve outcome . Within For most cancer studies reporting RNA-seq expression levels, data from normal tissues adjacent to the tumor are unavailable, requiring databases to provide control RNA-seq levels for differential expression analysis. Although these databases can be valuable for exploring gene expression, the samples were not adjacent to the tumor and were not taken at the same time as the tumor excision. Using gene expression databases as a source of normal expression level controls raises concerns that the samples used could be degraded after formalin-fixed paraffin embedding (FFPE), as well as long ischemia times in deceased donors ,26.In this study, we focused on measuring survivin isoform transcript levels in DCIS. The biological and diagnostic significance of survivin and its various splicing variants has been previously reviewed . BrieflyThe survivin 2B isoform, detected at background transcription levels in this cohort of DCIS samples, is also of general interest. The 2B isoform was reported to have reduced anti-apoptotic activity, possibly due to a disruption of the full length BIR domain and enhance sensitivity to chemotherapy, at least in leukemia . Other sEpidermal growth factor receptor (EGFR), HER2, progesterone receptor (PR), Ki-67, PD-L1 and survivin are important gene markers associated with breast cancer. RNA-seq has higher sensitivity than immunohistochemistry (IHC) assays while also providing a higher throughput evaluation of RNA expression in the whole transcriptome. IHC is the most common assay used in clinical settings to detect breast cancer markers. Previous research has shown that there is a correlation between IHC and RNA-seq data , and curLimitations of this study include the limited sampling of normal tissue from the surgical site, the relative insensitivity of the RNA-seq methods applied in this study, and the potential issue that the tumor tissue was studied in bulk. More recently developed RNA-Seq methods, such as spatial single-cell or subcellular RNA-Seq, will allow for a higher resolution understanding of survivin expression within tumor tissue .Various immunotherapies targeting the tumor-associated antigen survivin (BIRC5) have been described over the past two decades . ClinicaRecent advancements have made immunotherapy a useful tool in the treatment of various cancers. However, the inability of checkpoint inhibitors to show efficacy against tumors not expressing PD-L1  has limiThis study, describing the analysis of snap-frozen samples of tumor and normal breast tissue for gene expression of the survivin protein, showed that five out of the five patients studied had luminal breast cancer tumors secreting survivin at significantly higher levels than adjacent normal tissue taken from the excision site. This suggests that immunotherapy targeting breast cancer may be possible without destroying the normal breast tissue. Further work is required to develop a safe and effective immunotherapy targeting survivin protein TAAs, containing a suite of immunogenic HLA-restricted peptides across a broad population of patients.n = 5) were enrolled in the study based on planned partial mastectomy as a treatment for Ductal Carcinoma in situ. This choice was based on the need to collect both tumor tissue and adjacent normal tissue with the lowest chance of invasive tumor tissue contaminating the normal adjacent tissue. All patients provided informed consent to participate in this study, coincident with the planned surgical partial mastectomy for the removal of previously diagnosed ductal carcinoma.This study was designed as a prospective observational investigation at a tertiary care center in a university hospital. The Institutional Review Board (IRB) of the University of Nevada, Reno, approved the study , and the study was conducted in accordance with the Declaration of Helsinki. Inclusion criteria included the following; female subjects, 18 to 95 years of age having a planned surgical procedure for diagnosis or excisional treatment of all types of breast cancer, and able to provide consent or have a designated individual able to do so. A subgroup of these patients . Whole-exome sequencing was performed on the tumor and patient-matched blood PBMC. The input DNA for all samples was greater than 400 ng. Sequencing libraries were generated from the extracted DNA using the Agilent SureSelectXT2 Human All Exon V6 Kit . Normal and tumor tissue samples were sequenced at 100× and 300× coverage, respectively. Tumor tissue was sequenced at this depth to allow better characterization of variant allele frequencies and other structural variants (data not shown). RNA sequencing (RNA-Seq) was performed on the tumor and normal breast tissues to profile the transcriptome. The input RNA for all samples  was greater than 400 ng. Messenger RNA was captured via poly A tails and prepared for sequencing using NEBNext Ultra II . An Agilent 2100 bioanalyzer  was used to process samples, report the RNA integrity number (RIN), and visualize the ribosomal ratios. All RIN scores from the passing samples were above 6.0, with most samples scoring above 7.5. Normal samples were sequenced at 60 million paired-end reads and tumor samples were sequenced at 120 million paired-end reads. NGS was performed on all samples using NovaSeq6000  with paired-end reads of 150 bp.Human genomic data was uploaded to a secure Health Insurance Portability and Accountability Act (HIPPA)-compliant encrypted cloud storage system with redundant backup. All data were de-identified and organized using randomly generated patient study codes and sample types with associated hard-copy metadata and sample logs maintained in a fireproof locked safe.Genomic files were trimmed using FASTP sequences containing 20 adapters. Low-quality reads and those that were short or contained artifacts were removed during this process. Quality control was performed before and after the read trimming. Sequences were aligned to the GENCODE transcriptome using Kallisto, which pseudo-aligns the reads of individual transcripts per million. The Cancer Genome Atlas Breast Cancer Database Kallisto result files were downloaded and used for comparison ,54,55,56


Cells constantly encounter a wide range of environmental signals and rely on their signaling pathways to initiate reliable responses. Understanding the underlying signaling mechanisms and cellular behaviors requires signal generators capable of providing diverse input signals to deliver to cell systems. Current research efforts are primarily focused on exploring cellular responses to global or local signals, which enable us to understand cellular signaling and behavior in distinct dimensions. This review presents recent advancements in global and local signal generators, highlighting their applications in studying temporal and spatial signaling activity. Global signals can be generated using microfluidic or photochemical approaches. Local signal sources can be created using living or artificial cells in combination with different control methods. We also address the strengths and limitations of each signal generator type, discussing challenges and potential extensions for future research. These approaches are expected to continue to facilitate on-going research to discover novel and intriguing cellular signaling mechanisms. Cells possess the remarkable capability to perceive and respond to a wide array of time-varying signals from their environment. This ability stems from a diverse functional repertoire of genes, proteins, and metabolites that interact in response to various external physical cues, such as matrix stiffness  and fluiThe majority of studies in the field of cell signaling can be broadly categorized into two scenarios: 1) homocellular signaling, which involves signal transduction within identical cell types (monoculture), and 2) heterocellular signaling, which describes signal transmission between two distinct cell types (coculture). In the case of homocellular signaling , a populFurthermore, the microenvironment within the body is subject to rapidly changes influenced by various signaling processes. The presence of transient gradients of signaling molecules facilitates cellular communication and regulates cellular functions. For instance, gonadotropin-releasing hormone (GnRH) is secreted in short pulses, activating the synthesis and release of pituitary gonadotropin hormones, thereby regulating reproductive functions . PulsatiIt is widely recognized that dynamic signal processing are ubiquitous in cellular systems. However, understanding how cells interpret these input signals can be challenging. This challenge arises because population-level measurements often mask the heterogeneous behavior exhibited by individual cells, and conventional methods often lack the ability to generate various types of targeted perturbations other than continuous inputs in signaling pathways, for example, signal molecules simply added in well plates continuously stimulate cells. Moreover, observing cellular events in multiple contexts is essential for multi-dimensional understanding of signaling process, as evident in the distinct cellular responses to global and local inputs . ConsequGlobal signal generators provide uniform inputs that allow for the study of both population-averaged and single-cell responses. Currently, the primary methods employed for generating global inputs include microfluidic molecule delivery and the photodeprotection of caged input molecules. Microfluidic systems can provide a wide range of input modes, such as pulse , continuin vivo biological environments with great accuracy and enable high-content analysis of cells. Microfluidics technology offers precise automation and control of analytical functions, enabling high-resolution manipulation of cells and their microenvironments. With these properties, we can modulate cellular signaling pathways to gain insights into mechanisms underlying cell activation, migration, and intercellular communication. Recent studies investigating temporal signaling dynamics using microfluidics-based global input generators are summarized in In the past decade, microfluidics has made remarkable advancements in exploring temporal cellular behaviors . Microflin vitro, and its flexibility enables easy integration of membrane valves and pumps to create intricate networks of microchannels . Applying a stepwise ramping input of TNFα or interleukine-1β (IL-1β) to fibroblasts revealed that the activity of the NF-κB signaling pathway correlated with the rate of change in cytokine concentrations rather than the absolute cytokine concentrations. In addition, the implementation of sinusoidal inputs was realized using a multiple-layer PDMS device with eight triangular converging valves  by promoting TLR1/2 heterodimerization. In the presence of UV irradiation, trans-P10 is converted to cis-P10, which reduces the activities of APCs by impeding the TLR1/2 heterodimerization  and Resiquimod (R848), which are agonists of Toll-like receptor 7 (TLR7) and TLR7/8, respectively, were conjugated with the photo-protecting group carbamate of 2-(2-nitrophenyl)-propyloxycarbonyl (NPPOC) to suppress their spatial activity. Irradiation with 360 nm UV light deprotected these small-molecule agonists, triggering signal transmission and