Atherosclerosis is a disease of increased oxidative stress characterized by protein and lipid modifications in the vessel wall. One important oxidative pathway involves reactive intermediates generated by myeloperoxidase (MPO), an enzyme present mainly in neutrophils and monocytes. Tandem MS analysis identified MPO as a component of lesion derived high-density lipoprotein (HDL), showing that the two interact in the arterial wall. MPO modifies apolipoprotein A1 (apoA-I), paraoxonase 1 and certain HDL-associated phospholipids in human atheroma. HDL isolated from atherosclerotic plaques depicts extensive MPO mediated posttranslational modifications, including oxidation of tryptophan, tyrosine and methionine residues, and carbamylation of lysine residues. In addition, HDL associated plasmalogens are targeted by MPO, generating 2-chlorohexadecanal, a pro-inflammatory and endothelial barrier disrupting lipid that suppresses endothelial nitric oxide formation. Lesion derived HDL is predominantly lipid-depleted and cross-linked and exhibits a nearly 90% reduction in lecithin-cholesterol acyltransferase activity and cholesterol efflux capacity. Here we provide a current update of the pathophysiological consequences of MPO-induced changes in the structure and function of HDL and discuss possible therapeutic implications and options. Preclinical studies with a fully functional apoA-I variant with pronounced resistance to oxidative inactivation by MPO-generated oxidants are currently ongoing. Understanding the relationships between pathophysiological processes that affect the molecular composition and function of HDL and associated diseases is central to the future use of HDL in diagnostics, therapy, and ultimately disease management.  Thmediates .Of particular interest, the major HDL associated apolipoprotein A1 (apoA-I) is highly enriched (approximately 100-fold) in advanced human atherosclerotic plaques when compared with normal arterial walls . ApoA-I MPO makes up to 5% and 1% of the total cell protein content in neutrophils and monocytes, and in some tissue macrophages in vascular lesions ,25,26. MUnder physiological and pathophysiological conditions, MPO activity is associated with neutrophil accumulation, particularly during heavy neutrophil infiltration and acute or chronic inflammation. High MPO concentrations reside in the extracellular space in close proximity to degranulated or apoptotic neutrophils. Although oxidant formation by MPO is beneficial for the immune response to invading pathogens, there is ample evidence that inappropriate stimulation of oxidant formation by MPO can lead to host tissue damage. MPO is involved in numerous physiological processes, including microbial clearance, polymorphonuclear leukocytes recruitment, neutrophil extracellular trap formation and apoptosis, as well as protein, DNA and lipid modifications . The eff2O2 and halide or pseudohalide (thiocyanate ions) produces hypohalous acids: hypochlorous acid (HOCl), hypobromous acid, hypoiodous acid, and hypothiocyanic acid [2O2 as co-substrates to produce cyanate [Enzymatic reaction of MPO with Hnic acid . These onic acid ,8. Internic acid . The mosnic acid . The reanic acid . MPO, ca cyanate ,39, prom cyanate ,39. More cyanate , or indi cyanate . In addi cyanate . Alterna cyanate .Elevated MPO levels have been associated with cardiovascular disease ,44,45,46Studies have demonstrated that MPO released in the circulation quickly localizes in and around the endothelium ,50. EndoAlbumin is the predominant plasma protein responsible for maintaining transendothelial pressure gradient and regulating the transport of fatty acids, steroids and many other proteins . The albRecent research has provided compelling evidence for the atheroprotective activities of HDL at the vessel wall and within the extracellular space . To perfWhile the majority of HDL is present within the circulation, a fraction is constantly interacting with the endothelium or traveling through the extracellular space. Previous research investigated two principal pathways by which molecules can pass the endothelium barrier, being passive filtration through pores or by active transcytosis . Early sStudies using transwell systems with human aortic endothelial cells have shown that transendothelial transport is an active process that can be blocked by lowering the temperature . MoreoveAt least three different proteins are involved in the current model for the transport of HDL through endothelial cells: scavenger receptor class B (SR-BI), endothelial lipase (EL), and ATP-binding cassette G1 (ABCG1) . SR-BI cAttached to the endothelium and during its passage through the endothelium, HDL promotes a number of vasoprotective functions. Specifically, HDL induces endothelial nitric oxide synthase (eNOS) activity resulting in vascular relaxation. HDL promotes endothelial barrier function and inhibits endothelial apoptosis. Moreover, HDL promotes endothelial repair and suppresses the expression of endothelial adhesion molecules such as vascular adhesion molecule 1 (VCAM-1) . In addiN-chloramines, which is expected to further increase the interaction between HDL and the positively charged MPO. Of particular interest, apoA-I is highly enriched (approximately 100-fold) in human atherosclerotic plaques compared with normal arterial walls . First eSubsequent studies revealed that protein carbamylation is a major post-translational modification of HDL in the atherosclerotic vessel wall ,74. SincA critical factor in the development of cardiovascular disease is an alteration in endothelial cell function. This includes decreased endothelial nitric oxide availability, decreased endothelial barrier function, increased apoptosis, and adhesion molecule/chemokine expression. It is well established that HDL from healthy subjects  positively affect endothelial cell functions effects ,79. Oxid2-Chlorohexadecanal was identified as an active component mediating this inhibitory activity, which is formed during HOCl-mediated oxidative cleavage of HDL-associated plasmalogens . PlasmalA subsequent study showed that MPO modification of reconstituted HDL containing only apoA-I and phosphatidylcholine also impaired eNOS activity, suggesting that oxidized apoA-I itself also affects eNOS activity . MPO-modHDL transports cholesterol from peripheral cells to the liver. The ATP-binding cassette transporter A1 (ABCA1) mediates the first step of reverse cholesterol transport by transferring cellular cholesterol and phospholipids to lipid-poor HDL precursors . The impIn vitro and in vivo studies showed that with increasing MPO mediated oxidation of apoA-I, ABCA1-dependent cholesterol efflux from cholesterol-loaded macrophages was functionally impaired ,14. The The functional consequences of oxidation or posttranslational modification of single amino acid residues are complex and not fully understood. MPO mediated carbamylation of apoA-I lysine residues does affect cholesterol efflux capacity of apoA-I . In lineLoss of ABCA1-dependent cholesterol efflux activity has been associated with increased chlorotyrosine and nitrotyrosine content of apoA-I. Specifically, chlorination of Tyr 192 and oxidation of methionine 148 have been reported to impair cholesterol efflux capacity of apoA-I, since regeneration of methionine sulfoxide using methionine sulfoxide reductase recovered the functionality of oxidized apoA-I . More reSR-BI is an 82-kDa membrane glycoprotein with a large extracellular and two transmembrane domains . SR-BI iIn addition to mediating selective cholesteryl ester uptake from HDL , SR-BI aInterestingly, when reductively methylated albumin was oxidized with HOCl, it did not bind to SR-BI, despite oxidation of cysteine, methionine, tyrosine, histidine, and arginine residues. This supports the idea that alterations in the particular distribution of charged lysine residues of proteins increases binding affinity to SR-BI. In line with that assumption, also carbamylation of apoA-I lysine residues increases affinity to SR-BI . RemarkaPON1 is an HDL-associated enzyme considered as a potential therapeutic for cardiovascular disease, but the precise mechanisms by which PON1 exerts its systemic anti-inflammatory and antioxidant effects are not well understood or defined. The HDL complex is a repository for potentially toxic, hydrophobic components of plasma, notably oxidized lipids, which may be optimal for PON1 substrates. Many lipoprotein lipids cycle through HDL during the course of metabolic processes including lipolysis of triglyceride-rich lipoproteins transport bringing HDL–PON1 into contact with exogenous, dietary lipids, which can be a rich source of oxidized lipids . MoreoveStudies in mice ,114 and Reverse cholesterol transport is complex and involves numerous steps, including efflux of cholesterol from peripheral cells into the nascent discoidal HDL and maturation of the discoidal HDL into a cholesterol-laden spherical particle. ApoA-I is critical for both the transfer of cholesterol and phospholipids from peripheral tissues into the nascent discoidal HDL and the activation of LCAT, an enzyme critical for cholesterol esterification and maturation of HDL . ApoA-I HDL cholesterol-raising therapeutics are currently controversial, as most phase 3 trials of therapies to chronically raise HDL cholesterol concentrations by inhibiting cholesterol ester transfer protein have shown insufficient efficacy ,124,125.Of particular interest, a single intravenous dose of human apoA-I reconstituted with phosphatidylcholine (CSL111), delivered immediately postcardiac ischemia at the onset of reperfusion, improved heart function in mice . MoreoveSimilar to with HDL-cholesterol, there is a strong inverse observational relationship between apoA-I concentrations and risk of atherosclerotic cardiovascular disease . HoweverAs outlined above, apoA-I colocalizes with MPO in the atherosclerotic tissue ,16 and tThese studies suggest oxidation-resistant forms of apoA-I or apoA-I mimetics as new compounds for pharmacological therapy. One study demonstrated that the apoA-I mimetic 4F promoted endothelial repair and restored the re-endothelialization impaired by the presence of MPO-modified HDL . In vivoReplacing 4 apoA-I tryptophan residues with phenylalanine (4WF) was shown to lead to formation of a fully functional apoA-I variant with marked resistance against oxidative inactivation by MPO-generated oxidants . ImportaOn the other side, MPO inhibition itself could be effective to inhibit the formation of dysfunctional forms of HDL. There is accumulating evidence has implicated MPO in the pathophysiology of different diseases besides cardiovascular disease, including rheumatoid arthritis , kidney HDL is a selective in vivo target for MPO-catalyzed oxidation in the atherosclerotic vessel wall, and extensive MPO mediated posttranslational modifications, including oxidation of tryptophan, tyrosine and methionine residues, as well as carbamylation of lysine residues are detected in apoA-I isolated from atherosclerotic plaques. Interestingly, MPO has not been detected in proteomic studies of plasma HDL . This maLesion derived HDL is predominantly lipid-depleted in line with low lipid binding affinity and loss of function of lesion derived apoA-I. MPO-modified HDL is dysfunctional with respect to promote cholesterol efflux from macrophages and to activate lecithin cholesteryl-acyltransferase. MPO modified HDL lost its ability to induce endothelial nitric oxide synthesis and to promote endothelial wound healing. Therefore, it is likely that therapeutic elevation of HDL or apoA-I in the inflamed vessel wall (in the presence of high MPO activity) will not achieve the expected benefit. Unspecific antioxidant therapies have generally been ineffective, potentially due to ineffective doses but also due to interference with critical host defense and signaling processes . A targeIntriguingly, the apoA-I mimetic peptide 4F also serves as a reactive substrate for the MPO product HOCl, an antioxidant reaction that does not affect the lipid binding and cholesterol efflux capacities of the peptide . Another


