Recent breakthroughs in cancer therapeutics have occurred through the recognition of the immune system’s role in cancer cell eradication and surveillance. While these breakthroughs have primarily occurred in solid tumors, the role of immunotherapy as an anti-cancer treatment is best described through decades of work in allogeneic hematopoietic stem cell transplantation  for acute leukemias. Herein we review the history and mechanisms behind allo-HSCT and discuss how lessons learned through transplants and cancer evasion of the host immune system can be applied toward acute leukemias to provide future therapies.Immunotherapy as a cancer treatment modality has undergone recent widespread proliferation across all cancer types, especially amongst patients with solid tumors. However, the longest tenured immunotherapy approach to cancer is allogeneic stem cell transplantation  for two hematologic malignancies: acute myeloid and acute lymphoid leukemia . While allo-SCT remains a standard of care for eligible patients, recent advances/applications of monoclonal antibodies, immune checkpoint inhibitors, bispecific T-cell engagers (BiTEs), and CAR T-cell therapy are changing the treatment landscape for these acute leukemias by either direct to tumor immune targeting or through decreased toxicities that expand patient eligibility. Pre-clinical data and clinical trials have shown promising results for novel immunotherapies in acute leukemia, and multiple ongoing trials are investigating these novel approaches. While there have been promising results with these approaches, particularly in the relapsed/refractory setting, there remain challenges in optimizing the use of these therapies, such as managing cytokine release syndrome and other immune-related toxicities. Immunotherapy is a rapidly evolving field in the treatment of acute leukemia and has the potential to significantly impact the management of both AML and ALL. This review highlights the history of immunotherapy in the treatment of acute leukemias, the evolution of immunotherapy into more targeted approaches, the potential benefits and limitations of different immune targeting approaches, and ongoing research and development in the field. In recent decades, significant advances have been made in the field of immunotherapy revolutionizing the treatment landscape for various malignancies including acute leukemias. Among the earliest and most impactful therapeutic modalities explored was allogeneic hematopoietic stem cell transplantation , which utilized the graft-versus-leukemia effect to treat acute leukemias. This paper presents a historical perspective on the development of immunotherapy in acute leukemias, starting first with the pivotal role played by allo-HSCT then exploring the emerging and promising future directions for immunotherapeutic treatments in acute leukemias as well as limitations of this therapeutic strategy. Select mechanisms by which immunotherapy targets acute lymphocytic leukemia ALL,  and acutDr. William B. Coley, often referred to as the “father of immunotherapy”, laid the foundation for modern cancer immunotherapies. His work began after observing the remission of sarcoma in a patient who had developed a concurrent bacterial skin infection . Dr. ColThe concept of using the immune system to combat acute leukemias further evolved with the advent of allogeneic hematopoietic stem cell transplantation . The pioneering work of E. Donnall Thomas in 1957 demonstrated the first use of allo-HSCT in a case series of six patients . This laSubsequent studies confirmed that the curative potential of allo-HSCT was not solely attributed to the replacement of the diseased marrow but also to an immunological phenomenon known as the graft-versus-leukemia (GVL) effect . This phThe role of T-cells in the graft-versus-leukemia effect became evident in 1990 when research showed an increased risk of relapse after T-cell depletion in various hematological malignancies. Notably, the risk of relapse in T-cell depleted transplants was the most pronounced in CML, less in acute myeloid leukemia (AML), and lowest in acute lymphoblastic leukemia (ALL) . More reThe contribution of B-cells to the GVL effect has been reported in a group of high-risk AML patients with durable remissions and AML-specific cytotoxic antibodies. The authors were able to detect monoclonal antibodies directed against AML cell surface antigens that were leukemia-specific and not on normal hematopoietic or endothelial cells. Many of the antibodies recognized the U5 snRNP200 complex which is a spliceosome that is found intracellularly in normal cells but in leukemic blasts present on the cell surface. The investigators were able to show that these