NF-κB pathway activation in cells  Ryu et . Similarrization . These mPCGlue-NBD, carries multiple guanidinium ion (Gu+) pendants. This functional molecular glue can strongly adhere to the target protein, hepatocyte growth factor (HGF), and cover the region for protein-protein interactions (PPIs) on their surfaces. The PPIs are inactive, suppressing cellular signaling. Upon irradiation with UV light, PCGlue-NBD is photocleaved, reducing the multivalency for the adhesion. Consequently, uncaged HGFs regains its intrinsic PPI affinity toward c-Met, leading to pathway activation and cell migration  or one-dimensional (1D) path  path . The conLiving cell senders serve as natural local signal sources due to their ability to secrete signals within the physiological range. A critical step is the activation of sender cells. This section will discuss recent strategies for the controlled activation of living sender cells, including pre-stimulation, microfluidics-assisted stimulation, photocaged global input, and optogenetic activation. Recent studies on living cell-based local input generators are summarized in To construct a local signaling model, sender cells can be pre-stimulated before cocultured with receiver cells. The activated sender cells become local signal sources, secreting input signals in limited areas. Recently, a diffusion-consumption model has been created using the pre-stimulated T cells as the living senders to produce IL-2, which stimulates surrounding T cell receivers . ImmunofValve-integrated microfluidic devices enable the coculture of a single sender cell  and a population of receiver cells , as well as the control of signal propagation . These din vivo local signaling patterns are typically 2D or 3D. A 2D model of developmental signaling center has been created in microfluidic device . In the presence of 3OC6 HSL, both PFO and BDNF are produced, and BDNF is released through formed PFO pores. In a coculture system, the artificial cells responded to 3OC6 HSL, releasing BDNF that subsequently drives the differentiation of mouse embryonic stem cell-derived neural stem (mNS) cells  and perfringolysin O (PFO) gene expression construct . This syS) cells . CommuniNested (or embedded) architectures involving artificial and living cells provide non-native signaling configurations . In thisGlobal and local signal generators have been utilized in cellular signaling studies to gain insights into the activation of signaling pathways and dynamics of signaling proteins. Each type of generators has its own set of advantages and limitations, which will be discussed in this section .Microfluidic systems have been widely used as global signal generators for investigating temporal signaling dynamics . These sPCGlue-NBD (Another approach of generating global inputs involves light irradiation to induce the photodeprotection of caged input molecules . This meGlue-NBD  or PEG cGlue-NBD  and photLocal signal sources can be established using either living or artificial cell senders. Various strategies have been employed to control the activation of sender cells. A simple 2D signaling model can be constructed by coculturing pre-stimulated living sender cells with receiver cells . This meMicrofluidic cell coculture systems enable controlled local signaling by compartmentalizing sender and receiver cells in closed environments with integrated separation valves. Depending on the sensitivity of receiver cells to global stimuli, sender cells can be either separated from receiver cells  or confiThe photodeprotection of caged input molecules have also been applied in local signal generation . Sender Artificial cells have gained significant attention as substitutes for living cells . These cGlobal and local signal generators have significantly enhanced our understanding of temporal and spatial cellular signaling activities and cellular behaviors. In particular, microfluidic systems have emerged as powerful tools for investigating temporal activity of signaling pathways in single cells  and cellThe development of photocaging and photodeprotection-based global input generators has been a subject of ongoing research for years. This emerging technology has aided our exploration in control of cellular signaling activation. Several small molecule agonists of TLRs conjugated with 2-nitrobenzyl groups have been applied to control the activation of immune signaling pathways . By explLiving cells have been adapted to serve as local signal generators using various approaches, as discussed in this review. These local signal generators can be easily extended to explore other cell types and signaling pathways, offering versatility and flexibility in experimental design. While artificial cells have not been widely applied as local signal generators in observing signaling dynamics in living receiver cells, recent studies have demonstrated their potential in controlled signaling activation in neural and HEK293 cells . The utiIn conclusion, the development of robust platforms for both global and local signal generation holds significant promise in enhancing our understanding of how cells encode and decode diverse input information across spatial and temporal dimensions. The impact of these signal generators is evident in their potential to elucidate the underlying signaling mechanisms governing temporal and spatial signaling dynamics, as well as cellular behaviors. We firmly believe that advancing and expanding upon the techniques discussed in this review will further propel the discovery of novel and intriguing signaling mechanisms.


The Antimicrobial Stewardship Program (ASP) at Nebraska Medicine collaborated with a board-certified allergist to develop a penicillin allergy guidance document for treating inpatients with self-reported allergy. This guidance contains an algorithm for evaluating and safely challenging penicillin-allergic patients with beta-lactams without inpatient allergy consults being available.Following multi-disciplinary review, an order set for beta-lactam graded challenges (GC) was implemented in 2018. This contains recommended monitoring and detailed medication orders to challenge patients with various beta-lactam agents. Inpatient orders for GC from 3/2018–6/2022 were retrospectively reviewed to evaluate ordering characteristics, outcomes of the challenge, and whether documentation of the allergy history was updated. All beta-lactam challenges administered to inpatients were included, and descriptive statistics were performed.n = 150, 96%) were tolerated without any adverse event. There was one reaction (1%) of hives and six (4%) involving a rash, none of which had persistent effects. Allergy information was updated in the electronic health record after 92% of the challenges.Overall, 157 GC were administered; 13 with oral amoxicillin and 144 with intravenous (IV) beta-lactams. Ceftriaxone accounted for the most challenges (43%). All oral challenges were recommended by an Infectious Diseases consult service, as were a majority of IV challenges (60%). Less than one in five were administered in an ICU (19%). Almost all (Both intravenous and oral beta-lactam graded challenges were implemented successfully in a hospital without a regular inpatient allergy consult service. They were well-tolerated, administered primarily in non-ICU settings, and were often ordered by non-specialist services. In patients with a self-reported penicillin allergy, these results demonstrate the utility and safety of a broadly adopted beta-lactam GC process. Penicillin allergy is reported in approximately 7%–10% of patients, which makes it one of the most common medication allergies . Recent Both patients and providers have been hesitant to administer cephalosporins and carbapenems to patients with severe penicillin allergies, even with low rates of reported cross-reactivity. Thus, in 2017, Nebraska Medicine's Antimicrobial Stewardship Program (ASP) in conjunction with the University of Nebraska Medical Center's Division of Allergy and Immunology created a Penicillin Allergy Guidance Document  with a cThe following report describes an updated analysis  on our uPatients with orders for a graded challenge with oral amoxicillin (January 2019–June 2022) or intravenous beta-lactam (March 2018–June 2022) were retrospectively reviewed. Patients were included if they were admitted to Nebraska Medicine and received an intravenous or oral graded challenge and had a reported beta-lactam allergy documented. If patients received single doses of amoxicillin for indications other than an oral challenge, they were excluded. Patients were selected by providers to receive a graded challenge based on the need to receive a beta-lactam antibiotic and ASP's Penicillin Allergy Guidance document for treating inpatients with self-reported allergy.Intravenously administered graded challenges were standardized through an order set within the institution's electronic health record (EHR). This order set contains various beta-lactam antibiotics with detailed administration instructions, rescue medications, associated monitoring to challenge penicillin allergic patients, and requires providers to acknowledge that the patient provided verbal consent, per our institution recommendation, to undergoing the graded challenge. This process was designed to be used for low-risk patients defined as having a non-IgE mediated allergy, or any reaction reported greater than 10 years ago, including IgE mediated reactions, except a severe cutaneous adverse reaction. The challenge was administered with test dose infusions of 1% of the target dose, then 10%, and finally the full dose, each 30 min apart. Oral amoxicillin was not included in the graded challenge order set for the time frame included; these challenges were constructed manually based on the safety parameters from the intravenously administered order set and doses were selected based on previously reported literature –21.The EHR-abstracted data included characteristics of the graded challenge  and patient characteristics . Historical penicillin reactions were recorded and categorized based on the Penicillin Allergy Guidance Document.This review aims to assess ordering, outcomes of the challenge, and allergy documentation. The primary outcome was safety of the graded challenge as defined by characterization of reaction to the graded challenge. Other outcomes included appropriateness of graded challenge, use of rescue medications, need for intensive care unit (ICU) care due to allergic reaction, days of therapy for challenged antibiotic class, and subsequent antibiotic used.Data was abstracted from the EHR by manual review. Descriptive statistics were used including counts and percentages for categorical variables and means and medians for continuous data. This project was assessed by the Institutional Review Board at the University of Nebraska Medical Center as a quality improvement project and the need for full IRB review was waived.Of the 161 intravenous graded challenges ordered, 147 were administered and 144 were IV beta-lactams. The others were discontinued prior to administration for reasons such as new culture susceptibility results. Additionally, of the 216 one-time amoxicillin orders, 203 were excluded due to indications other than an oral challenge. Thirteen oral