Viral-associated respiratory infectious diseases are one of the most prominent subsets of respiratory failures, known as viral respiratory infections (VRI). VRIs are proceeded by an infection caused by viruses infecting the respiratory system. For the past 100 years, viral associated respiratory epidemics have been the most common cause of infectious disease worldwide. Due to several drawbacks of the current anti-viral treatments, such as drug resistance generation and non-targeting of viral proteins, the development of novel nanotherapeutic or nano-vaccine strategies can be considered essential. Due to their specific physical and biological properties, nanoparticles hold promising opportunities for both anti-viral treatments and vaccines against viral infections. Besides the specific physiological properties of the respiratory system, there is a significant demand for utilizing nano-designs in the production of vaccines or antiviral agents for airway-localized administration. SARS-CoV-2, as an immediate example of respiratory viruses, is an enveloped, positive-sense, single-stranded RNA virus belonging to the coronaviridae family. COVID-19 can lead to acute respiratory distress syndrome, similarly to other members of the coronaviridae. Hence, reviewing the current and past emerging nanotechnology-based medications on similar respiratory viral diseases can identify pathways towards generating novel SARS-CoV-2 nanotherapeutics and/or nano-vaccines. Viral infectious diseases and respiratory viral infections are among the most severe global health threats. According to the World Health Organization (WHO), millions of people are globally affected by viral diseases annually . VRIs caAlthough pathogens of viruses in the respiratory system are different, the most common associated and fatal viral infections have specific tropism to the lower respiratory tract, causing severe pneumonia and acute respiratory distress syndrome (ARDS) . The susIn this review, the innate immune system responses to different VRIs and nanotechnological approaches to combating the coronavirus family are discussed. We, then, conduct a holistic review of the past evolutions and current opportunities of nanotechnology in respiratory viral disease treatments and active immunizations.In this section, the immune system framework is considered in the case of interventional nano-medical tools. According to the latest findings in nanomedicine, the treatment strategies would be focused on synergizing anti-viral targeted therapy or enhancing the immunomodulation responses against exaggerated anti-viral responses that lead to viral infection associated immunopathogenesis. There are three general immunological approaches in viral respiratory infections, including physical-mucosal barrier (innate immunity), natural, and secondary IgA and cell mediated immunity (adoptive immunity). The barriers from the perspective of the nanomedicine interventions are discussed.® and FluMist® are designed as effective intranasal influenzas vaccines ), sucrose, acetic acid, sodium acetate and tromethamin hydrochloride [® vaccine does not have restrictions on transport and storage at ultra-cold temperatures and it is advantageous for nanotechnology. Finally, ARCoV is a thermostable mRNA vaccine that encode receptor binding domain (RBD) of SARS-COV2 and is encapsulated in an LNP [RES has a potency for entrapment by liposomes, making them suitable for targeted delivery in APCs. This mechanism is the basis of vaccine design . Accordi vaccine . Here, tc LNP SM- containin an LNP .Polymeric nanoparticles (PNs) are another example of nanocarriers for anti-viral therapeutic delivery systems. PNs are generally composed of monomeric units in the form of a colloidal phase, categorized into synthetic polymers, natural polymers, and copolymers. Besides the application of polymeric nanostructures in the pharmaceutical industry, PNs have multiple advantages for vaccine delivery applications, including controlled release of antigens, intracellular persistence in APCs, and adjustable properties such as size, composition, and surface properties . Althoug® and Moderna® mRNA-based vaccines. NVX-CoV2373 (Novavax) is a protein-based vaccine containing saponin Matrix-M™ adjuvant [Commonly used polymeric nanoparticles for such applications are PLGA, poly-ε caprolactone (PCL), poly-(γ-glutamic acid) (γ-PGA), polymethylmethacrylate (PMMA), poly-alkyl-cyanoacrylates, polyvinylpyridine, polygluteraldehyde, polyacrylamides, polyethyleneimine (PEI), gelatin chitosan, and human serum albumin (HSA) . Similaradjuvant . With thadjuvant ,114. Othadjuvant , long-tiadjuvant ,117, andadjuvant  make theadjuvant .As an example, PLGA nanocapsules have been used for the encapsulation of various virus antigens or RNA for systemic or local nano-vaccine designing. The safety of poly lactic-co-glycolic acid (PLGA) as a biodegradable and biocompatible polymer has been approved by the FDA and European Medicines Agency (EMA) for medicinal applications . The encIn another study, Okamoto and his co-workers designed a nanoparticle by adding γ-PGA hydrophobic derivative  to influenza virus hemagglutinin (HA) vaccine, in order to amplify the protective immune responses against influenza virus (H1N1) in the mice. The researchers proved that the PGA-NP HA vaccine was more effective in protection against different influenza viruses when administered via intranasal vaccination, compared to subcutaneous injection .Chitosan, a natural polymer composed of randomly distributed β-(1–4)-linked d-glucosamine, N-acetyl-d-glucosamine, and N-(2-hydroxypropyl) methacrylamide/N-isopropylacrylamide (HPMA/NIPAM), are two frequently used polymeric nanoparticles for nano-vaccine delivery. Chitosan nanogels have been investigated as intranasal vaccine nanocarrier against different respiratory viruses, specifically influenza virus, with enhanced mucosal and systemic immune responses demonstrated in pigs ,126. ChiDendrimers are a group of star-shaped three-dimensional macromolecular networks with some particular properties that make them a lucrative nanocarrier for anti-viral therapy. It is theorized that their anti-viral effect mechanism is attributable to host cell-virus interaction disruption during infection, where they form stable complexes with viral structures or receptors at the surface of cells . In thisQuantum dots (QDs) are semiconductor inorganic nanocrystals with size-dependent optical and electronic properties, and have been widely used for virus detection and imaging, given their inherent fluorescent emission . QDs can2) NPs, zinc oxide nanoparticles, titanium dioxide (TiO2) NPs, silver NPS (Ag-NP), and gold NPs (Au-NP) [2 nanoparticles against avian influenza virus [Other inorganic nanoparticles include mesoporous silica as well as metal oxide NPs like zirconia (ZrO (Au-NP) . Among t (Au-NP) . Karamov (Au-NP) . In ordeza virus , with thza virus . Additioza virus .A/California/04/2009 (H1N1pdm) pandemic strain, A/Victoria/3/75 (H3N2) strain, and A/Vietnam/1203/2004 (H5N1) infections [A/Ck/Malaysia/5858/04 (H5N1) (pcDNA3.1/H5), and were shown to induce both antibody and cell-mediated immune responses with enhanced cytokine production [While gold nanoparticles are most commonly used for rapid SARS-CoV-2 diagnostic kits ,145, thefections . Silver oduction . Hanako oduction .+ T cell responses.Self-assembling protein and peptide nanoparticles (SAPNs) are complexes made from monomeric protein oligomerization using recombinant technologies and are considered suitable candidates for pharmaceutical nanocarriers . They caIn one study, SAPNs were used against the purified coronavirus spike protein in the Middle East Respiratory Syndrome coronavirus (MERS-CoV) and ferritin ,153. In M2e epitopes (M2e5x) of the influenza virus resulted in strong humoral and cellular immune responses, therefore providing protection against different serotypes of influenza viruses [RQ3011-RBD) with three structure VLP  and LNPs for comparison. Notably, the NAb titration of mice that received RQ3013-VLP was significantly higher than the S-specific binding antibody of mice that receiving RQ3012-spike [Further, Linling He et al. decorated a three-part SAPN including RBD, the modified spike peptide (S2G-HR2) of SARS-CoV-2, and ferritin, using a SpyTag/SpyCatcher system. This formulation enhanced the neutralizing antibody of SARS-CoV-2 ten times more than one SANP and other nanoparticles . Kang et viruses . In anot viruses . Xu et a viruses . Similar12-spike . A summaIn addition to systemic nano-vaccine delivery, therapeutic medications can be directly delivered to the lungs via intranasal administration. This method of airway delivery provides advantages over systemic methods such as targeted delivery, rapid drug absorption due to the high surface area of the capillary network and extensive vascularization of lungs, protection of drug molecules from enzymatic degradation due to fewer degradative enzymes within the lungs, and most importantly, minimally invasive delivery ,179. TheNanotechnology can potentially facilitate the efficacy of advanced therapeutics or vaccines by encapsulation inside the micro/nano-carriers to be administered using intranasal inhalation, as opposed to systematic delivery. In this way, Broichsitter et al. claimed that the anti-inflammatory corticosteroid Salbutamol could be effectively loaded in a polymeric nanocarrier composed of poly - graft-poly  for sustained pulmonary drug release . To furt®  liposome inhalation suspension. In a related study, a liposomal formulation of ciprofloxacin with the average size of 350 nm was synthesized using a film-hydration method with phospholipids and cholesterol as precursor materials. Besides the high drug loading efficiency (ca. 93%), the amount of drug release from the liposomal formulation was shown to be higher in the simulated lung medium compared to the saline medium, thus, demonstrating selective drug release in a lung simulating medium. Furthermore, in vivo studies in rat models revealed the effective lung targeting ability of the drug-loaded liposome formulation in comparison to the free form of the drug [Other specific drugs, such as antibiotics can also be encapsulated inside nano-carriers to enhance the efficacy of therapy against bacterial lung infections through intranasal administration ,191. In the drug .Airway delivery of therapeutic nucleic acids (DNA and RNA) is also a practical approach for the treatment of side effect diseases caused by a viral infection. The invasion of viruses causes several lung associated diseases through their pathogenic genes infection or genetic malfunction . TherefoAirway delivery of drug-loaded nano-carriers to the lungs and other parts of the respiratory tract could be performed by various methods such as nasal or oral spray, nebulization, dry powder inhaler devices or pressurized metered-dose inhalers . Among tIn the case of SARS-CoV-2 as a type of VARID, various FDA-approved prescribed drugs have been evaluated for the treatment of infected patients ,203,204.Intranasal vaccines, in addition to antigen delivery to the epithelial cells and local APCs at the site of infection, also stimulate NALT and BALT to produce IgA, which blocks the binding and entry of the virus. The formulation of these types of vaccines is a key point in the design and manufacturing of vaccines with enhanced stability and efficacy. These vaccines may be used in single doses due to the strong enrollment of mucosal immunity . ChAd in2, and SiO2 nanoparticles [Localized delivery of the antigens and epitopes to the specific cells in the respiratory tract requires the rational design of nano-carriers for targeted delivery in a controlled and prolonged manner ,85. Nevearticles ,211. Antarticles ,213. Nexarticles ,215. Thearticles ,219,220.articles ,221.COVID-19 vaccine candidates may follow different technology platforms ,220. LivDespite the overall success of mRNA vaccines in inducing a proper immune response, nano-formulation of these subcategories via encapsulation in positively charged nanocarriers, can potentially enhance the stability and reduce the delivery challenges of mRNA or DNA across the cell membrane or even through the cell nucleus. In this regard, the patent application (WO2017070626) by Moderna Inc. disclosed mRNA vaccines consist of mRNAs encoding viral antigenic full-length S, S1, or S2 subunits from SARS-CoV and MERS-CoV viruses, formulated in cationic lipid nanoparticles. The mice vaccinated with mRNA encoding full-length S protein elicited much higher neutralizing antibody titers when compared to the S2 subunit. In this study, New Zealand white rabbits immunized with the MERS-CoV mRNA vaccine, encoding the full-length S protein, demonstrated a 90% reduction in viral load with significant levels of neutralizing antibody against MERS-CoV. On February 2020, Moderna announced the release of the first batch of mRNA-1273 against SARS-CoV-2 for use in humans.The most advanced candidates that have recently shifted into clinical development include mRNA-1273 from Moderna (LNP-encapsulated mRNA vaccine encoding S protein), Ad5-nCoV from CanSino Biologicals (Adenovirus type 5 vector that expresses S protein), INO-4800 from Inovio (DNA plasmid encoding S protein delivered by electroporation), and LV-SMENP-DC , and pathogen-specific APC  from Shenzhen Geno-Immune Medical Institute. The clinical trial details of these candidates are summarized in Engineered nanocarriers have demonstrated their outstanding role in efficient drug and vaccine delivery against viral diseases. Various nanostructures have been proposed for use as carriers for antiviral deposition. Depending on the target tissue, these structures can be chemically modified to enhance conventional antiviral properties by providing controlled release and drug protection with the aid of nano systems. In the case of vaccine production, the use of nano-formulations as carriers of adjuvant therapies can further improve the shortcomings of conventional vaccines by enhancing antigen stability and targeted delivery properties. In relation to the specific nano-vaccines used for immunizing against respiratory viruses, local administration through the nasal route generates efficient mucosal or systemic immunity. The immunogenicity of these nano-formulated vaccines can be enhanced through facile recognition and endocytosis by the APCs.As a perspective view of the vaccines and nano-vaccines development against the COVID-19 pandemic, the structural proteins of SARS-CoV-2 make attractive candidates and should be considered as necessary elements for the cellular infection and virion assembly . As the


Cytomegalovirus (CMV) is one of the most important opportunistic infections in solid organ transplant (SOT) recipients. However, current techniques used to predict risk for CMV infection fall short. CMV-specific cell mediated immunity (CMI) plays an important role in protecting against CMV infection. There is evidence that assays measuring CMV-CMI might better identify SOT recipients at risk of complications from CMV compared to anti-CMV IgG, which is our current standard of care. Here, we review recently published studies that utilize CMV-CMI, at various points before and after transplantation, to help predict risk and guide the management of CMV infection following organ transplantation. The evidence supports the use of these novel assays to help identify SOT recipients at increased risk and highlights the need for larger prospective trials evaluating these modalities in this high-risk population. Human cytomegalovirus (CMV) infection is associated with considerable morbidity and mortality in the solid organ transplant (SOT) population ,2. It isCMV can be characterized as (1) infection, which is defined as evidence of replicating virus in blood or tissue, irrespective of symptoms, or (2) disease, which is defined as CMV infection with accompanying symptoms. CMV disease can be further categorized as (a) CMV syndrome, in which individuals may develop fevers, malaise, and/or bone marrow suppression or (b) tissue invasive disease ,5. In adThe risk of CMV infection following organ transplantation is increased in recipients receiving lymphodepleting immunosuppression such as anti-thymocyte globulin (rATG) or alemtuzumab ,15, seroThere are two strategies for managing CMV following organ transplantation: (1) universal anti-viral prophylaxis and (2) pre-emptive therapy, which involves routine monitoring of CMV viral load with prompt initiation of therapy once a pre-established viral load threshold is met. Each has its own distinct advantages and disadvantages. For high-risk patients, anti-viral prophylaxis reduces the incidence of early CMV disease resulting in improved patient mortality and graft survival. However, anti-viral prophylaxis is associated with higher rates of late-onset CMV disease, increased drug costs, and drug toxicities such as leukopenia ,20,21. CAssessment of CMV T cell immunity prior to transplantation to predict risk of CMV infection post-transplantation;Assessment of CMV T cell immunity during or at the end of prophylaxis to predict risk of CMV infection;Assessment of CMV T cell immunity upon completing treatment of CMV infection to determine the need for secondary prophylaxis or predict risk of CMV relapse.Predicting CMV disease in organ transplant recipients is difficult. While quantitative PCR is routinely used to monitor viral DNAemia, active CMV disease does not always correlate with the presence of DNAemia, and a proportion of patients may have detectable viral loads without development of clinical disease. There is growing interest within the transplant community to utilize assays that measure CMV-specific T cell immunity to help stratify an individual’s risk for CMV disease following transplantation. These assays assess cytokine release, specifically interferon-gamma (IFN-γ), from cells following stimulation with CMV-specific antigens. Several clinical uses for these assays have been proposed:In this review, we will briefly discuss the host immune response to CMV infection, describe the current assays in use to assess CMV-specific cell-mediated immune response (CMI), and review the clinical evidence supporting the use of these assays in the solid organ transplant population, with a specific focus on clinical studies published within the past five years.During natural human CMV infection, CMV elicits strong innate, humoral, and cellular immune responses. Following infection, CMV is first detected by the innate immune system via pathogen recognition receptors that detect glycoprotein B (gB) on the envelope of CMV. This in turn triggers the production of type I interferons (IFNs) and inflammatory cytokines such as tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) . ActivatThe sustained control of CMV infection is predominantly mediated by the cell-mediated immune response. The importance of cell-mediated immunity in the control of CMV viral replication was first recognized in murine CMV studies in which the selective depletion of CD4+ and CD8+ T lymphocytes increased susceptibility to CMV infection ,40 and tIn humans, numerous studies highlight the essential role both CD8+ and CD4+ T cells play in controlling and protecting against CMV infection. The development of CMV-specific CD8+ T cell responses following bone marrow transplantation (BMT) correlate with protection and recovery from CMV disease . PivotalWhile CMV-specific CD8+ T cell responses dominate early responses to primary CMV infection and are responsible for containment of virus-infected cells , there iThere are several assays capable of measuring CMV-specific cellular-mediated immune responses (CMI). These assays include enzyme-linked immunosorbent assay (ELISA), enzyme-linked immunosorbent spot assay (ELISpot), and intracellular cytokine staining (ICS) with flow cytometry. In general, they all rely on the detection of IFN-γ following stimulation of whole blood or peripheral blood mononuclear cells (PBMCs) with CMV-specific antigens or peptides. ICS and flow cytometry may also measure other cytokines such as interleukin-2 (IL-2) and TNF-α. For quality control, these immune assays include a positive control and negative control to monitor for errors in laboratory processing. The positive control, which uses superantigens such as phytohemagglutinin or staphylococcal enterotoxin B to stimulate T cells, identifies individuals with T cells that may be anergic due to effects of immunosuppression or low lymphocyte counts. The negative control, which can include media alone, neutral buffer, or “mock” antigen, determines non-specific background reactivity see .The use of ICS and flow cytometry provides an in-depth analysis of CMV-specific cellular immunity through the concurrent detection of cell surface markers and cytokines. To perform ICS, either whole blood or PBMCs are first incubated with CMV peptides or whole virus lysate, with or without a co-stimulatory molecule , for 6–18 h to stimulate the production of various cytokines. T cells are then fixed and stained using fluorescent antibodies against cell surface markers and cytokines of interest, allowing one to determine not just the frequency of cytokine-producing T cells but also the source of cytokine production (CD4+ or CD8+ T-cells). The widespread adoption of ICS/flow cytometry to measure CMV-CMI has been limited primarily by its high cost and because the assay is labor-intensive. Additionally, there is a lack of standardization, as no consensus exists on the appropriate cutoff (frequency of cytokine-positive T cell) for defining protection from CMV. Recently, Eurofins Viracor, Inc. introduced the CMV T Cell Immunity Panel (TCIP), which utilizes ICS/flow cytometry to assess CMV CMI. It is the only commercially available assay measuring CMV-CMI in the United States. CMV-specific CD4+ or CD8+ responses >0.2% are considered indicative of CMV-CMI.The QuantiFERON-CMV (Qiagen) measures CD8+ T cell IFN-γ responses to a variety of HLA class I restricted CMV T cell epitopes. In this assay, whole blood is incubated with 21 CMV peptide epitopes including pp65, IE-1, IE-2, pp50, and gB, for 18–24 h, after which the supernatants are harvested, and the levels of IFN-γ are measured using a standard enzyme linked immunosorbent assay (ELISA) ,57. The One heavily debated limitation of the QFN-CMV is that its use of HLA-restricted CMV epitopes may limit some individuals’ ability to recognize and respond to the antigenic determinants . StudiesThe enzyme-linked immunosorbent spot (ELISpot) assay measures IFN-γ produced by both CD4+ and CD8+ cells in response to CMV antigen stimulation. The production of IFN-γ is quantified by measuring the number of spot forming units (sfu) in a given number of PBMCs. There are currently two commercially available assays: T-Track CMV  and T-SPOT.CMV . Both assays are available commercially in Europe (CE marked). CMV ELISpot assays are performed using PBMCs isolated from whole blood. PMBCs are placed in wells and stimulated with CMV antigens, IE-1 and pp65, either as urea formulated proteins (T-Track CMV) or peptides (T-SPOT.CMV). Following 17–21 h of incubation, the secreted IFN-γ is bound by specific antibodies within the wells, and a second, enzyme-linked antibody is utilized to detect antibody-bound IFN-γ by producing insoluble precipitates or spots . AlthougBefore reviewing the clinical utility of CMV T cell assays, it is important to first review factors that may influence CMV-CMI in the setting of organ transplantation.Following organ transplantation, CMV-specific T cell responses decline over the first couple months post-transplantation, with gradual increases