U5 snRNP200 complex-specific antibodies could induce leukemic death through an Fc receptor-dependent mechanism and could inhibit leukemic growth in a murine model further underscoring the possible contribution of antibodies to the GVL effect . Despite the beneficial effects, allo-HSCT it is still not universally available for all acute leukemia patients. Previously, a lack of a suitable donor was a major barrier to a transplant which has now been largely overcome through improved outcomes in mismatched grafts and cord blood transplants. Now, the limitation is primarily based on the patient’s age and co-morbid conditions which can be evaluated by the hematopoietic cell transplantation co-morbidity index . AlthougRelapse remains the most common cause of death for allo-HSCT patients and is largely mediated through antigen recognition by the allogeneic cells, either through HLA loss following mismatched transplants, downregulation of major histocompatibility genes in leukemic blasts, and an increase in immune inhibitory checkpoint markers on leukemic blasts and donor T-cells ,19,20,21Building on the role of T-cells as a therapeutic target in malignancies, immune checkpoint blockade has revolutionized the treatment landscape for many solid tumors. Expanding the repertoire of immunotherapeutic approaches in leukemia, immune checkpoint inhibitors have emerged as a promising target to augment the graft-versus-leukemia effect following allogenic transplant. Disease relapse following allogenic transplant in leukemias is associated with poor survival with limited treatment options . The mecThe first study to show the effectiveness of checkpoint blockade in relapsed hematological malignancies after allo-HSCT was a phase I/Ib clinical trial, which examined the use of CTLA-4 inhibition, specifically using ipilimumab, on patients with relapsed hematological malignancies following allo-HSCT. Twenty-eight patients were enrolled of which 14 had refractory or relapsed AML and MDS. The trial demonstrated that 5 out of the patients with myeloid malignancies managed to achieve a complete response. Nevertheless, the study also reported significant adverse events. Specifically, 6 patients (21%) experienced grade ≥3 immune-related adverse events (irAEs), including 1 fatality. Furthermore, 4 patients (14%) developed graft-versus-host disease (GVHD), which prevented further administration of ipilimumab . AnotherLater studies have shown the limited use of checkpoint blockade in relapsed myeloid malignancies after allo-HSCT. In a prospective study, David et al. in 2020 showed minimal activity of nivolumab in relapsed myeloid malignancies after allo-HSCT (ORR = 22%) and modest activity in lymphoid malignancy (ORR = 44%) . In anotOutside of the post-transplant setting, combination strategies involving immune checkpoint inhibitors with hypomethylating agents (HMAs) are being actively explored both in the front-line and relapsed/refractory setting to further enhance therapeutic efficacy in AML. The rationale of combining hypomethylating agents with checkpoint blockade is based on upregulation of genes expressing checkpoint blockade  following exposure to HMAs . An init+ T-effector cells of non-responders displayed an exhausted phenotype which may be an avenue for future targets [Immune checkpoint blockade has also been explored in combination with cytotoxic chemotherapy for acute myeloid leukemia. The scientific rationale for this combination is based on pre-clinical studies showing that cytarabine suppresses PD-1 on myeloblasts thereby enhancing their killing by cytotoxic T-cells and thus restoring immune surveillance . Cytotox targets . In anot targets . Anti-CD47 monoclonal antibody therapy represents an exciting frontier in the immunotherapy of acute leukemias and provides a shift away from T-cell-directed immune approaches. CD47 is broadly expressed on normal cells. It acts as a ‘do not eat me’ signal by binding to the signal-regulatory protein alpha (SIRPα) on macrophages. By overexpressing CD47, leukemic blasts can evade phagocytosis facilitating their survival and proliferation. CD47/SIRPα therefore presents a promising new target in immune checkpoint blockade . In 2009+ B-ALL [The role of immune checkpoint blockade in B-ALL remains limited due to a lack of pre-clinical evidence showing efficacy. However, there is evidence that checkpoint blockade has a role to play in resistance to the bispecific T-cell engager targeting CD3 and CD19 and CAR T-cell blinatumomab . There i+ B-ALL .Monoclonal antibody therapy has emerged as a critical element of the immunotherapeutic landscape in hematological malignancies. This section will explore two key instances of monoclonal antibody therapy in