amoxicillin challenges were administered. See For the intravenous graded challenges , the mosOf the 144 intravenous beta-lactam graded challenges, 137 (96%) were tolerated without any documented adverse event . Of the Of the 13 oral amoxicillin challenges, all were tolerated without any documented adverse event. No patients required ICU level of care or rescue medications . Twelve After the evaluation of graded challenge outcomes, the order set was updated to include oral amoxicillin. Previous institutional guidance did not include recommendations for de-labeling penicillin allergies in the inpatient setting. Therefore our Penicillin Allergy Guidance Document was also revised  to incorWe reviewed our institution's intravenous and oral graded challenges and found that in patients with self-reported penicillin or beta-lactam allergies, graded challenges can be safely administered in a hospital setting and were well tolerated in low-risk patients. This aligned with previous literature assessing outcomes from inpatient beta-lactam allergy guidance at multiple institutions that employed intravenous graded challenges, where 5–10% of patients experienced signs or symptoms of an adverse drug reaction and 3%–5% had confirmed hypersensitivity reactions –25. At tClostridioides difficile infection, respectively.Most ASP-led beta-lactam allergy interventions in the literature focus on penicillin-skin testing; however, in the absence of this option, graded challenges represent an alternative stewardship opportunity to address beta-lactam allergies. The AAAAI/ACAAI updated drug allergy practice parameter places a greater emphasis on single to multi-step graded challenges and penicillin allergy de-labeling instead of penicillin skin testing . This isThis review demonstrated that intravenous and oral graded challenges can be administered in a non-ICU level of care and without infectious diseases or allergy consultation. Previous literature supports the safety of both inpatient and outpatient intravenous and/or oral graded challenges , 15, 25.Patient allergy profile updates and documentation of successful graded challenge completion occurred for over 90% of patients. Drug allergy documentation and updated drug allergy profiles are important not only for patient safety but also quality of care . InpatieFinally, this review of graded challenges demonstrated the applicability of implementation, utilization, and adherence to ASP Penicillin Allergy Guidance at an academic medical center. For our intravenous graded challenges, all were considered appropriate and for the oral amoxicillin graded challenges, 92% were appropriate. This demonstrated that among appropriately and carefully selected patients with self-reported penicillin or other beta-lactam allergies, graded challenges were safe and well-tolerated with very low adverse event rates . We attribute these lower than previously reported adverse event rates to the close adherence of our institution to our Penicillin Allergy Guidance algorithms  3). Fur. Fur3). There are many strengths to our review, but we recognize that there are also several limitations. First, this was a retrospective, single-center review, limiting generalization. Second, the majority of the graded challenges were intravenous, with few oral amoxicillin challenges. However, we saw this as an opportunity to provide updated penicillin allergy guidance that incorporates an oral amoxicillin challenge and additional education to our clinicians on the safety, efficacy, and utility of oral amoxicillin challenges to help de-label penicillin allergies inpatient. Additionally, while these numbers were low, we recognize that this warrants further study to determine if a two-step oral amoxicillin challenge is required instead of the one-step challenge we utilized. Third, we did not compare our graded challenges with penicillin skin testing for patients with self-reported penicillin allergies; however, this is in line with the more recent drug allergy practice parameter and since no patients had documented follow-up with allergy after hospital discharge. Finally, we did not prospectively follow the patients administered a graded challenge to determine how this impacted selection of any future antimicrobial courses after the first. However, during this review period there were no repeated graded challenges in the same patient, which we attribute to the high percentage of updated allergy profiles.Thus, our review demonstrated that based on previous and current drug allergy practice parameter updates in combination with ASP allergy guidance, both intravenous and oral graded challenges are safe and well-tolerated in an inpatient population.


The coronavirus (COVID-19) pandemic has killed more than six million people and disrupted health care systems globally. In the United States alone, more than one million people have died from COVID-19 infections. At the start of the pandemic, nearly all aspects of our lives paused to prevent the spread of the novel coronavirus. Many institutions of higher education transitioned to remote learning and enacted social distancing measures. This study examined the health needs and vulnerabilities of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) college students at the start of the COVID-19 pandemic in the United States.We fielded a rapid-response online survey between April and June of 2020. We recruited 578 LGBTQ-identifying college students aged 18 years and older by reaching out to LGBTQ-serving organizations on 254 college campuses and via targeted social media advertising.Approximately 40% of LGBTQ college students surveyed were dissatisfied with life at the start of the COVID-19 pandemic, and almost all (90%) were concerned that COVID-19 would threaten their mental health. Moreover, about 40% of LGBTQ college students reported unmet mental health needs, and 28% were worried about seeking care during the pandemic because of their LGBTQ identity. One out of four LGBTQ college students had to go back in the closet because of the pandemic, and approximately 40% were concerned about their finances or personal safety during the COVID-19 pandemic. Some of these adverse outcomes were prominent among younger students, Hispanic/Latinx students, and students with unsupportive families or colleges.Our study adds novel findings to the large body of research demonstrating that LGBTQ college students experienced distress and elevated mental health needs early in the pandemic. Future research should examine the long-term consequences of the pandemic among LGBTQ and other minoritized college students. Public health policymakers, health care providers, and college and university officials should provide LGBTQ students affirming emotional supports and services to ensure their success as the COVID-19 pandemic transitions to endemic.The online version contains supplementary material available at 10.1186/s12889-023-15909-z. The novel coronavirus disease COVID-19) pandemic has led to more than 6 million deaths globally, including more than 1 million deaths in the United States 9 pandemi which afn = 36,875) sample of college students from at least 28 universities, found that one-fifth of participants reported symptoms of depression and nearly one-third of participants reported symptoms of anxiety by fall of 2020.A growing body of research has documented the mental health toll of COVID-19 on college and university students across the United States . An online survey of 725 full-time college students found that approximately 40% of respondents somewhat agreed or agreed with the statement that they were so anxious about COVID-19 that they “couldn’t pay attention to anything else” , a largeA subpopulation of college and university students who already experienced pre-existing disparities in mental and physical health includes lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) students , 8. LGBTSeveral peer-reviewed studies  have examined the health and wellbeing of LGBTQ college students during the COVID-19 pandemic  and whether they agreed (versus disagreed) that the COVID-19 pandemic threatens their mental health. Next, we measured three dimensions of health care access. We assessed whether LGBTQ students were unable to receive medical care or unable to receive mental health care because of cost, stay-at-home order restrictions, or other reasons (multiple options could have been selected). LGBTQ college students were also asked the extent that they were worried about seeking health care because of their LGBTQ status should they become infected with COVID-19 . Finally, we examined whether LGBTQ college students reported that they have gone back into the closet to some extent because of the COVID-19pandemic, whether the COVID-19 pandemic made participants concerned about their personal finances, or if the COVID-19 pandemic put them in a position where they were concerned about their personal safety.First, we used descriptive statistics to characterize the study sample. We examined the following sociodemographic characteristics of our sample of LGBTQ college students: sexual orientation , gender identity , age in years , race/ethnicity . We also gauged the extent that participant lives were disrupted by COVID-19 , their risk aversions and concerns about COVID-19 , and whether the participant, a family member, or a close friend tested positive for COVID-19. Finally, we examined the following two social supports which may buffer adverse experiences during the COVID-19 pandemic: whether the participant’s immediate family  were supportive of their LGBTQ identity, and whether the participant felt supported by their college or university’s LGBTQ office during the COVID-19 pandemic.After describing the sample, we estimated fully adjusted multivariable logistic regression models to identify the subpopulations at greatest risk for each outcome of interest. All logistic regression models controlled for sexual orientation, gender identity, age, race/ethnicity, experiences and concerns with COVID-19, and social supports from the participant’s family and college. All logistic regression results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI). This study was deemed exempt from full review by the Vanderbilt University Institutional Review Board.Table Table Approximately 40% of LGBTQ college students were dissatisfied with life, and this prevalence was significantly higher for younger LGBTQ college students aged 18–20 years  compared to older LGBTQ college students aged 25–29 years. LGBTQ students with families that were unsupportive or unaware  or neutral  about their LGBTQ status were also more likely to be dissatisfied with life compared to LGBTQ college students with supportive families. Almost all (90%) LGBTQ college students agreed that COVID-19 posed a threat to their mental health, and these concerns were elevated for LGBTQ college students who indicated that COVID-19 disrupted their life by a fair amount  or a great deal  compared to those whose lives were not disrupted by COVID-19.Table Nearly 40% of LGBTQ college students reported unmet mental health care needs. The odds of unmet mental health care needs were significantly higher for gender non-conforming students , genderqueer students , LGBTQ college students who knew someone that had