in CMV-specific T cell responses over subsequent months . HoweverFrequencies of CMV-specific T cells following transplantation may also be influenced by induction immunosuppression. Jarque et al. demonstrated that lymphocyte depleting antibodies (rATG) caused greater reductions in the frequency of CMV-specific T cell responses than anti-IL2 receptor antibodies  . These rFinally, the impact of anti-viral prophylaxis on the development of CMV-CMI has been a subject of debate. A study comparing early anti-viral prophylaxis (within three days of transplantation) to delayed anti-viral prophylaxis (initiated on day 14 after transplantation) in D+/R− SOT recipients failed to find any differences in CMV-CMI between the groups . AdditioOver the past two decades, there have been a number of studies published evaluating the clinical utility of CMV-CMI assays. These studies have consistently demonstrated that high CMV-CMI predicts protection against CMV outcomes whereas low CMV-CMI increases the likelihood of CMV outcomes. Despite these consistent findings, CMV-CMI assays are not routinely integrated into clinical practice. In the United States, CMV-CMI assays are available only for research or as laboratory-developed tests with the exception of the Eurofins Viracor TCIP. The main reasons for this are (1) poorly defined thresholds for positive and negative results, (2) variability in CMV antigen stimulation protocols , and (3) heterogeneity in the populations being studied . Additionally, most data supporting CMV-CMI use are observational, with only a few interventional studies where treatment decisions were made based on the results of a given CMV-CMI assay. In this section, we will review the existing clinical data assessing CMV-CMI assays both pre- and post-transplantation to predict the risk of CMV infection, focusing primarily on data accrued over the past five years see .At present, donor and recipient CMV IgG is the only test utilized to stratify the risk of CMV infection following organ transplantation. While D+/R- patients are at highest risk of CMV disease, not all D+/R− recipients develop CMV infection in the absence of anti-viral prophylaxis. Moreover, late onset CMV develops in 8–34% of R+ recipients, depending on the type of organ transplanted ,90, highOne of the first studies to assess whether pre-transplant CMV-CMI could predict post-transplant CMV events was a single center retrospective study using a CMV ELISpot assay in D+/R− and R+ kidney transplant recipients . Investip = 0.067). Among R+ individuals, pre-transplant CMV-CMI was associated with lower CMV viral loads at diagnosis, lower incidence of CMV disease, and reduced need for anti-viral therapy when compared to R+ individuals without pre-transplant CMV-CMI.Schachtner and colleagues prospectively evaluated pre-transplant CMV-CMI in both D+/R− and R+ kidney transplant recipients as a predictor of post-transplant CMV infection using CMV ELISpot . ApproxiA number of additional observational studies have similarly demonstrated a higher risk of CMV events among SOT recipients without CMV CMI pre-transplantation using CMV ELISpot ,90, QFN-In the only prospective, interventional study published, Jarque et al.  evaluateData accrued over the past several years consistently show that individuals with pre-transplant CMV-CMI are at lower risk of developing CMV infection following transplantation. For those with pre-transplant CMV-CMI that do develop CMV infection, infection tends to be milder . Induction immunosuppression could impact the predictive value of CMV-CMI pre-transplantation; however, this has not been consistently demonstrated. Finally, much of the data come from kidney transplant recipients. A recent study in liver transplant recipients following a pre-emptive CMV monitoring strategy failed to find a correlation between pre-transplant CMV-CMI and post-transplant CMV viremia. Although, when restricting the analysis to episodes of CMV viremia occurring two months after liver transplantation, the presence of CMV-CMI pre-transplantation did appear to confer protection against CMV viremia . WhetherWhile anti-viral prophylaxis is highly effective at decreasing incidence of CMV DNAemia and disease, it leads to higher costs, toxicities and increases rates of late-onset CMV infection. Measuring CMV-CMI at the end of prophylaxis (EOP) may allow for individualization of prophylaxis by identifying those who would benefit from early cessation of prophylaxis versus those requiring extended prophylaxis and/or closer monitoring following discontinuation of anti-viral prophylaxis.p < 0.0001) and 97.7% for IE-1 (p < 0.0001). There was a significant difference in risk of CMV event for patients with IE-1 and pp65 sfu values above the established threshold when compared to those below .The largest study to date by Kumar et al.  measuredN = 50) or rATG (N = 46). CMV-CMI was assessed using T-SPOT.CMV. Similar to Kumar and colleagues, these authors found that frequencies of CMV-specific T cells at EOP (three months post-transplantation) were significantly lower in patients that developed late-onset CMV infection. There were no differences in mean CMV-CMI at EOP when comparing individuals receiving rATG or anti-IL2RA for induction immunosuppression. The authors also assessed the risk of late-onset CMV based on stratification of CMV-CMI, defining HR (high risk) as a negative test against both IE-1 and pp65, LR (low risk) as positive tests against both antigens, and IR (intermediate risk) as a negative result against 1 of the 2 CMV antigens. The risk of late-onset CMV infection gradually increased in accordance with risk stratification groups .Another notable study by Jarque et al.  prospectp = 0.03). A large multicenter randomized clinical trial  is currently underway in Spain that aims to evaluate the role of QFN-CMV in guiding primary prophylaxis duration in R+ lung transplant patients [Two studies evaluating the predictive value of CMV-CMI at the EOP in lung transplant recipients have recently been published. Donadeu et al.  retrospepatients .p = 0.036). In a second study, authors performed a prospective, non-randomized, interventional study involving 159 heart transplant recipients (>80% R+) at a single center in which QFN-CMV was measured at EOP (100 days post-transplantation) and patients were assigned to CMV-CMI guided prophylaxis or standard of care [p = 0.03); however, the duration of anti-viral prophylaxis was greater in the CMV-CMI guided group , with no difference in rates of leukopenia between the two groups.CMV-CMI has also been evaluated in two cohorts of heart transplant recipients. In the first, investigators retrospectively evaluated CMV-CMI using QFN-CMV in 44 R+ heart transplant recipients . Investi of care . In the Finally, several studies have evaluated whether the detection of CMV-CMI at time points preceding EOP could predict the development of subsequent CMV infection. Lee et al.  found thp = 0.002). While the frequency of CMV-specific CD8+ T cells was also lower in those with CMV events, the results did not reach statistical significance . Finally, Gabanti and colleagues used an in-house CMV T cell assay based on T cell stimulation by autologous HCMV-infected dendritic cells to determine CMV-CMI using flow cytometry [5 DNA copies/mL) had higher CMV-specific CD4+ and CD8+ T cell responses when compared to recipients with higher peak CMV viral load infection (peak VL >3 × 105 DNA copies/mL).Although most of the recent published data involve assessment of CMV-CMI using QFN-CMV or CMV ELISPOT, three studies in the past several years have assessed CMV-CMI using flow cytometric analysis. Snyder et al. performed a cross-sectional analysis of CMV-CMI in R+ lung transplant recipients by stimulating PBMCs with CMV pp65 and IE-1 peptide pools. Using flow cytometry, they identified polyfunctional T cell signatures (CD107a−/IFN-y+/IL-2+/TNF-a+CD4+ T cells and CD107a−/IFN-y+/IL-2+/TNF-a+CD8+ T cells) that were predictive of protection against future CMV infection . In a reytometry . In theip = 0.244). Modifying the manufacturer’s interpretative criteria led to some improvement in diagnostic performance. The negative results in this study could be attributed to the inability to detect CMV-specific CD4+ T cell responses, as patients in this cohort received rATG induction and CMV-CMI was assessed using QFN-CMV. In another study, Lee et al. also failed to find a correlation between CMV-CMI assessed by QFN-CMV at 1 or 3 months post-transplantation and subsequent CMV viremia, but they did find better accuracy using CMV ELISPOT [Not all studies have found a clear association between CMV-CMI and protection against future CMV infection. Recently, Fernandez-Ruiz et al. reported on the assessment of CMV-CMI using QFN-CMV at EOP in R+ kidney transplant recipients receiving rATG induction . Their d ELISPOT .In summary, assessment of CMV-CMI at the end of prophylaxis consistently demonstrates a higher risk of late-onset CMV events among individuals without CMV CMI across organ groups. Assessment of CMV-CMI at time-points as early as one-month post-transplantation can predict subsequent risk of CMV infection, but the predictive value may be impacted by induction immunosuppression. Finally, there appear to be assay-specific differences in prediction of CMV infection or disease, with several studies demonstrating poor correlation between CMV-CMI detected by QFN-CMV and subsequent risk of CMV infection.The risk of recurrent CMV infection is estimated to be between 20% and 30% ,96,97. LFinally, the largest study to date evaluating the role of CMV-CMI in predicting the risk for CMV relapse is an interventional study conducted by Kumar et al. that enrolled all organ transplant patients with a documented episode of CMV infection . CMV-CMIAlthough data are limited, the evidence generated to date supports the clinical assessment of CMV-CMI testing at EOT to guide decisions regarding the need for and duration of secondary prophylaxis in transplant recipients that have recovered from CMV infection post-transplantation.The use of CMV immune monitoring to better identify SOT recipients at increased risk of CMV-related complications has long been considered an area of clinical interest and need. The development of assays measuring CMV-specific immune responses such as T-Track CMV, T-SPOT.CMV, QuantiFERON-CMV, and the Viracor TCIP have propelled this field forward. Observational studies published in the past several years evaluating the utility of these assays continue to add support for the routine clinical use of these assays. Importantly, several recent large, prospective, interventional studies have begun to provide long-awaited answers to questions about the ideal timing for performing these assays, the utility of repeated assessments of CMV-CMI, and the benefits of CMV-CMI in relation to standard of care.However, there are still some unresolved questions about these assays including cost efficacy, impact of different immunosuppressive regimens on the predictive value of these assays, standardization of cutoff values for CMV-CMI determination, and predictive value in thoracic organ transplant recipients, as current data from interventional studies has come from kidney transplant recipients. Additionally, there are few head-to- head comparisons of the various CMV T cell immune assays. In the coming years, additional data from several ongoing prospective, interventional clinical trials evaluating CMV-CMI will be published, including one in lung transplant recipients, which hopefully will help answer some of these lingering questions.In conclusion, there are compelling data supporting the role of CMV T cell immune assays in the management of CMV infection in SOT recipients. While we do not yet have sufficient data for the widespread adoption of these assays into routine clinical use, data accumulated over the past 5 years has brought us one step closer.