leukemias—anti-CD20 therapy in B-ALL and anti-CD38 in T-ALL. Both therapies illustrate the potential of targeting specific antigens on the surface of leukemic cells to enhance the immune response to eliminate leukemic cells. + cells include antibody-dependent cellular cytotoxicity (ADCC), antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity (CDC), and apoptosis [CD20, a transmembrane protein, is primarily expressed on the surface of mature B- cells and most B-cell malignancies, including B-ALL. Rituximab, a chimeric anti-CD20 monoclonal antibody, was initially used with tremendous efficacy in non-Hodgkin’s lymphoma (NHL) . The mecpoptosis . Recognipoptosis ,58. + Ph-negative ALL [+ B-ALL  has lagged development for B-ALL for several reasons including the heterogeneity of cell surface expression in T-cell lymphoblasts. Pre-clinical studies have shown that T-ALL blasts have cell surface expression of CD38, a transmembrane receptor expressed on thymocytes, activated T-cells, terminally differentiated B-cells but minimally expressed in normal myeloid and lymphoid cells, making it a promising therapeutic target . Daratumumab, an anti-CD38 monoclonal antibody, which was studied and approved for the front-line treatment of multiple myeloma , has shoAmong the emerging immunotherapeutic strategies in acute leukemias, immune cell engagers (ICEs) have garnered significant attention. These antibody-derived molecules have the unique capability to bind various populations of normal immune cells, including T-cells, NK cells, and macrophages, as well as cancer cells, redirecting the cytotoxic activity of effector cells against the tumor.− B-ALL) has been demonstrated in the pivotal TOWER trial, a phase III study where continuous infusion of blinatumomab showed superior overall response rates and overall survival compared to standard of care [+ B-ALL) and promising results in B-ALL with persistent minimal residual disease (MRD), leading to approval of blinatumomab in these indications [In the context of acute lymphoblastic leukemia (ALL), one of the pioneering ICEs is blinatumomab, a bispecific T-cell engager (BiTE) that targets both CD3 and CD19. By bridging T-cells and B-lymphoid targets, blinatumomab effectively redirects T-cell cytotoxicity against leukemic cells. Its success in relapsed/refractory (R/R) Philadelphia chromosome-negative B-cell ALL . This strategy of combining ICEs with TKIs in Ph+ B-ALL has led to higher rates of molecular response and survival leading to the discussion on whether allo-SCT is needed in first remission in Ph+ B-ALL [Building on the success of blinatumomab in the refractory setting, the D-ALBA study examined the use of a first-line combination of dasatinib and corticosteroid induction in Philadelphia-positive B-ALL followed by blinatumomab consolidation ,68. Thish+ B-ALL .ICEs are associated with specific adverse events, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). However, blinatumomab has shown a better safety profile than chemotherapy, with reduced incidences of mucositis, cytopenias, and febrile neutropenia ,66,67. FThe use of ICEs has witnessed a remarkable expansion within the realm of AML and other myeloid malignancies. These ICEs include a variety of therapeutics such as bispecific T-cell engagers (BiTEs), dual-affinity retargeting (DART) antibodies, and trispecific killer engagers (TriKEs), all designed to stimulate immune responses against various cell surface targets on leukemic blasts.AMG330 (eluvixtamab) is a human BiTE that targets CD3 and CD33 redirects T-cell cytotoxicity towards CD33-positive AML cells. Preliminary results from studies involving heavily pre-treated AML patients have shown some activity, with higher response rates observed in patients with low tumor burden . FollowiVibecotamab, another BiTE targeting CD3 and CD123, had shown activity in heavily pre-treated refractory/relapsed AML patients. Patients who responded were found to have lower pre-therapy disease burden . FlotetuTriKEs, another class of ICEs, are under evaluation. These novel constructs are capable of engaging natural killer (NK) cells to mediate the killing of AML cell lines. They contain a wild-type IL-15 moiety and domains against CD16 and AML-specific antigens. GTB3550, a first-in-class TriKE, was evaluated among a small group of patients with R/R AML, revealing reproducible NK cell activity in all patients and suggesting that TriKEs could be a promising alternative to CD33-targeted agents .The development and clinical application of ICEs have ushered in a new era in the treatment of acute leukemias, demonstrating unprecedented response rates and improved survival outcomes. Another groundbreaking development that is changing the paradigm of acute leukemia management are cellular-based therapies such as chimeric antigen receptor T-cell (CAR-T) therapy. CAR-T are engineered T-cells that act by bringing together an extra-cellular domain which recognizes a tumor antigen independent of major histocompatibility complex proteins. Its use was pioneered in B-ALL and is now making inroads into the treatment of other acute leukemias. In the following section, we will explore the evolution, clinical efficacy, and challenges of CAR-T therapy in the management of acute leukemias.