tested positive for COVID-19 , LGBTQ college students with families that were neutral  or unsupportive  of the participant’s LGBTQ status, and those not feeling enough support from their college or university LGBTQ office .Approximately 28% of LGBTQ college students were worried about seeking care at the start of the pandemic because of their sexual orientation or gender identity. These concerns were significantly higher for LGBTQ college students who identified as transgender , non-binary , gender non-conforming , agender , genderqueer , or other gender-diverse identities  compared to cisgender men. Hispanic and Latinx students  also expressed elevated concerns about seeking care because of their LGBTQ identity compared to their White peers.Table This study provides a more in-depth examination of LGBTQ college student health and wellbeing compared to our previously reported analysis . The premachismo, familism, or religious beliefs of the family [We found consistent health vulnerabilities among a subset of LGBTQ college students. For instance, Hispanic/Latinx students were more likely to report poor/fair self-rated health, elevated levels of unmet medical care needs, and concerns about seeking medical care because of their LGBTQ status compared to White LGBTQ students. This finding should serve as a reminder that intersectional approaches to research, policy, and practice remain critical. Some Hispanic/Latinx LGBTQ college students may experience distress when coming out to their families due to e family . Therefoe family .We also found that, compared to cisgender men, transgender and gender diverse  students were more likely to report poor/fair self-rated health, personal safety concerns, unmet medical care needs, and concerns about seeking mental health care because of their gender identities. These findings may exacerbate underlying mental health disparities faced by gender diverse adolescents and young adults . Public LGBTQ students who did not feel supported by their college or university also reported significantly greater levels of unmet medical care and mental health care needs. Colleges should consider mitigating the impact of hunger, homelessness, financial challenges, and lack of access to the internet and/or technology – issues which impact all students but may be particularly pronounced for LGBTQ students during and after the COVID-19 pandemic. Some research suggests that novel zoonotic viruses will be more common as global temperatures continue to rise . Thus, iMeanwhile, many residential students rely on the student health centers and campus resources while attending college. Indeed, evidence suggests that LGBTQ students are more likely to seek on-campus mental health services compared to non-LGBTQ students . CollegeLGBTQ college students with families that were unsupportive or unaware of the participant’s LGBTQ status reported poor/fair health, dissatisfaction with life, unmet mental health care needs, and having to go back into the closet during the COVID-19 pandemic. Other studies have also found that returning to parental homes during COVID-19 was associated with LGBTQ identity concealment and bans on seeing romantic or sexual partners , 23. ColLimitations of this study include its nonrandom-based sampling that may not be generalizable to the entire LGBTQ college student population. Moreover, we were limited by the sample sizes based on volunteered participation. Thus, small sample sizes prevented us from exploring specific identities with fewer participants . Our study was also limited by selection bias and may be missing LGBTQ college students who were unhoused, lacking internet access, or were not comfortable responding to an LGBTQ-focused online survey. Our targeted advertisements may have also missed students who were avoiding or unable to access social media because of privacy concerns, stressful news coverage, or traumatic experiences of returning home. Finally, our sample only included LGBTQ college students in the United States, and data from non-LGBTQ college students were not collected. Future studies should leverage population-based samples, when available, to address these concerns.While the case count and death toll due to COVID-19 rises as we transition from a COVID-19 pandemic to endemic infection, the virus has exacerbated many of the contextual issues that already impacted LGBTQ college students before the pandemic took hold. Several studies have documented the adverse mental and behavioral health impacts of the pandemic on LGBTQ college students. We provide more evidence to document the experiences of LGBTQ college students at the start of the pandemic with a focus on self-rated health, personal safety, and access to care, finding that large proportions of LGBTQ college students were dissatisfied with life and concerned about their mental health, finances, and safety, and faced unsupportive families and unmet medical and mental health care needs. Even within this group, there are important intragroup differences to recognize. LGBTQ students of color, transgender students, and gender-diverse students have a greater likelihood of enduring worse physical health, mental health, and access to care. While the long-term effects of the pandemic on LGBTQ students are still unknown, findings from the earliest days of the pandemic can inform best practices for achieving LGBTQ health equity among young adults enrolled in colleges and universities during future public health emergencies. Ensuring everyone’s safety and wellbeing during and following the pandemic will have lasting effects on reducing health disparities.Additional file 1.


The 2018 Changchun Changsheng vaccine incident is an emergent public health event in China with reports of DTaP vaccines with compromised efficacy. This study aimed to estimate the impact of the vaccine incident on real-world vaccination behaviors in China.A cross-sectional survey was conducted in ten provinces in 2019. Vaccination records were collected from 5294 children aged 6-59 months, with information on 75,579 vaccine doses for seven National Immunization Program (NIP) vaccines and two non-NIP vaccines received from 2014 to 2019. Chi-square test, interrupted time series, and logistic regression were used to evaluate the impacts of vaccine incident on vaccination delay, measured as the proportion of delayed doses out of total doses in schedule.p = 0.000) and > 3 months  for DTaP vaccine after the incident. By scaling nationally, there will be extra 2.1 million doses delayed ≤ 3 months and 2.8 million doses delayed > 3 months in the year following this incident. More guardians choose expensive private-market substitutes containing DTaP elements over government-funded DTaP vaccines. Controlling for socio-demographic factors, doses scheduled after the incident have higher odds of delays for DTaP vaccine  and other NIP vaccines , but not for non-NIP vaccines.Here we show significant increases in doses delayed ≤ 3 months (19.12% to 22.51%, The observed delays in the incident-involved DTaP vaccine immunization reflect the negative effects of the vaccine incident on vaccination behaviors under the NIP. However, its effects seem minimal for non-NIP vaccines. In the 2018 Changchun Changsheng vaccine incident, the vaccine manufacturer was accused of producing substandard vaccines with compromised efficacy. This study assessed the impacts of the vaccine incident on subsequent vaccination of children in China. We found that vaccinations occurred later than normal for the specific vaccine involved in the incident, but there was no impact on the timing of other childhood vaccines. Children’s guardians also chose different vaccines from that involved in the vaccine incident. Information about how children’s guardians reacted to this incident could be used to improve the information provided in future about childhood vaccination, and be used to decide how vaccination programs could respond following similar incidents. Hou, Lai et al. estimate the impact of reports regarding a childhood vaccine with compromised efficacy on subsequent vaccination behaviors. The administration of the reported vaccine was delayed, while there was minimal effect on other vaccinations. In the age of social media, misinformation around vaccine safety and anti-vaccine movements have proliferated2, and vaccine hesitancy has been considered one of the top ten threats to global health by the World Health Organization3. Vaccine incidents worldwide, such as the misreporting of the association between measles-mumps-rubella (MMR) vaccine and autism4 and the suspected safety concerns around human papillomavirus vaccines in Japan5, have contributed to this growing global health threat. Maintaining public confidence and acceptance of vaccines has become increasingly important as timely vaccination is a major defense against new and emerging disease outbreaks, such as the COVID-19 pandemic6.Receiving recommended childhood vaccinations on schedule is a cornerstone of public health, but incidents involving vaccine safety concerns affect public confidence in and timely uptake of vaccines8. The most recent and widespread one is the Changchun Changsheng vaccine incident, as a major public health event with extensive social influence. In July 2018, Changchun Changsheng Biotechnology Company was charged by China Food and Drug Administration (CFDA) with two counts of malpractice: (i) manufacturing and selling substandard diphtheria-tetanus-acellular-pertussis (DTaP) vaccines (November 2017), and (ii) illegal production of freeze-dried rabies vaccines by making up production and inspection records (July 2018)9. As one of these contraventions, the titer indicators of the sample-test DTaP vaccines produced by Changchun Changsheng Biotechnology Company were detected to be substandard based on the requirements of the CFDA, resulting in 247,359 substandard DTaP vaccines being administered to Chinese children9. The CFDA clarified that the affected vaccines were not fully efficacious, but met safety standards and would not directly harm children’s health. Although no long-term sequelae or deaths were officially reported as a result of these substandard vaccines, claims that the substandard vaccines were poisonous spread widely on the internet and social media sites. This incident evoked nationwide anxiety about the safety of vaccines and vaccine production in China10. After regulatory investigations, this company was fined $1.3 billion and declared bankrupt11. This incident culminated in the rapid enactment of the first Vaccine Administration Act in just one year12.China has experienced a series of serious vaccine incidents over the last decade that have significantly undermined public confidence in vaccines17, none have drawn links from attitudes about vaccines to vaccination outcomes, such as vaccination delays or refusal. Some researchers believe that this incident was unlikely to have affected childhood vaccination rates due to the widespread support for the government-funded National Immunization Program (NIP) combined with strict vaccination requirements for school enrollment in China18. However, up to now there has been little evidence to substantiate this. There is also little literature to examine the effects of vaccine incidents on individuals’ vaccination behaviors across the world. Using data from a nationwide survey with childhood vaccination records, our study aims to evaluate the effect of the Changchun Changsheng vaccine incident on vaccination behaviors, especially focusing on the degree and duration of its effect and differential effects across vaccine types. This would provide evidence to fight potential vaccine incidents or crises in the future, particularly in the dual era of the COVID-19 pandemic and infodemic for mass vaccination, such as the administration of expired COVID-19 vaccines.Although a series of cross-sectional surveys on vaccine confidence conducted following this vaccine incident reported a loss of public confidenceIn this study, significant increases in delayed doses are observed following the vaccine incident for the DTaP vaccine and some other NIP vaccines, while no significant changes are observed for non-NIP vaccines. After the incident, more guardians choose the self-paid quadrivalent DTaP-Hib or pentavalent DTaP-IPV/Hib doses over government-funded DTaP vaccines involved in the incident.We conducted a national cross-sectional survey from August to October 2019, around one year after the Changchun Changsheng vaccine incident, and collected children’s vaccination records till the survey time. A total of 148 vaccination centers  from 10 provinces/provincial-level cities were approached to join an on-site survey on childhood vaccination records and household characteristics for children aged 6-59 months. This study was approved by the Peking University Institutional Review Board (IRB00001052-19076) and registered at clinicaltrials.gov (NCT04038333).20. First, 10 of 31 provinces/provincial-level cities were selected as our study sites in mainland China based on geographical location and financial governance division. Second, a capital city and a non-capital city were selected in each province . Third, two subdistricts/counties were chosen in each city or district. Fourth, in each subdistrict/county, three to four communities and the corresponding vaccination centers were sampled according to socio-economic strata. Fifth, guardians (parents or grandparents) of all children aged 6–59 months visiting the sampled vaccination centers on a given day during the survey period were invited to participate in the survey. In China, all children under five years of age are supposed to receive NIP vaccines based on the routine vaccination schedule at these vaccination centers. Thus, the on-site survey participants could be a representative sample of the local children, as the NIP vaccine coverage reached around 99% in China in 2019 according to official statistics21.A pilot study was conducted for 30 guardians of children to engage in the design of the study and survey questionnaire in a non-study-site community. The formal survey adopted a multistage cluster sampling method, as extensively elaborated in Supplementary Note 122. Written informed consent was obtained from children’s guardians.Guardians of children were interviewed by trained interviewers using an online questionnaire system on a portable Android device (PAD) which allowed quality control in a timely manner. The survey questionnaire covered the socio-demographic characteristics of the children  and their guardians . Using PAD, we took snapshots of children’s vaccination records where the type and date of different vaccine doses received by each child were clearly written or printedThe sample size was initially set to 3840 , a total of 75,579 vaccine doses received from 2014 to 2019 were reported for the nine types of vaccines mentioned above.The outcome of interest was vaccination delay, and this outcome was compared before and after the vaccine incident. In this dose-based study, vaccination delay was measured as the proportion of delayed doses out of the total doses on schedule, and the delayed doses were defined as those not administered in the vaccination window. For the first dose of each vaccine (or only dose of a single-dose vaccine), the vaccination window was defined as the entire month of age at which the vaccine is scheduled  short-term delay where vaccine dose is delayed but vaccinated within 3 months beyond the vaccination window, and (ii) long-term delay where vaccine dose is delayed for more than 3 months beyond the vaccination window25. We then compared the total proportions of delayed doses before and after the vaccine incident using the chi-square test, and adopted an equal time period restricted to Jul 2017-May 2018 (before the incident) and Jul 2018-May 2019 (after the incident) as a sensitivity analysis to explore the robustness of the comparison.Frequencies and proportions were used to describe the characteristics of children and their guardians. We conducted an interrupted time series analysis to examine the impact of the vaccine incident on vaccination delay across vaccine types, and its impact was modeled using a segmented generalized linear model (GLM) with pre-incident trends  and the weekly proportion of delayed doses in post-incident period Logistic regression was used to evaluate the association between vaccine incident and vaccination delays, and multinomial logistic regression was further adopted to investigate its associations with short-term and long-term delays separately. The dependent variable was whether one vaccine dose was delayed or not according to the vaccination schedule, and independent variables included whether the dose was scheduled after the vaccine incident, and the socio-demographic characteristics of children and their guardians.In addition, both trivalent DTaP vaccine in NIP and quadrivalent DTaP-Hib or pentavalent DTaP-IPV/Hib vaccine outside the NIP are available for children in China. In the Changchun Changsheng vaccine incident, substandard vaccines were only reported for trivalent DTaP vaccines. Thus, guardians’ choice of different vaccines containing DTaP antigens was also examined to understand the change in vaccination behaviors after the vaccine incident. We then conducted additional analyses to explore the factors associated with the decision to procure self-paid vaccines.p-value below 0.05 was considered statistically significant in the present study. All data were analyzed using Stata version 17.0 26.Odds ratio (OR), relative-risk ratio (RRR), and their 95% confidence intervals (CIs) were presented. A two-sided Further information on research design is available in the 27. Additionally, the study identified four age categories, namely, < 1, 1-, 2-, and 3-5 years old, which accounted for 27.18%, 29.22%, 18.53%, and 25.07%, respectively. While the distribution of age groups was not fully consistent with the yearbook, this can be attributed to the fact that the targeted children of immunization ages tended to be younger (Supplementary Table Table p = 0.001), a significant and immediate reduction in the level  but a significant increase in the slope  of delay ≤ 3 months, and a significant and immediate increase in the level of delay > 3 months  following the vaccine incident. However, we did not find any significant change in levels and slopes of other NIP vaccination delays after the vaccine incident. For weekly proportions of delayed non-NIP vaccine doses, we found a significant and immediate reduction in the levels of overall delay  and delay > 3 months  after the vaccine incident, but no significant change was found on the slopes. A closer look at the trend before and after the incident can be found in Supplementary Fig. Figure p = 0.000), doses delayed ≤ 3 months , and doses delayed > 3 months  were observed for overall surveyed NIP vaccines. Among them, DTaP vaccines showed the highest increases in vaccination delay after the incident: the proportion of overall delayed DTaP doses increased from 26.29% to 34.33% (p = 0.000), the proportion of doses delayed ≤ 3 months increased from 19.12% to 22.51% (p = 0.000), and the proportion of doses delayed > 3 months increased from 7.17% to 11.82% (p = 0.000). By scaling these vaccination delays nationally, the Changchun Changshen vaccine incident would lead to an extra 2,062,168 doses delayed ≤ 3 months and 2,828,638 doses delayed > 3 months for the four-dose DTaP vaccines when extrapolating these delayed proportions to the 2018 national live birth cohort in China 28.Table p = 0.000) but a significant decline for Polio doses  following the incident. Besides, no significant changes were observed for vaccination delays of two non-NIP vaccines, i.e. Hib and Varicella vaccines. The sensitivity analysis with a restricted study period (Jul 2017–May 2018 and Jul 2018–May 2019) indicated similar results  and other six NIP vaccines as a whole , while no significant association was found between the vaccine incident and non-NIP vaccination  following the vaccine incident, which was mainly driven by long-term vaccination delay. The risk of long-term delay of DTaP vaccination (from 7% to 12%) increased to a larger extent compared to short-term delay (from 19% to 22%). These indicated that the vaccine incident was negatively associated with timely vaccination, especially for the incident-involved DTaP vaccines. Our findings were consistent with research on other vaccine incidents worldwide using aggregated vaccination data. Rumors about the safety of oral polio vaccine led to an eleven-month boycott of polio vaccine and a substantial decrease in its coverage with only 13% of children aged 12–23 months fully vaccinated in Nigeria in 2003–2004, reaching the lowest point since 199832. If no switch from low-efficacy trivalent DTaP vaccines to quadrivalent DTaP-Hib or pentavalent DTaP-IPV/Hib vaccines, there would be more and/or longer delays of DTaP vaccination. This shift in guardians’ choice due to the vaccine incident revealed a public avoidance of incident-involved vaccines, despite imposing a large financial burden on the families involved. In 2018, the procurement price was 39 US Dollars for a quadrivalent DTaP-Hib dose and 84 US Dollars for a pentavalent DTaP-IPV/Hib dose. This burden may be mitigated by appropriate government action to ensure the safety of government-provided vaccines, the timeliness of vaccination service delivery, and the accurate communication of key information to the public. Moreover, sufficient preparation is also necessary for the demand surges for self-paid alternative vaccines.Our results also demonstrated a shift in guardians’ choice between different vaccines containing DTaP antigens following the vaccine incident. In the Changchun Changsheng vaccine incident, substandard vaccines were only reported for trivalent DTaP vaccines which are provided for free in the NIP, but were not reported for quadrivalent DTaP-Hib or pentavalent DTaP-IPV/Hib vaccines which rely on out-of-pocket payments by the guardians. We found that after the vaccine incident, guardians reduced the use of trivalent DTaP vaccines, but increased the use of quadrivalent DTaP-Hib or pentavalent DTaP-IPV/Hib vaccines accordingly. This was consistent with a previous study which found that seven months after the Changchun Changsheng vaccine incident, 10.80% of parents in Guangzhou city were reported to choose self-paid vaccines in general over government-provided vaccines for their children12. These government responses