Dear Sirs,Little is known about how infection with SARS-CoV-2 impacts the course and severity of multiple sclerosis (MS). Here, we report on a patient in whom SARS-CoV-2 infection was followed by severe exacerbation of previously stable MS and Takotsubo cardiomyopathy (TTC). Of note, repeated intravenous pulse therapy with high-dose methylprednisolone (IVMP), plasma exchange, and administration of ocrelizumab interfered with the development of a long-lasting immune response against SARS-CoV-2.Case report. In a 39-year-old woman, relapsing remitting MS was first diagnosed in 2011 and had been stable since 2014 with continuous administration of dimethyl fumarate (DMF). In December 2020, 10 days after the onset of marked general malaise and fatigue, the patient developed nystagmus, dizziness and headache. The next day she experienced tachycardia, followed the day after by coughing and shortness of breath requiring admission to hospital. Chest CT showed multifocal central and peripheral ground-glass opacities involving both pulmonary lobes suggesting COVID-19 pneumonia. PCR testing of a throat swab was positive for SARS-CoV-2-RNA and negative for influenza virus. Laboratory tests and ECG screening revealed elevated hs-troponinT  and intermittent ventricular bigeminy, respectively. Cardiac catheterization showed no coronary artery disease but regional wall motion abnormalities compatible with atypical TTC. Cranial MRI depicted a symptomatic novel lesion in the dorsomedial medulla oblongata Below is the link to the electronic supplementary material.


Bcl-x pre-mRNA splicing serves as a typical example to study the impact of alternative splicing in the modulation of cell death. Dysregulation of Bcl-x apoptotic isoforms caused by precarious equilibrium splicing is implicated in genesis and development of multiple human diseases, especially cancers. Exploring the mechanism of Bcl-x splicing and regulation has provided insight into the development of drugs that could contribute to sensitivity of cancer cells to death. On this basis, we review the multiple splicing patterns and structural characteristics of Bcl-x. Additionally, we outline the cis-regulatory elements, trans-acting factors as well as epigenetic modifications involved in the splicing regulation of Bcl-x. Furthermore, this review highlights aberrant splicing of Bcl-x involved in apoptosis evade, autophagy, metastasis, and therapy resistance of various cancer cells. Last, emphasis is given to the clinical role of targeting Bcl-x splicing correction in human cancer based on the splice-switching oligonucleotides, small molecular modulators and BH3 mimetics. Thus, it is highlighting significance of aberrant splicing isoforms of Bcl-x as targets for cancer therapy. Apoptosis regulator Bcl-extra (Bcl-x), also named BCL2L or BCL2L1, is a typical example of apoptotic response gene impacted by splicing. It is an essential member of B-cell lymphoma 2 (Bcl-2) apoptosis family that regulates cell fate , 4. HoweAlternative splicing expands the coding capacity of genomes of eukaryotes significantly through splice site selection Fig.  7]. Nea. Nea7]. Bcl-x, a critical apoptotic gene of the Bcl-2 family, is located in chromosome 20 (20q11.1). It was first discovered by using Bcl-2 fluorescent probe hybridization in chickens –17. DespCis-regulatory elements are short nucleotide motifs within pre-mRNA transcripts that providing binding sites for specific trans-acting factors. It can be categorized into exonic splicing enhancers (ESEs), exonic splicing silencers (ESSs), intronic splicing enhancers (ISEs) and intronic splicing silencers (ISSs) depending on their position and impact on the use of splice site  Bcl-x prA variety of trans-acting factors are involved in the formation of splicing regulatory network, including SR proteins, hnRNPs as well as some transcription factors Fig. a 25]. P. P25]. PEpigenetic modifications had been suggested to interplay intricately with alternative splicing . It had Apoptosis, characterized by a series of morphological alternations including cell shrinkage, pyknosis and karyorrhexis, plasma membrane blebbing and apoptotic body formation, is a mechanism for all multicellular organisms to modulate cell life development . Abnormaet al. suggested that the allosteric regulation by Bcl-xL complexes might play an important role in this process . . 158]. TThe inactivation or dysfunction of essential genes caused by defective splicing is emerging as a potential driver of cancer development. Therefore, controlling splicing is of great therapeutic benefit. Dysregulated Bcl-x splicing plays a key role in promoting malignant phenotypes of cancers and weakening the toxicity of treatment. Bcl-xL contributed to the invasion, metastasis, and angiogenesis of cancers. On the contrary, Bcl-xS overexpression was suggested to sensitize apoptosis induced by drugs . Bcl-x s


The combination of nanotechnology and chemotherapy has resulted in more effective drug design via the development of nanomaterial-based drug delivery systems (DDSs) for tumor targeting. Stimulus-responsive DDSs in response to internal or external signals can offer precisely controlled delivery of preloaded therapeutics. Among the various DDSs, the photo-triggered system improves the efficacy and safety of treatment through spatiotemporal manipulation of light. Additionally, pH-induced delivery is one of the most widely studied strategies for targeting the acidic micro-environment of solid tumors. Accordingly, in this review, we discuss representative strategies for designing DDSs using light as an exogenous signal or pH as an endogenous trigger. Successfully developed cytotoxic drugs have enabled advances in chemotherapy, which has greatly improved the prognosis and quality of life of cancer patients . ChemothAmong previously mentioned methods for external stimulation, light is a particularly attractive strategy for therapeutic applications owing to easy adjustment of its intensity, non-invasive application, and exquisite temporal and spatial control. Light-responsive systems that absorb light, a type of electromagnetic wave, use light energy to trigger changes in the chemical bonds, polarity, and chemical groups or induce the generation of heat and reactive oxygen species (ROS) A. On thiex) than normal tissues, with a mean value of 6.8 (ranging from 5.7 to 7.8) ..o-nitro a 4.5). This Wolff rearrangement reaction can be generated by one high-energy UV photon and two low-energy NIR photons. Therefore, it can be effectively applied to NIR-triggered drug release systems ..42].sn-glycero-3-phosphoethanolamine-N-[methoxy(polyethylene glycol)-2000] (DSPE-PEG2k) nanoparticles incorporated with pyropheophorbide a (PPa) and thioether/selenoether-linked conjugates of cabazitaxel (CTX) and oleic acid (OA)   44]. In. Insn-glIn addition, hypoxic conditions have been used in nanovehicles based on photo-induced mediators. PDT was performed through light irradiation and continuously decreased oxygen generation, which resulted in a temporary hypoxic environment at the target sites. Hypoxia-responsive systems can detect and target tumor sites in a hypoxic environment ,45,98,99Although controlled drug release using PDT has been demonstrated, photodynamic responsive nanovehicles present certain challenges that need to be overcome. Endogenous ROS or hypoxia in biological systems can lead to inappropriate drug release and side effects. In addition, the PSs in these PDT systems are usually organic dyes that have poor optical stability upon light irradiation . Hence, pH-responsive nanovehicles have been intensively exploited among environmental stimuli-responsive nanovehicles, since it was discovered that the extracellular pH near tumors is more acidic than that in normal tissues . HydrogeDe/protonation is the most commonly used mechanism for pH-responsive nanovehicles in cancer therapy. As shown in sn-glycero-3-phosphoethanolamine-N-[methoxy(polyethylene glycol)] conjugated poly(β-amino esters), PEG-poly(2-(diisopropylamino) ethyl methacrylate-co-dithiomaleimide), PEG-poly(2-(dibutylamino) ethyl methacrylate-co-dithiomaleimide), and poly(N-vinylpyrrolidone)-poly(4-vinylpyridine) -PEG (PABI-PEG) for docetaxel (DTX) delivery 4-zinc β-tetra-(4-carboxyl benzyloxyl)phthalocyanine (PDCZP) capable of targeting tumors and responding to dual stimuli, light, and pH. The pH responsiveness of PDCZP resulted from pDEA chains, which could shrink in weakly basic environments (pH 7.4) through hydrophobic interaction and, in contrast, extend in weakly acidic environments (pH 6.5 or 5.0) because of increased hydrophilicity due to protonation of the amines of pDEA. The DOX-loaded nanovehicles showed the formation of 50 nm-sized spherical particles at pH 7.4. In the nanovehicles delivered to tumor cells, the rapid DOX release was triggered by the acidic pH, resulting in enhanced antitumor effects through chemotherapy with DOX and PDT with core PS under light irradiation -poly(methacrylic acid-co-spiropyran methacrylate) (DPCL-b-P(MAA-co-SPMA)). In this system, the isomerization of SP groups under UV light irradiation or low pH resulted in either light- or pH-responsive abilities. The SP isomerized to hydrophilic merocyanine MC under light irradiation and changed to merocyanine H+ (MCH) through protonation upon acid addition. These results showed that the DOX-loaded dendrimers exhibited drug release when triggered by UV irradiation or under acidic conditions and that, consequently, the controlled release system based on SP was developed by either adjusting UV/Vis light illumination or changing the pH values . In addiMany studies have reported the utilization of light- and pH-responsive systems for triggering the degradation/cleavage/breakage of nanovehicles. Oh’s group researched polyelectrolyte nanoparticles composed of  PEG-PLL(-g-DMA)-PLA . They deIn a recent study, Wu et al. studied a cap removal strategy using acetal bonds for multimodal imaging-guided low-temperature PTT/chemotherapy of cancer. They encapsulated ICG and the Hsp90 inhibitor 17AAG in hollow mesoporous organic silica nanocapsules (HMONs) and subsequently blocked them with gemcitabine (Gem) molecules through acetal covalent bonds. At pH 7.4, small amounts of ICG and 17AAG were released, confirming the excellent capping effect of Gem under physiological conditions. In contrast, the release of ICG and 17AAG increased dramatically at pH 5.0. The investigation of cellular uptake and intracellular drug release using a laser confocal scanning microscope showed strong intracellular ICG fluorescence at pH 6.0 but relatively weak fluorescence at pH 7.4. These results indicated that ICG release was greatly stimulated by cleavage of the acetal bond. In quantitative flow cytometric measurements, the cellular uptake of the nanoplatform increased dramatically as the cell culture pH was changed from 7.4 to 6.0. This study presented a nanoplatform applying a pH-responsive gatekeeper, which minimizes damage to normal cells and provides an excellent low-temperature PTT strategy for cancer cell inhibition  172]..172].o-nitrobenzyl ester bond. DOX-loaded liposomes composed of Fa-ONB lipid and dipalmitoylphosphatidylcholine (FOBD) showed an increase in drug release efficiency according to pH change and UV irradiation synergistically  consisting of activated folic acid combined with 4-(bromomethyl)-3-nitro-benzoic acid and a didodecylamine scaffold. The Fa-ONB lipid could be cleaved by both an acidic environment and UV light irradiation because of the stically  173]. N. No-nitrKnežević et al. constructed a photo- and pH-dual-responsive nanovehicle using nitroveratryl-carbamate-protected aminopropyl-functionalized MSNs. DOX was adsorbed on nitroveratryl-carbamate-protected aminopropyl-functionalized MSNs. The photo-cleavage of the carbamate linkages yielded the release of the drug from the nanovehicle. Under UV light irradiation, positively charged propylammonium groups were generated on the nanoparticle surface, leading to the desorption of positively charged DOX from the surface of the nanoparticles. An increase in DOX release was under a weakly acidic environment and prolonged irradiation time . Xing etIn this review, we address the mechanisms and design of photo-responsive nanovehicles on the basis of recent research and the properties of polymers, peptides, and chemical groups responsive to the tumor acidic micro-environment. Several materials that absorb light can change their structures or release heat and ROS directly or indirectly through PSs, thus exhibiting a great potential for constructing photo-responsive nanovehicles for drug delivery. In addition, various materials with pH sensitivity and acid-labile chemical bonds can be used in nanovehicles depending on their properties. Such smart nanovehicles can improve the targeting of anticancer drugs and enhance tumor intracellular accumulation and uptake, resulting in increased anticancer efficacy and reduced systemic side effects. Recently, the development of two or more stimulus-based smart nanovehicles has been eagerly supported. In the future, it will be possible to obtain better results for cancer treatment owing to these multifunctional nanovehicles. Despite the wide range of efforts in this new direction, there remain several challenges in improving the therapeutic efficacy and safety of smart nanovehicles for clinical applications ,179,180.Photo-based transformation has critical drawbacks, such as low sensitivity to NIR light and relatively high optical power density for most reactive motifs. Indirect photo-responsive delivery may have disadvantages such as hypoxia-boosted tumor metastasis and ROS or heat-induced damage to the drug encapsulated in the carrier. The acidic pH region of tumors is generally far from the bloodstream, which may lead to an insufficient response of acidic-pH-responsive nanoparticles. Additionally, as shown in