+ relapsed or refractory B-ALL were treated. Results showed high rates of initial response in relapsed patients and long-term remission in some [The first successful CAR-T target was CD19 which was developed for CD19 expressing malignancies including B-ALL. Tisagenlecleucel, an autologous anti-CD19/4-1BB/CD3z CAR-T, was studied in the phase I/IIa ELIANA trial in which pediatric and young adult patients with CD19 in some ,75,76. F in some . Long-te in some . A syste in some . One of the challenges of autologous CAR-T encountered in previous trials was that certain patients could not be included due to manufacturing failure, disease progression, or severe adverse events occurring during the manufacturing process. Allogenic CAR-T or “off-the-shelf” CAR-T have been developed to reduce time in CAR T-cell infusion to overcome those challenges. UCART-19, allogeneic 4-1BB/CD3z CAR T-cells manufactured from non-HLA compatible donors, were investigated in two phase I clinical trials  in patients with relapsed/refractory B-ALL. These trials showed a favorable safety profile and some anti-leukemic activity ,80.+ CAR T-cell dose and peak expansion [n = 20) achieved MRD-CR without any grade 3 adverse events. These results led to the ongoing FELIX trial which is a phase II trial which is using this construct in adult patients with relapsed/refractory B-ALL (NCT04404660) [While CAR-T remains a promising therapeutic option for relapsed/refractory B-ALL, its use is limited by significant toxicities, namely, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). These toxicities have been reported in higher rates in ALL patients as compared to other B-cell malignancies, especially in adults. Factors associated with higher severity CRS include higher T-cell dose, and pre-treatment bone marrow burden and risk factors for ICANS include bone marrow disease burden, cyclophosphamide and fludarabine lymphodepletion, presence of any pre-existing neurologic comorbidity and CD8xpansion . To overxpansion . Obecabt4404660) . Other s4404660) .In contrast to the clinical success of CAR-T-cell therapy in ALL, the development of CAR T-cells in myeloid malignancies remains challenging. The major challenge with the development of CAR-T in myeloid malignancies is that myeloid leukemia cells share cell surface markers with normal hematopoietic cells which may lead to prolonged cytopenias which is a much more difficult problem to deal with compared to the lymphopenia seen in targeting CD19 in B-ALL . MultiplIn the ongoing exploration of cellular-based treatments for AML, natural killer (NK) cells have garnered attention. NK cells are innate lymphoid cells known for their inherent ability to recognize and destroy tumor cells without prior sensitization. Their early promise was initially showcased in the context of T-cell-depleted mismatched-donor allo-HSCT. Researchers observed that donor vs. recipient NK cell alloreactivity avoids relapse and graft rejection in patients with AML . SubsequWith the advancement of genetic engineering, researchers have begun to explore the potential of genetically modified NK cells to further harness and amplify their anti-leukemic activity specifically against AML targets. Preliminary results from clinical trials using CAR-NK cells and other therapeutic NK cell products are indeed promising, however, they are currently in the early phases of clinical trials and have yet to achieve FDA approval .The spotlight on T-cells in the realm of immunotherapy for acute leukemias is well deserved, given their crucial role in graft-versus-leukemia effect. However, as highlighted throughout this review, there is growing recognition that additional targets beyond T-cells hold significant promise. From immune checkpoint inhibitors targeting PDL-1 to monoclonal antibodies against CD20, CD38, and CD47, as well as the emerging field of immune cell engagers and genetically modified cell therapies, new avenues for effective treatment strategies are being explored. While T-cells have paved the way, the horizon of immunotherapy in acute leukemias extends beyond them offering hope for improved outcomes and expanded therapeutic options for patients.