may partly offset the negative impacts of this incident. Without government remedy and respondents’ switch to self-paid alternative vaccines, we may even find more and/or longer delays of DTaP vaccination.Fortunately, following the 2018 Changchun Changsheng vaccine incident, revaccination was immediately scheduled for children who had received substandard DTaP vaccines, and the Chinese government passed the first Vaccine Administration Act, which aims to strengthen government supervision of the whole process from vaccine development, production to distribution33. Immediate actions and adequate responses are required to curb its negative impacts. An effective surveillance system targeting vaccine safety may help early warn potential safety risks during mass vaccination. When vaccine incidents occur, the government should conduct thorough investigations into the incidents and promptly implement measures to revise the vaccination plans. At the same time, transparent internal and external communication is crucial for properly responding to vaccine incidents. Effective and precise communication of existing information by officials has the potential to foster public confidence, irrespective of the ongoing nature of the investigation34. Additionally, proactive measures should be taken to counteract the dissemination of misinformation35.It is necessary to early prepare and timely respond to vaccine incidents, especially facing public health emergencies. During the COVID-19 pandemic, COVID-19 vaccine-related events frequently occurred, and several vaccines have been suspended or withdrawn, which jeopardized public trust in vaccination and hindered the global efforts to control the pandemic21. Fourth, non-vaccination cannot be determined using survey data or vaccination records since young children may finally get vaccinated after the survey time. Therefore, we measured long-term delays of vaccination encompassing individuals who remained unvaccinated until the survey time, instead of focusing solely on non-vaccination, and substantial delays in vaccination may lead to a heavy burden of vaccine-preventable diseases.This study has several limitations. First, we only conducted the cross-sectional survey after the vaccine incident and no survey data are available before it, although we had access to vaccination records before the incident. Second, around 20% of participants declined to provide their complete vaccination records (19.26%) or the records were illegible due to blurred pictures (1.35%), which may have led to selection bias. However, the sex and age distribution among children included in this study were similar to the Chinese population eligible for vaccination. Third, potential bias may be introduced when conducting vaccination-related surveys in vaccination centers since guardians who decided to reject all vaccines following the vaccine incident would not be part of the sampling frame (they would not appear at the vaccination center), so our findings may underestimate the impact of the incident. However, this bias would be of limited magnitude as the coverage rate of more than one NIP dose is nearly 100% in China in 2019The 2018 Changchun Changsheng vaccine incident in China was associated with an increase in the proportions of delayed vaccine doses, especially for DTaP vaccines that were involved in the incident. By scaling nationally, there would be an estimated extra 2.1 million doses delayed ≤ 3 months and 2.8 million doses delayed >3 months or even unvaccinated for the four-dose DTaP vaccine in the year following this incident. After the vaccine incident, more guardians chose the relatively more expensive private-market substitutes containing DTaP elements over government-funded DTaP vaccines involved in the incident, imposing a financial burden on families. This study evaluated the changes in individuals’ vaccination behavior, which might provide policy implications for potential vaccine incidents in the future, particularly in the era of the COVID-19 pandemic with mass vaccination.Supplementary InformationReporting Summary


Considerable evidence has been reported that tobacco use could cause alterations in gut microbiota composition. The microbiota-gut–brain axis also in turn hinted at a possible contribution of the gut microbiota to smoking. However, population-level studies with a higher evidence level for causality are lacking.This study utilized the summary-level data of respective genome-wide association study (GWAS) for 211 gut microbial taxa and five smoking phenotypes to reveal the causal association between the gut microbiota and tobacco smoking. Two-sample bidirectional Mendelian randomization (MR) design was deployed and comprehensively sensitive analyses were followed to validate the robustness of results. We further performed multivariable MR to evaluate the effect of neurotransmitter-associated metabolites on observed associations.Intestinimonas, Catenibacterium, and Ruminococcaceae, observed from previous studies) with boosted evidence level and identified another 13 taxa which may be causally affected by tobacco smoking. As for the other direction, we revealed that smoking behaviors could be potential consequence of specific taxa abundance. Combining with existing observational evidence, we provided novel insights regarding a positive feedback loop of smoking through Actinobacteria and indicated a potential mechanism for the link between parental smoking and early smoking initiation of their children driven by Bifidobacterium. The multivariable MR results suggested that neurotransmitter-associated metabolites  probably played a role in the action pathway from the gut microbiota to smoking, especially for Actinobacteria and Peptococcus.Our univariable MR results confirmed the effects of smoking on three taxa  and in turn smoking on specific gut microbes. Our findings highlighted the hazards of tobacco use for gut flora dysbiosis and shed light on the potential role of specific gut microbiota for smoking behaviors.The online version contains supplementary material available at 10.1186/s12916-023-02863-1. Bifidobacterium (the representative bacteria of probiotics) for example, existing population studies unanimously found that the abundance of Bifidobacterium was significantly decreased in current smokers compared with non-smokers, regardless of the ethnicities  , which was in line with the evidence from a mice model showing that exposure to the major cigarette smoke carcinogens (NNK plus BaP) could elevate fecal level of Intestinimonas [Catenibacterium[g]  as well as lower abundance of RuminococcaceaeNK4A214[g]  and RuminococcaceaeUCG005[g] , corroborating previous observational findings from two cross-sectional studies based on a Bangladeshi population [Pasteurellales[o] , Pasteurellaceae[f] , Christensenellaceae[f] , ChristensenellaceaeR[g] , and Romboutsia[g] . A higher genetically predicted age of smoking initiation was causally related to a higher abundance of Lactococcus[g] , but a lower abundance of Eisenbergiella[g] . Neither horizontal pleiotropy nor heterogeneity (among IVs) was detected at statistically significant levels . The results estimated by cML-MA method was highly consistent with the estimates using IVW. The FDR adjusted P-value and the family-wised corrected P-value could be found in Additional file The results of IVW analyses showed that the genetic liability for smoking initiation had a causal contribution to an increased abundance of inimonas  . Estimated by IVW test, six taxa were identified, after FDR correction, to reach a statistical significance. Concordant results were observed using cML-MA method , Actinobacteria[c] , Bifidobacteriales[o] , Bifidobacteriaceae[f] , and Bifidobacterium[g]  were negatively associated with the number of cigarettes smoked per day. Increased abundance of Actinobacteria[p] , Bifidobacteriales[o] , Bifidobacteriaceae[f] , and Bifidobacterium[g]  lead to later smoking initiation. When considering lifetime smoking as an outcome, the results showed a trend similar to that of cigarettes per day analysis . Heterogeneity was not found among SNPs .The MR analysis revealed that the abundance of β-coefficients .Another two key findings are displayed in Fig. Considering the possible contribution of serum metabolites on the progress from the gut microbiota to smoking, we used multivariable MR for observed significant associations  and Peptococcus[g] (P = 0.502) on lifetime smoking, while the majority of results remained robust. Another change worth mentioning is that, by making rough comparisons, relatively lower β-coefficient  for the associations between the gut microbiota and age of initiation were observed compared with the results without adjustment for the metabolites. Subsequently, focused on Actinobacteria[c] and Peptococcus[g], we implemented adjustment of one metabolite at a time. Signals of decline in significance of association were detected for tryptophan , tyrosine , and valerate (P = 0.218 for Peptococcus[g]). Additionally, the results of MVMR-Egger indicated that our multivariable MR estimates were unlikely biased by pleiotropy (most of Pfor MVMR-Egger intercept > 0.05).When adjusting the six metabolites together using MVMR-IVW, we found a noticeable increase in The intriguing finding was presented in Fig. To our best knowledge, this work is among the first to systematically evaluate the causal relationships between the gut microbiota and tobacco use from a genetic perspective. This two-sample MR study gave reasonably strong evidence that genetically predicted abundance of specific gut microbes play non-negligible roles in the occurrence and progression of cigarette smoking, in which, metabolites may be participating. As for the other direction, the MR confirmed and strengthened the role of smoking on the gut microbiota. Leveraging the power of molecular genetic markers as instrumental variables, the MR approaches largely avoided the interference of confounders  and reversed causality which make regular observational study vulnerable .Actinobacteria while our results found that a lower abundance of Actinobacteria may cause an increase in the number of cigarettes smoked per day, i.e., worse smoking status. More severe smoking conditions may in turn cause a further diminishment in Actinobacteria abundance, implying a potential positive feedback effect  versus between genetic variants and Cigarettes Per Day. The slope of each line represents the causal effect estimate using the corresponding MR analysis model, and the intercept can be interpreted as an estimate of the average horizontal pleiotropic effect across the genetic variants. Figure S3. Forest plot of individual SNP estimates and summary estimates for the causal associations between Actinobacteria[p] abundance and Cigarettes Per Day. Figure S4. Leave-one-out plot to assess if a single SNP drives the causal association between Actinobacteria[p] abundance and Cigarettes Per Day. Figure S5. Funnel plot of MR estimation for the causal association between Actinobacteria[p] abundance and Cigarettes Per Day.Additional file 2: Table S4. All results of causal links between gut microbiome and smoking phenotypes. Table S5. Instrumental variables used in our study for univariate MR and multivariable MR, respectively.