We describe a case of a suspected cutaneous hypersensitivity reaction to ticagrelor. The patient displayed a localized bullous fixed drug eruption after being loaded with ticagrelor, which resolved with oral antihistamines and topical steroids after one week. Clopidogrel and rivaroxaban were successfully administered as alternative antithrombotic therapy without any apparent further hypersensitivity skin reaction. The risk of thrombotic events is lower with dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI) . TicagreHypersensitivity skin reactions to ticagrelor are exceedingly rare, with less than 40 cases reported by the United States Food and Drug Administration (FDA) . The indWe describe a case of localized bullous fixed drug eruption, which resolved after transitioning from ticagrelor to clopidogrel and rivaroxaban.A 44-year-old South Asian male with no significant medical or family history presented to the emergency department with typical chest pain and shortness of breath. He did not report any significant social history, and his review of systems was unremarkable. His vital signs indicated systolic blood pressures of 156/92 mmHg, heart rate of 108 beats per minute, respiratory rate of 20 breaths per minute, with an oxygen saturation of 97% on room air. The brief physical examination was normal. An emergency 12-lead electrocardiogram revealed marked, 6-millimeter ST-segment elevation in leads V1-V6 with reciprocal ST-depressions in the inferior leads, II, III, and aVF.He was immediately administered oral aspirin, ticagrelor load, high-intensity rosuvastatin in addition to an intravenous nitroglycerin infusion and subsequently proceeded for primary PCI. During cardiac catheterization, it was discovered that the patient had the much dreaded "widow-maker" lesion - a proximal left anterior descending (LAD) artery occlusion with high-grade thrombus burden. He successfully underwent transfemoral drug-eluting stent (DES) implantation after thrombus aspiration with a Boston Scientific Corporation  SYNERGY® everolimus DES.Post-procedure, the patient developed translucent bullous lesions with surrounding erythema on the distal flexor aspect of the right forearm, for which he promptly received intravenous hydrocortisone and chlorphenamine. At this juncture, the tentative diagnosis was a contrast-media reaction . During the subsequent hospitalization, the patient was hemodynamically stable. He was subsequently discharged on guideline-directed medical therapy on DAPT with ticagrelor, high-intensity statin, low-dose beta-blocker, and angiotensin-receptor neprilysin inhibitor, and mineralocorticoid receptor antagonist, in addition to oral antihistamine and topical steroid cream therapies. A skin biopsy was not performed, as there were no available dermatologists during the coronavirus disease 2019 (COVID-19) pandemic.The patient contacted the interventional cardiologist one-week post-procedure and alerted him that the lesions were worsening despite the therapies. At that time, a measured decision was taken to transition him to clopidogrel  and rivaroxaban 2.5 milligrams twice daily. Over the following four days, the bullous lesions spontaneously ruptured, with resolving erythema and induration. After a further three-day period, the lesions almost fully healed with areas of hyperpigmentation. There was no generalized body or mucosal involvement. Provocation tests with ticagrelor were not performed Figure .Oral antiplatelet cutaneous hypersensitivity reactions often present the clinical conundrum of drug discontinuation at the expense of possibly fatal cardiovascular complications such as stent thrombosis -10. ThesHypersensitivity skin reactions to ticagrelor are relatively rare ,10. To tWe report a case of a suspected ticagrelor-induced bullous fixed drug eruption, which was conservatively managed with topical steroids and antihistamines. The physician should be aware of the rare dermatologic manifestations of ticagrelor, an antiplatelet therapy rapidly gaining traction in treatment algorithms for acute coronary syndromes.


The COVID-19 pandemic has elevated mRNA vaccines to global recognition due to their unprecedented success rate in protecting against a deadly virus. This international success is underscored by the remarkable versatility, favorable immunogenicity, and overall safety of the mRNA platform in diverse populations. Although mRNA vaccines have been studied in preclinical models and patients with cancer for almost three decades, development has been slow. The recent technological advances responsible for the COVID-19 vaccines have potential implications for successfully adapting this vaccine platform for cancer therapeutics. Here we discuss the lessons learned along with the chemical, biologic, and immunologic adaptations needed to optimize mRNA technology to successfully treat cancers. For decades cancer vaccines have been utilized to induce antitumor immune responses against cancer antigens, sometimes in association with clinical responses. Initial cancer vaccination strategies targeted antigens linked to oncogenesis and cancer progression that are shared by many cancers — either overexpressed cancer-initiating gene products (driver antigens) such as HER-2 or reactivated gene products such as MAGE , 2. WithWhile many studies have used DNA or peptide platforms for cancer vaccine delivery, mRNA-based therapeutics have demonstrated equal or greater activity in preclinical studies and early-stage clinical trials. The mRNA platform is also versatile and has successfully been used in systemic, subcutaneous, intramuscular, and in situ vaccine strategies and to genetically modify dendritic cell–based vaccines and create chimeric antigen receptor (CAR) T cell therapies. But progress in mRNA vaccine clinical development has been slow because of challenges relating to stability, cost of personalized production of patient-specific vaccines, and delivery. The SARS-CoV-2 pandemic led to the successful clinical development and application of several mRNA vaccines, underscoring the remarkable versatility, favorable immunogenicity, and overall safety of the mRNA platform on a global scale. A large part of the more recently conducted foundational research that led to this success has rested on transformative biomedical engineering and novel delivery methods aimed to optimize the therapeutic potential of this vaccine platform. Understanding the advancements that yielded successful mRNA vaccines for COVID-19 should accelerate progress in overcoming the remaining challenges for their application to cancer vaccination.+ T cell responses capable of detecting and lysing virus-infected cells in a murine model of influenza infection, demonstrating the immunogenic potential of RNA vectors  and Moderna (mRNA-1273) SARS-CoV-2 mRNA–lipid nanoparticle (mRNA-LNP) vaccines established worldwide protocols for and feasibility of large-scale good manufacturing practice, broad vaccine distribution, and vaccine administration, from which several lessons were learned. Importantly, SARS-CoV-2 mRNA vaccine studies have uncovered the diversity of adaptive immune responses that are elicited and contribute to early and long-term disease control.+ T cells and cytotoxic CD8+ T cell responses  — notably macrophages and dendritic cells — the specialized immune cells that most effectively prime T and B cells . Thus faAn additional challenge for cancer vaccines in general is overcoming the local and systemic immunosuppressive mechanisms often associated with transformed cells that prevent priming or effector function of anticancer T cells. While most tested vaccines demonstrate priming of antigen-specific T cell responses, the immunosuppressive tumor microenvironment (TME) of cancers often hinders T cell access and function at the tumor site. Immune checkpoint therapies successfully reprogram one or more immunosuppressive signals in the TME to allow T cell access and function. Thus, in situ vaccines that successfully induce anticancer T cell responses require the co-delivery of costimulatory molecules or immune checkpoint inhibitors to achieve antitumor immunity . BecauseThere are three broad categories of mRNA vaccine constructs: non-replicating, self-replicating, and trans-replicating (or splitzicon) RNAs. Non-replicating and self-replicating RNAs have been primarily used in cancer vaccine strategies. Non-replicating mRNAs, such as the SARS-CoV-2 vaccine, encode the target antigen that is translated into protein immediately after uptake into the target cell’s cytoplasm. This results in initial high protein expression that diminishes over a few days . The proA key consideration in developing mRNA vaccines for cancer treatment is the optimal balance of innate sensing of the mRNA construct and vector expression. Exogenous mRNAs are inherently immunogenic, as their features are detected by several cellular pattern recognition receptors (PRRs) . CollectN1-methyl-pseudouridine into the mRNA construct during in vitro transcription, as was used in both SARS-CoV-2 mRNA vaccines, dramatically reduces TLR recognition  tail by incorporating ATP analogs, such as ATPαS, with non-bridging atoms at the α-phosphate; this stabilizes the transcript without impacting translation . SimilarCancer cells develop multiple mechanisms that modulate both local and systemic immunosuppression, including metabolic reprogramming, recruitment of immunosuppressive cells, and upregulation of inhibitory cytokines and signals. For successful treatment outcomes with mRNA-based therapeutics, the vaccine should ideally induce high-quality antigen-specific T cells and simultaneously reduce immunosuppressive signals within the TME. In this regard, modulation of the cytokine milieu in which T cells engage cognate antigen influences cell fate and memory phenotype. In addition to robust cytotoxic effector cells, generation of stem-like, memory T cells is important for durable immunologic memory and cell renewal in cancer therapy , 125. Onl-lysine (co-glycolic acid) (PLGA)–core/shell RNA-nanoparticle–induced potent antitumor immune responses  benzene-1,3,5-tricarboxamide–formulated (TT-formulated) nanoparticles promoted particle uptake in tumor cells in vitro and in vivo, and induced cell lysis while conferring IL-12 transgene expression (+ T cell–mediated reduction of tumor growth in a murine B16F10 melanoma model (Ka of the particle, which is directly related to ionizable lipid shape and size (Targeting tumor cells directly to deliver immunogenic payloads or to induce oncolysis provides an alternative mechanism to reduce tumor burden and initiate remodeling of the TME. Leaky tumor vasculature and damaged lymphatic structures within the TME improve retention of systemically delivered nanoparticle constructs. Thus, similar to immune cell targeting, particle size and charge dictate propensity for tumor cell–specific uptake . It was pression , 164. Thma model , 164. Alma model , 165. A ma model . Regardland size , 168. Maand size , 169–171Intradermal, subcutaneous, and intramuscular injection routes of any mRNA vaccine capitalize on the presence of diverse APC populations within the skin and muscle , 173. NomRNA vaccines have been studied in different formats and settings and as part of combinatorial therapies in cancer clinical trials . Two str+ and CD8+ T cells (A second approach using lipid-complexed mRNAs demonstrated both favorable safety and robust immune responses against immunizing antigens expressed by different tumor types . For exa T cells .+ and CD4+ T cells, respectively (+ T cell phenotype from Tregs to Th1-like cells (mRNA vaccines can also be enhanced using TriMix, a cocktail of three naked mRNAs encoding constitutively active TLR4 to facilitate dendritic cell antigen presentation, and CD70 and CD40L to activate CD8ectively . Both thke cells , 180. Noke cells .Human studies testing mRNA vaccines in cancer have provided evidence for safety and immunogenicity. However, these trials have had a relatively small sample size, with clinical responses that are mixed, despite robust immune responses seen peripherally. This is particularly true in patients with “immunologically cold” tumors, such as glioblastoma. These early studies reiterate the need for co-delivery of immunomodulating agents to effectively bypass tumor-specific immunosuppressive signals. Furthermore, most of the immune responses are evaluated using assays requiring ex vivo expansion, which provide an antigen-specific readout but may not accurately quantify and assess the quality of the overall T cell response in vivo.Early mRNA-based therapeutics have shown promise in cancer therapy. Clinically, these agents can be potent T cell inducers and can also remodel the immunosuppressive TME. However, because of the inherent heterogeneity of cancer both within and across clinical indications, additional technological advances are needed to develop successful RNA-based cancer therapies . OngoingIn summary, considerable progress has been made in mRNA-based cancer therapeutics. This progress is made more tangible with the global success of the SARS-CoV-2 mRNA vaccines, further promoting promise for cancer immunotherapy.