Abdominal magnetic resonance imaging (MRI) with diffusion-weighted sequence with a b value of 1000 was performed, which identified a second metastasis of the liver.Detection of hepatic metastasis from colorectal cancer remains a clinical challenge. In this case report, we present a 66-year-old male patient with a rectal carcinoma who underwent 18F-FDG PET-CT.This case report illustrates that, in some patients, diffusion-weighted MRI with a b value of 1000 might be a more sensitive technique for detecting small hepatic metastases than  In contrast, magnetic resonance imaging (MRI) can detect smaller hepatic metastases but has lower specificity [218F-FDG PET-CT failed to identify a hepatic metastasis, while abdominal MRI with diffusion-weighted sequence (DWI) with a b value of 1000 identified all metastases, which were subsequently confirmed intraoperatively and histopathologically. This paper highlights the usefulness of high b value DWI MRI for detecting small hepatic metastases and their relevance for guiding treatment and monitoring the disease.Colorectal cancer (CRC) most frequently develops in the sigmoid colon, accounting for 35–50% of all cases, followed by the upper rectum, which represents approximately 20% of cases . Imaging18F-FDG PET-CT staging revealed focal uptake in the upper rectum . r rectum  and 2, wASP. r rer rectum .18F-FDG PET-CT; however, it further identified numerous affected lymphatic nodules and another suspicious 12-mm lesion with restricted diffusion in the left medial segment of the liver (18F-FDG PET-CT (Given the increased risk of other distant metastases in colorectal cancer, a surveillance MRI using a 1.5 Tesla GE Optima 450W system was performed. Abdominal-pelvic MRI with DWI with a b value of 1000 revealed the lesions identified by he liver . This leG PET-CT . The lesG PET-CT .After three months of neoadjuvant chemoradiotherapy, colectomy with resection of the upper rectum and liver metastasectomy was done. Postoperative histopathological examination of the resected specimen revealed a moderately differentiated adenocarcinoma and metastases in six regional lymph nodes, as seen on MRI. Both metastatic lesions in the liver were confirmed histopathologically. The patient was subsequently referred for adjuvant chemotherapy and remained disease-free on clinical and radiological follow-up for three months after surgery.18F-FDG PET-CT in detecting small hepatic metastases from CRC, although further studies are needed to draw definitive conclusions [This case report provides strong evidence supporting the higher sensitivity of DWI MRI compared to clusions 5. Some tIn patients with CRC, multimodal imaging techniques might be useful for detecting and staging of cases with high risk of liver and peritoneal metastases. Our case demonstrates the clinical relevance of this recommendation and the benefits of early detection of hepatic metastases.18F-FDG PET-CT. This cost-effective MRI-based technique can be used as a surrogate method for pre-operative assessment and post-operative follow-up.In patients with rectal cancer, MRI with high b value DWI can successfully detect small metastatic lesions of the liver that may not be detected by


Optical-range bulk diffraction nanogratings were fabricated via challenging direct inscription by ultrashort  laser pulses inside heat-shrinkable polymers (thermoplastics) and VHB 4905 elastomer. The inscribed bulk material modifications do not emerge on the polymer surface, being visualized inside the materials by 3D-scanning confocal photoluminescence/Raman microspectroscopy and by the multi-micron penetrating 30-keV electron beam in scanning electron microscopy. The laser-inscribed bulk gratings have multi-micron periods in the pre-stretched material after the second laser inscription step, with their periods continuously reduced down to 350 nm on the third fabrication step, using thermal shrinkage for thermoplastics and elastic properties for elastomers. This three-step process allows