Conduction system pacing (CSP) has been emerging over the last decade as a pacing option instead of conventional right ventricular (RV) pacing and biventricular (BiV) pacing. Numerous case reports, some observational studies and a few randomized control trials have looked at optimum pacing strategies for heart failure (HF) with left bundle branch block (LBBB) or cases where left ventricular (LV) dysfunction is anticipated due to chronic RV pacing (RVP). Evolution of pacing strategies from standard RVP to septal RVP, BiV pacing and now CSP have shown improving hemodynamic responses and possible ease of implantation of CSP systems. In this review article, we review the literature on the evolution of CSP and common scenarios where it might be beneficial. The cardiac conduction system comprises specialized cells with properties of automaticity and conduction. The sinoatrial (SA) node and the atrioventricular (AV) node can function as pacemakers with the ability of automaticity. The Bundle of His, approximately 18 mm long in an adult heart, traverses the right fibrous trigone commonly dividing into two specialized bundle branches . These are encapsulated by a fibrous sheath that separates the specialized myocytes from the myocardium thus allowing rapid electrical conduction. At the distal branches of these bundles, there is absence of this fibrous sheath, allowing communication with the local ventricular myocardium resulting in myocardial contraction  (1). TheLBBB cause interventricular dyssynchrony with RV systole earlier than LV systole. It also contributes to intraventricular dyssynchrony, which is a result of myocyte-to-myocyte propagation of signal from RV to LV through the septum, with the earliest breakthrough of signals being the LV septum and the latest being the inferior-basal LV wall. This mechanical disparity results in a pre-systolic stretch of the late activated areas, which by way of Frank-Starling law results in an enhanced systolic, albeit late, contraction. As a result, systolic stress, strain, and myocardial oxygen consumption is increased in late activated regions and reduced in early activated regions, with subsequent loss of pumping efficiency –4.Disruption of the conduction system can have varying detrimental effects. Early landmark data, such as the Framingham study, showed that new LBBB was associated with underlying coronary artery disease, cardiomyopathies, infiltrative diseases and heart failure . IncidenLandmark clinical trials had shown that resynchronization with Biventricular Pacing—Cardiac Resynchronization therapy (BiV-CRT) improved quality of life, reduced LV remodeling, and reduced cardiovascular outcomes such as hospitalization and mortality in patients with impaired LV function in the setting of LBBB –12. CorrThere is minimal evidence supported by case reports to suggest that correcting the LBBB in preserved LV function has any long-term benefit . More stPatients with symptomatic SA node disease and AV block will require pacemakers. The pacemakers can be RV-only, dual-chamber pacemakers, CRT, endocardial LV lead, HIS Bundle pacing (HBP) or LBBAP . AdvanciRight ventricular pacing (RVP) has saved the lives of a substantial number of people, especially those with sick sinus syndrome (SSS) and AV block such as complete heart block (CHB). However, chronic RVP has resulted in LV dysfunction in some patients.The placement of the leads at the RV has deleterious effects on the normal functioning of the heart with the weakening of heart muscle, heart failure and risk of arrhythmia. Pacing-induced cardiomyopathy (PICM) from chronic high burden RVP has varied in definitions across studies, with several different thresholds for drop in LVEF identified. Most widely used definition is drop in LVEF to less than 40%–50%, with an absolute drop in LVEF of at least 5%–10%, with 10%–20% of patients with normal LVEF speculated to develop PICM from chronic high burden RVP –19. PermConduction system pacing (CSP) requires engaging the conduction system at either the level of the His bundle (HBP) or the left bundle branch (LBBAP) resulting in myocardial capture that is considered physiological. Physiological pacing through CSP has been evolving to avoid the unfavourable effects of RV pacing resulting in ventricular dyssynchrony –24.HBP is considered the most physiological as it captures the proximal origin of the ventricular conduction system beyond the AV node, and proximal BBB can be corrected at its level due to the longitudinal dissociation theory , 26. ThiDespite HBP being the optimal pacing site for a physiological response, it has its limitations. The technique of HBP requires precision skills in targeting a small zone and is found to be challenging in patients with distorted anatomy due to dilated hearts, resulting in high fluoroscopic radiation exposure and a long duration of procedures. Oversensing the atrial and undersensing the ventricular signals is a frequent concern due to the anatomical location of HBP. The success rate of achieving HBP with predefined parameters varies between 76% and 96% depending on the operator's experience and the level of conduction system disease . There iLBBAP technique was first described by Huang et al. in 2017 by capturing the LBB area deep into the RV septum in a patient with heart failure and LBBB , 39. DepLBBAP has shown to be safe and effective in LBBB patients with LV impairment to maintain or improve cardiac function compared to RV pacing and BiV-CRT pacing, while taking a shorter time and less radiation exposure to the patient than HBP . Early sLBBAP represents a natural evolution of conduction system pacing to overcome the challenges posed by the current limitations of HBP . There aFor instances where adequate narrowing of the QRS cannot be achieved by HBP due to distal conduction tissue disease, His optimized CRT (HOT-CRT) was considered an alternative for narrowing QRS by fusion of HBP and LV pacing via the coronary sinus . SimilarCurrent recommendations for CSP (HBP or LBBAP) from the 2023 HRS/APHR/LAHRS guidelines include patients with indications for pacemaker therapy with anticipated ventricular pacing ≥40% and an LVEF of 36%–50% (class IIa) or LVEF >50% (class IIb). CSP maybe considered if less than 40% pacing is anticipated, with LVEF of 36%–50%, with or without a LBBB (class IIb), whereas only LBBAP maybe considered if LVEF is >50% (class IIb). CSP maybe also considered in HF patients with LBBB, LVEF 36%–50%, QRSd ≥150 ms and NYHA class II-IV (class IIb), or if effective CRT cannot be achieved with BiV pacing and LVEF ≤35% (class IIa). In patients with non-LBBB, LVEF ≤35%, QRSd 120–149 and NYHA class III–IV, CSP could be considered (class IIb) .BiV pacing (BVP) was developed in the early 2000s by pacing both ventricles resulting in fusion and correcting BBB in the management of heart failure . Conventmax) of the LV, is one of the oldest measures of LV global contractility and is a good index of ventricular performance. Shortening of an inappropriately long AV delay by CRT results in an earlier pressure development in the LV due to pre-excited pacing, increasing the pulse pressure and LV dP/dTmax  and broad QRS and has shown to have promising results as supported by a recent meta-analysis . There hP < 0.001), improved LVEF , reduced LV end-diastolic dimension , improved NYHA class , and higher echocardiographic and clinical response rate (P < 0.001). Furthermore, LBBP demonstrated higher clinical and echocardiographic response, especially higher super-response (≥20% absolute increase or LVEF ≥50%) compared to BVP-aCRT  compares CSP to BiV-CRT in 130 patients with indications for CRT, and Left vs. Left (NCT05650658) comparing both pacing strategies in 2,136 patients with LVEF <50%, RAFT-Preserved (NCT04582578) compares CSP to BiV-CRT in HF with preserved ejection fraction, RAFT P&A (NCT05428787) compares LBBAP to BiV-CRT in patients with AF underdoing a pace and ablate strategy, CSP-SYNC (NCT05155865), HOT-CRT (NCT04561778), PHYSPAVB (NCT05214365) compares CSP versus conventional RV pacing, LEAP (NCT04595487) compares CSP to RV pacing, LEAP-Block (NCT04730921) compares LBBAP to RV pacing in patients with AV block, HIS-PrEF (NCT04529577) compares RV pacing to HBP in HFrEF, HIS-alt_2 (NCT04409119) compares CSP to BiV-CRT in HFrEF with LBBB, LBBAP-AFHF (NCT05549544) compares LBBAP with BiV pacing in patients requiring an AV node ablation in LVEF <50%, LEFT-BUNDLE-CRT (NCT05434962) compares LBBAP to BiV-CRT in HFrEF. Some of these studies are reviewing the clinical effectiveness of CSP to current conventional and gold standards such as BiV-CRT with outcomes targeting electrical (QRS), function (LVEF) and biochemical changes (NT-proBNP). Other studies are looking at mechanisms of clinical response, and myocardial activation sequence using CSP compared to BiV.The rapid acceptance and evolution of CSP along with its safety has led to rapid growth of research in multiple facets being explored. Current randomized recruiting studies on CSP listed on Conduction tissue pacing in HIS Bundle pacing and LBBAP is feasible, safe, and quicker, with results comparable to cardiac resynchronization therapy. Extensive studies are required to directly compare the long-term clinical effectiveness of conduction system pacing against CRT.