The predicted zoonotic capacity and proximity to humans suggest enhanced transmission risk from several common mammals, and priority areas of geographic overlap between these species and global COVID-19 hotspots. With molecular data available for only a small fraction of potential animal hosts, linking data across biological scales offers a conceptual advance that may expand our predictive modelling capacity for zoonotic viruses with similarly unknown host ranges.Back and forth transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between humans and animals will establish wild reservoirs of virus that endanger long-term efforts to control COVID-19 in people and to protect vulnerable animal populations. Better targeting surveillance and laboratory experiments to validate zoonotic potential requires predicting high-risk host species. A major bottleneck to this effort is the few species with available sequences for angiotensin-converting enzyme 2 receptor, a key receptor required for viral cell entry. We overcome this bottleneck by combining species' ecological and biological traits with three-dimensional modelling of host-virus protein–protein interactions using machine learning. This approach enables predictions about the zoonotic capacity of SARS-CoV-2 for greater than 5000 mammals—an order of magnitude more species than previously possible. Our predictions are strongly corroborated by  The bspillback infections since the emergence of SARS-CoV-2 in 2019 . In spillback infection, human hosts transmit SARS-CoV-2 virus to cause infection in non-human animals. In addition to threatening wildlife and domestic animals, repeated spillback infections may lead to the establishment of new animal hosts from which SARS-CoV-2 can then pose a risk of secondary spillover infection to humans through bridge hosts (e.g. [Neovison vison) with the secondary spillover of a SARS-CoV-2 variant from mink back to humans [Mus musculus) [The ubiquity of ACE2 coupled with the high prevalence of SARS-CoV-2 in the global human population explains multiple observed ts , redo humans  and reduo humans . Converso humans , two newsequence-based studies), or by modelling the structure of the viral spike protein bound to ACE2 orthologues (structure-based studies) to yield a wide range of predictions with varying degrees of agreement with laboratory animal experiments  and non-human ACE2, and assume that a high degree of similarity correlates with stronger viral binding, especially at amino acid residues where hACE2 interacts with the SARS-CoV-2 spike glycoprotein. For some species, such as rhesus macaques , these q studies , but pre studies . Mismatcequences ,40.Structure-based studies model the three-dimensional structure of protein-protein complexes to address some of the limitations of sequence-based approaches. Structural models have proven useful for predicting how different ACE2 orthologues bind to the SARS-CoV-2 viral spike protein receptor-binding domain (RBD) ,28. ThesAlthough structural modelling has produced the most accurate results to date, all currently available approaches for predicting the host range of SARS-CoV-2 are fundamentally constrained by the availability of ACE2 sequences across species. ACE2 is ubiquitous across chordates, probably because of its role in highly conserved physiological pathways, for example in regulating blood pressure, salt and water . The vasHere, we combine structural modelling of viral binding with machine learning of species ecological and biological traits to predict zoonotic capacity for SARS-CoV-2 across 5400 mammal species, expanding our predictive capacity by an order of magnitude . CrucialAs COVID-19 is primarily a disease affecting humans, spillback infection of SARS-CoV-2 from humans to animals is the most likely mode by which new animal hosts will become established. We therefore identify a subset of species for which the threat of spillback infection appears greatest due to geographic overlaps and opportunities for contact with humans in areas of high SARS-CoV-2 prevalence globally. These approaches underscore the utility of establishing interdisciplinary and iterative processes that join computational modelling, field surveillance and laboratory experiments to more efficiently quantify zoonotic risk , and bet. 2 (a)We assembled ACE2 sequences from the NCBI GenBank and MEROPS databases. The modelling of 326 ACE2 orthologues bound to SARS-CoV-2 spike RBD was carried out using the HADDOCK software as described previously , with a  (b)We gathered ecological, life history, phylogenetic and biological trait data from AnAge , Amniote (c) (i)in vivo experiments suggest that some species are capable of binding SARS-CoV-2 but not capable of transmitting active infection to other individuals , currently the species with weakest predicted binding but confirmed conspecific transmission [Sus scrofa), which shows the strongest estimated binding for which experimental inoculation failed to cause detectable infection [ACE2 binding is necessary for viral entry into host cells, but it is not sufficient for SARS-CoV-2 transmission. Multiple s taurus ; bank volareolus ). Viral smission , and thenfection . Binding (d)https://github.com/HanLabDiseaseEcology/zoonotic_capacity.We applied generalized BRT  to host . 3Currently available ACE2 protein sequences came from 326 species spanning eight classes and 87 orders . The majWe next constructed a trait-based machine learning model to predict zoonotic capacity (a binarized binding threshold) in mammals. We used the best-performing model to generate predictions of zoonotic capacity among mammal species . Citation count in Web of Science, used as a proxy for study effort, had approximately 1% relative importance , suggesting that sampling bias across species had little influence on the model.This model predicted 540 species spanning 13 orders to have zoonotic capacity within the 90th percentile . Most p (a)in vivo studies , in which farmed individuals present severe infection and demonstrate the capacity to transmit to conspecifics as well as to humans [Eptesicus fuscus [These model predictions matched the experimental infection outcomes of several  studies . For insiculatus ,66) and yonoides ) confirmo humans . Our mods fuscus ).Sus scrofa, probability = 0.72, approximately 80th percentile), but in vivo studies report no detectable infection or onward transmission [Bos taurus), our model estimated a moderately high probability for zoonotic capacity , whereas in a live animal experiment, cattle were susceptible but with no onward transmission to conspecifics [There were notable differences between our model results and currently available experimental studies. Our model estimated high zoonotic capacity for pigs . Importantly, this approach extends our predictive capacity beyond the limited number of species for which ACE2 sequences are currently available. Numerous mammal species were predicted to have zoonotic capacity that meets or exceeds the viral susceptibility and transmissibility observed in experimental infections with SARS-CoV-2 Bubalus bubalis), widely kept for dairy and plowing, had the highest probability of zoonotic capacity among livestock (0.91). Model predictions in the 90th percentile also included American mink (Neovison vison), red fox (Vulpes vulpes), sika deer (Cervus nippon), white-lipped peccary (Tayassu pecari), nilgai (Boselaphus tragocamelus) and raccoon dogs (Nyctereutes procyonoides), all of which are farmed. The escape of farmed individuals into wild populations has implications for the enzootic establishment of SARS-CoV-2 [Given that contact with humans fundamentally underlies transmission risk, it is notable that our model predicted high zoonotic capacity for multiple captive species that have also been confirmed as susceptible to SARS-CoV-2. These include numerous carnivores, such as large cats from multiple zoos and pet dogs and cats. Our model also predicted high SARS-CoV-2 zoonotic capacity for many farmed and domesticated species. The water buffalo (RS-CoV-2 . These f (b)Macaca genus comprised the majority of live-traded primates. Our model predicted high zoonotic capacity for all species . Several live-traded carnivores and pangolins were also assigned high zoonotic capacity, including the Asiatic black bear (Ursus thibetanus), grey wolf (Canis lupus) and jaguar (Panthera onca), and the Philippine pangolin (Manis culionensis) and Sunda pangolin (M. javanica). One of the betacoronaviruses with the highest sequence similarity to SARS-CoV-2 was isolated from Sunda pangolins [The angolins . Interesangolins .Cephalophus zebra, West Africa), warty pig  and two deer . The white-tailed deer (O. virginianus) was recently confirmed to transmit SARS-CoV-2 to conspecifics via aerosolized virus particles [Commonly hunted species in the top 10% of predictions include duiker (articles . (c)Rhinolophus, our model identified the large rufous horseshoe bat (Rhinolophus rufus) as having the highest probability of zoonotic capacity (0.89). Rhinolophus rufus is a known natural host for bat betacoronaviruses [Rhinolophus affinis (0.58), R. malayanus (0.70) and R. shameli (0.71)) and also predicted relatively high probabilities for two congeners, Rhinolophus acuminatus (0.84) and R. macrotis (0.70). These predictions agree with recent experiments demonstrating efficient viral binding of SARS-CoV-2 RBD for R. macrotis [R. acuminatus harbouring a closely related betacoronavirus [Our model identified 35 bat species within the 90th percentile of zoonotic capacity. Within the genus aviruses  and a coaviruses ,74,75. Fmacrotis  and confonavirus .Pteropus (flying foxes) with high probabilities of zoonotic capacity for SARS-CoV-2. Some of these species are confirmed reservoirs of other zoonotic viruses , with Southeast Asia also having the most mammal species with a high predicted zoonotic capacity Peromyscus maniculatus) and white-footed mouse (P. leucopus), which are reservoirs for multiple zoonotic pathogens and parasites in North America [P. maniculatus [Rattus argentiventer (0.84) and R. tiomanicus (0.79)  [Vulpes vulpes) or domestic cats (Felis catus) who themselves were predicted to have high zoonotic capacity by our model.Our model identified 76 rodent species with high zoonotic capacity. Among these are the deer mouse  –87. It i (e)Sus scrofa) would be susceptible to SARS-CoV-2  and viral persistence that collectively determine where and when viral shedding and spillover will occur [Disconnects between real-world observations, ll occur –91. Infell occur ), and onll occur . Insofarll occur ,93,94; rll occur ,96). Morll occur ) can be These examples illustrate that there is no single methodology sufficient to understand and predict zoonotic transmission, for SARS-CoV-2 or any zoonotic pathogen. They also demonstrate the need to capitalize on underused or disconnected data sources, such as natural history collections, which are well-positioned to fill knowledge gaps about the spatial and temporal extents of animal hosts and their pathogens ,99. InteClick here for additional data file.