Intravenous propofol did not provide any protection against large artery vasospasm or sensory–motor neurological deficits induced by SAH. Our data show that propofol did not afford significant protection against SAH-induced DCI. These results are consistent with recent clinical studies that suggest that the neurovascular protection afforded by anesthetic conditioning is critically dependent on the class of anesthetic agent.Delayed cerebral ischemia (DCI) is an important contributor to poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. We previously showed that volatile anesthetics such as isoflurane, sevoflurane and desflurane provided robust protection against SAH-induced DCI, but the impact of a more commonly used intravenous anesthetic agent, propofol, is not known. The goal of our current study is to examine the neurovascular protective effects of propofol on SAH-induced DCI. Twelve-week-old male wild-type mice were utilized for the study. Mice underwent endovascular perforation SAH or sham surgery followed one hour later by propofol infusion through the internal jugular vein (2 mg/kg/min continuous intravenous infusion). Large artery vasospasm was assessed three days after SAH. Neurological outcome assessment was performed at baseline and then daily until animal sacrifice. Statistical analysis was performed via one-way ANOVA and two-way repeated measures ANOVA followed by the Newman–Keuls multiple comparison test with significance set at  Aneurysmal subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke with very high morbidity and mortality . The amoIn our previous preclinical studies, we demonstrated that conditioning with volatile anesthetics, specifically isoflurane, provides robust multifaceted protection against SAH-induced DCI including large artery vasospasm, microvessel thrombosis, and short-term neurological deficits ,3. Our fn = 14), SAH (n = 13), and SAH + propofol conditioning (n = 16) groups. Mice were randomly assigned to one of the above-mentioned experimental groups and the experiments were replicated independently (a minimum of three times) with all three groups represented on each day. Neuroscore and large artery vasospasm assessment and data analysis were conducted in a blinded manner. The endovascular perforation SAH model and the internal jugular vein catheter insertion in the mice were performed by an experienced technician from our laboratory. All mice that underwent SAH had a brief episode of apnea, and none of the sham mice experienced apnea. SAH induction was confirmed by the apneic episode after endovascular perforation and by the identification of blood on the ventral surface of the brain after animal sacrifice. Animals which died during or after the SAH procedure, and mice with improper staining or an unclear middle cerebral artery vessel, were not included in the analysis; the rest of the animals were included. Surgical procedures and outcome assessments were performed during the light phase of the 12 h dark–light cycle. The overall design of the experiment is represented in Approval to conduct this study was obtained from the institutional animal care and use committee of Washington University in Saint Louis  and it was confirmed to follow the National Institutes of Health Guidelines for the Care and Use of Animals in Research. Twelve-week-old wild-type male mice (C57BL/6) were obtained from Jackson laboratories  for the study. Mice were placed in temperature- and humidity-controlled rooms with a 12 h dark–light cycle. Five mice were housed in a cage with free access to laboratory chow and water. The experimental groups were divided into sham  propofol or saline infusion, a central line catheter was inserted through the left internal jugular vein in all groups during the brief period of isoflurane anesthesia. Propofol exposure was achieved by administering an IV propofol infusion (2 mg/kg/min for one hour) beginning one hour after SAH using an automatic injector  with the mice placed inside a mouse restrainer. To maintain normothermia during propofol infusion, the mouse restrainer was placed above a homeothermic blanket . Propofol conditioning or saline infusion was instituted twenty-four hours post central line catheter insertion. Propofol dosing in the current study was chosen to maintain a constant brain propofol concentration, producing a steady state of general anesthesia .® software . Cerebral vasospasm was measured in the left  MCA. The average of three independent measures of the smallest width in the first 1 mm segment of the MCA from internal carotid artery bifurcation was calculated as a measure of vasospasm.Middle cerebral artery (MCA) diameter, as a measure of vasospasm, was examined on day 3 after SAH as per our published methods ,3,6. BriNeurological outcome was evaluated based on our previously published methods ,3,6. Brip < 0.05.Statistical analysis was performed using Prism software . Data are expressed as mean ± standard error of mean. Large artery vasospasm was evaluated using one-way ANOVA followed by the Student Newman–Keuls multiple comparison test. Neurological outcomes were analyzed using two-way repeated measures ANOVA followed by the Student Newman–Keuls multiple comparison test. Statistical significance was fixed at n = 14 in the sham group, n = 13 in the SAH group and n = 16 in the SAH + propofol group. All animals in the SAH group experienced apnea immediately after perforation, but none in the sham group developed apnea. Mice in the SAH group showed significant vasospasm compared to the sham group , aneurysm treatment (clipping/coiling), and/or sedation while in the intensive care unit. Hence, the selection of appropriate anesthetics during this critical period may significantly impact patient outcomes.Propofol is a commonly used intravenous anesthetic agent for induction and maintenance in the operating room for aneurysmal repair procedures (coiling/clipping), and also one of the commonly used anesthetics in the intensive care unit for sedating mechanically ventilated SAH patients. However, studies examining the impact of propofol on SAH-induced DCI are lacking. A preliminary clinical study in SAH patients undergoing aneurysmal clipping under propofol anesthesia measured the plasma concentrations of endothelin-1(ET-1) and calcitonin gene related peptide (CGRP) and showed that intravenous propofol anesthesia significantly reduced CGRP levels, but had no effect on ET-1 levels. Given the fact that CGRP is a significant vasodilator, the authors speculated that intravenous propofol may play a role on the pathogenesis of cerebral vasospasm in SAH patients . AnotherComplementing the previous studies, our series of clinical studies suggested that volatile anesthetics have a robust neuroprotective effect against cerebral vasospasm and DCI in SAH patients compared to intravenous propofol ,8,9. In The potential reasons for the neuroprotective effect of commonly used halogenated volatile anesthetics  compared to intravenous propofol in SAH-induced DCI are the following. (1) Volatile anesthetics are shown to have a direct effect on cerebral vasculature, causing vasodilation and resulting in a dose-dependent increase in cerebral blood flow, whereas intravenous propofol was shown to significantly reduce cerebral blood flow, possibly due to maintaining an intact flow–metabolism coupling in the cerebral vasculature ,14,15.  This is the first experimental study to explore the impact of propofol on SAH-induced DCI. This information is critical to know, as practitioners commonly utilize only intravenous anesthesia (propofol) for the management of SAH patients for various interventions. (2) We simulated the administration of propofol in human patients by running a continuous intravenous propofol infusion through a central line catheter in the mice. An alternative option to run a continuous propofol infusion in mice is via the tail vein; however, this route of administration, for prolonged infusions, has been shown to be extremely unreliable . Our stuOur data show that propofol, a commonly used intravenous anesthetic in SAH patients, does not afford protection against large artery vasospasm or neurological deficits produced by SAH. Further prospective randomized clinical studies are warranted to examine the effects of volatile anesthetics and intravenous propofol on secondary brain injury and neurologic outcomes in SAH patients.