Unique life challenges occur across life phases, including later life. Life story research suggests that the way challenges are narrated has consequences for multiple domains of well-being. Two factors for positively reframing challenges are one’s sense of purpose in life  and redemption . This study used moderated-mediation analyses to investigate whether: 1) challenge relates to psychosocial and cognitive well-being, differentially by age, and 2) narrating with greater purpose and redemption ameliorates effects of challenges on well-being, by age. Participants  rated self-disruption of challenging events from their lives (IV1) and reported number of recent life challenges experienced (IV2). Eudaimonic well-being (DV1) and cognitive well-being (DV2) were assessed. Purpose (M1) and redemption (M2) were reliably content-analyzed from participants’ narratives of autobiographical challenges . For Aim 1, young and older adults who experienced more challenges showed lower eudaimonic well-being but higher cognitive well-being. Perceived self-disruption was unrelated to well-being. For Aim 2, results showed that how individuals narrate  the challenges that have occurred in their lives mediates effects of challenge. Specifically, exhibiting a sense of purpose mediated the relation between perceived self-disruption and cognitive well-being. Redemption buffered negative effects of both self-disruption and number of challenges on eudaimonic well-being. Mediation results held regardless of age. Findings suggest purpose and redemption are two narrative mechanisms that act as psychological resources to support well-being in the face of life’s inevitable challenges.


Recently, there has been a sudden surge in COVID-19–associated mucormycosis (CAM) infections. Rhino-oculo-cerebral and pulmonary mucormycosis are the two most common forms of CAM. Radiology plays an integral role in the management of CAM. Computed tomography (CT) determines gross bony and soft tissue involvement in COVID-19–associated rhino-oculo-cerebral mucormycosis, whereas magnetic resonance imaging helps in evaluation of the orbital and intracranial extension. Paranasal sinus soft tissue with extrasinus infiltration with or without bony destruction is suggestive of COVID-19–associated rhino-oculo-cerebral mucormycosis. High-resolution CT chest scan has shown to be helpful in the diagnosis of COVID-19–associated pulmonary mucormycosis. Consolidation and cavitation are the most common imaging features. Other CT abnormalities include the reverse-halo sign, pleural effusion, ground-glass opacities, pneumothorax, nodules, and pulmonary embolism. A high index of suspicion with appropriate imaging findings can lead to the early diagnosis of CAM and timely initiation of antifungal treatment and/or surgical debridement, which can be lifesaving. COVID-19 has wreaked havoc on healthcare systems around the world. There was a sudden surge of COVID-19–associated mucormycosis cases, following the second wave of the COVID-19 pandemic. A systematic review published in August 2021 described 275 published cases of COVID-19–associated mucormycosis, out of which maximum have been reported in India (233), followed by Iran (19) and the United States (9).The diagnosis of COVID-19–associated rhino-oculo-cerebral mucormycosis is made by a combination of clinical and imaging parameters. Endoscopy with histopathology is required to confirm the diagnosis. Imaging is helpful in suggesting the diagnosis and delineates the extent, which is essential for surgical management of the patient. Both computed tomography (CT) and magnetic resonance imaging (MRI) contribute to the management. CT helps delineate the extent of bony and soft tissue involvement, whereas MRI shows the involvement of sinuses, orbits, cavernous sinuses, palate, skull base, and intracranial structures with more clarity. Noncontrast CT of paranasal sinuses is the initial investigation of choice to evaluate suspected cases of COVID-19 associated rhino-oculo-cerebral mucormycosis. In cases with suspected intracranial or orbital involvement, contrast enhanced MRI of the maxillofacial region will allow precise assessment of the soft tissue extension. The area of coverage should include the cavernous sinuses also. Brain MRI with and without contrast may be performed in patients with suspected intracranial spread.,COVID-19–associated rhino-oculo-cerebral mucormycosis shows initial involvement of nasal mucosa with soft tissue thickening. The ‘black turbinate’ sign is a distinctive feature, indicating acute invasive fungal sinusitis. It refers to nonenhancement of the nasal turbinates, due to infarction of overlying mucosa, on contrast-enhanced MRI of the paranasal sinuses. Bony erosions of the nasal septum and turbinates and partial or complete opacification of sinuses may be seen. Extrasinus spread may occur with or without associated bony destruction. There may be involvement of the buccal spaces, including the retromaxillary fat pad, the palate, or the oral cavity. The disease spreads into adjacent subcutaneous planes also. The presence of paranasal sinus involvement with extra sinus soft tissue infiltration is a characteristic finding that helps augment diagnostic accuracy .4 IntraThe differentiation of acute invasive fungal sinusitis from chronic sinusitis is essential. Chronic sinusitis presents as mucosal thickening or polyposis with sclerosis of underlying bones without evidence of bony destruction or erosions.Recent case series have been published describing the imaging findings of COVID-19–associated rhino-oculo-cerebral mucormycosis. In a study by Joshi et al.,The largest reported series of rhino-oculo-cerebral mucormycosis, without COVID-19 , by Therakathu et al.,Lungs are the other commonly involved organs after the rhino-oculo-cerebral system. COVID-19–associated pulmonary mucormycosis (CAPM) is more difficult to diagnose and has higher mortality than nonpulmonary mucormycosis.–Streptococcus pneumoniae, Hemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella pneumoniae, and Mycobacterium tuberculosis can also show cavitatory lesions. However, the concurrent presence of random nodules, halo sign, reverse-halo sign, or sinus infection will lead to the probable diagnosis of CAPM. Mucormycosis infection can be confirmed by the evaluation of endotracheal aspirate, sputum, or fine needle aspiration cytology. Imaging helps in the diagnosis of CAPM and can alert the radiologist and the treating clinician to plan further work-up for mycological evidence and institute antifungal therapy in appropriate clinical settings.Consolidation, ground-glass opacities, pleural effusion, pneumothorax, and pulmonary embolism can be seen on CT in patients with COVID-19 pneumonia;A high index of clinical suspicion followed by appropriate radiological investigations is essential for the early diagnosis of COVID-19–associated mucormycosis and initiation of antifungal treatment or surgical debridement, both of which can be lifesaving.


On February 27, 2021, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the Janssen COVID-19 (Ad.26.COV2.S) vaccine , and on February 28, 2021, the Advisory Committee on Immunization Practices (ACIP) issued interim recommendations for its use in persons aged ≥18 years   the rate and characteristics of TTS cases; 2) recent COVID-19 epidemiology; 3) modeling and risk-benefit analysis results to quantify COVID-19 hospitalizations, ICU admissions, and deaths prevented with resumption of use of the Janssen COVID-19 vaccine in the United States; and 4) data from jurisdictional COVID-19 vaccination programs regarding whether changes to ACIP recommendations would disproportionately affect certain populations.https://www.cdc.gov/vaccines/covid-19/info-by-product/janssen/risk-benefit-analysis.html). The population-level risk-benefit analysis assumed continued use of the mRNA vaccines and estimated the number of COVID-19–related hospitalizations, ICU admissions, and deaths that could be prevented by use of the vaccines; benefits from vaccination were applied to the entire population, both directly to vaccinated persons and indirectly because of herd immunity. The modeling data showed that in 6 months, resuming use of the Janssen COVID-19 vaccine among persons aged ≥18 years at 50% of the prepause administration rate could prevent 3,926−9,395 COVID-19–related hospital admissions, 928−2,236 ICU admissions, and 586−1,435 deaths (depending on assumed future COVID-19 transmission levels), compared with 26 expected cases of TTS  prevention tool that can be useful in communities with increasing COVID-19 incidence and emerging variants of SARS-CoV-2, the virus that causes COVID-19 . LimitinFDA has added a warning to the Janssen COVID-19 vaccine EUA and fact sheets regarding rare clotting events that have been reported among vaccine recipients .Treatment for TTS that occurs after receipt of the Janssen COVID-19 vaccine is different from the treatment typically administered for blood clotsCDC and FDA will continue to closely monitor reports of TTS after receipt of the Janssen COVID-19 vaccine and will bring any additional data needed to guide benefits and risks to ACIP for consideration. The risk-benefit analysis can be updated as needed to reflect changes in the COVID-19 pandemic and additional information on the risk for TTS after COVID-19 vaccination. The ACIP recommendation for use of the Janssen COVID-19 vaccine under an EUA is interim and will be updated as additional information becomes available.https://vaers.hhs.gov/index.html or 1-800-822-7967. Any person who administers or receives a COVID-19 vaccine is encouraged to report any clinically significant adverse event, whether or not it is clear that a vaccine caused the adverse event. In addition, CDC has developed a new, voluntary smartphone-based online tool (referred to as v-safe) that uses text messaging and online surveys to provide near real-time health check-ins after receipt of a COVID-19 vaccine. In cases of v-safe reports that include possible medically attended significant health events, CDC’s v-safe call center follows up with the vaccine recipient to collect additional information for completion of a VAERS report. Information on v-safe is available at https://www.cdc.gov/vsafe.FDA requires that vaccine providers report vaccination administration errors, serious adverse events,On April 13, 2021, CDC and the Food and Drug Administration (FDA) recommended pausing use of the Janssen COVID-19 vaccine after reports of thrombosis with thrombocytopenia syndrome (TTS) among vaccine recipients.On April 23, the Advisory Committee on Immunization Practices concluded that the benefits of resuming Janssen COVID-19 vaccination among persons aged ≥18 years outweighed the risks and reaffirmed its interim recommendation under FDA’s Emergency Use Authorization, which includes a new warning for rare clotting events among women aged 18–49 years.Resuming use of the Janssen COVID-19 vaccine will ensure flexibility, choice, and improved access. Education about TTS risk with Janssen COVID-19 vaccine is critical.