facile laser micro-inscription of diffraction patterns and their following controlled scaling down as a whole pattern to pre-determined dimensions. In elastomers, utilizing the initial stress anisotropy, the post-radiation elastic shrinkage along the given axes could be precisely controlled until the 28-nJ threshold fs-laser pulse energy, where elastomer deformation ability is dramatically reduced, producing wrinkled patterns. In thermoplastics, the fs-laser inscription does not affect their heat-shrinkage deformation up to the carbonization threshold. The measured diffraction efficiency of the inscribed gratings increases during the elastic shrinkage for the elastomers and slightly decreases for the thermoplastics. High 10% diffraction efficiency was demonstrated for the VHB 4905 elastomer at the 350 nm grating period. No significant molecular-level structural modifications were observed by Raman micro-spectroscopy in the inscribed bulk gratings in the polymers. This novel few-step method paves the way for facile and robust ultrashort-pulse laser inscription of bulk functional optical elements in polymeric materials for diffraction, holographic and virtual reality devices. The ongoing progress in nanofabrication technologies breaks the receding barriers in the integration of functional elements in nanoelectronics and nanophotonics, boosting the modality and functionality of the integrated devices ,2. SpeciDirect ultrashort pulse laser inscription emerges as a facile tool for fabricating optical elements in different materials 2–103 kPa), non-linear deformation versus stress and minimal plasticity—were not ultimately harnessed in nanophotonics up to the date.Recently, ultrashort laser pulses were utilized for refractive index modification in polymers—both on surfaces and in bulk, producing diffraction gratings ,14,15,16Similarly, heat-shrinkable (thermoplastic) polymers could potentially be a perspective material platform in nanophotonics ,27. Suchnanopatterning inside polymers via ultrashort pulse laser micro-scale inscription, exploring a few pre-stretched elastomers and thermoplastics for direct fs-laser inscription of sub-wavelength one-dimensional bulk diffraction gratings, utilizing their abovementioned shrinking modalities via the three-step fabrication process. Diffraction efficiencies of the resulting (down)scaled gratings were measured, while their buried arrangement was identified by 3D-scanning confocal photoluminescence/Raman micro-spectroscopy and highly penetrating 30-keV electron beam in scanning electron microscopy at the absence of observable AFM-acquired surface relief. Their molecular-level structural states were characterized by 3D-scanning confocal photoluminescence/Raman micro-spectroscopy too.In this study, we demonstrated very challenging bulk In our studies, we used commercially available 1 mm thick sheets of thermoplastic polyethylene terephthalate (PET) and polyurethane (PU), and elastomer VHB 4905 . The samples were processed regarding bulk DOE laser-based fabrication in the following way . First, 1/e, equal to 0.7 or 1.9 µm , respectively, with the pulse energy in the range of 3.2–14.7 nJ for the thermoplastics and up to 30 nJ for the elastomer. The exposure occurred at the 100 kHz repetition rate with the laser polarization arranged along the grating stripes. Micro-gratings were inscribed inside the stretched thermoplastic samples within the regions of 1.5 × 1.5 mm in size, utilizing the 3D-translation stage  at the scan speed of 350 µm/s (exposure N0.25 = 500 pulses/spot and N0.65 = 200 pulses/spot), with their periods of 2, 3 and 10 µm. The elastomer VHB 4905 was four-fold stretched in all directions, while the thermoplastic materials were stretched 2.5 fold along the grating wave vector and up to 1.5 fold in the orthogonal direction.Laser inscription of the micro-gratings in the polymer sheets was performed by means of a laser micromachining workstation based on a Yb-doped fiber laser Satsuma . Its second harmonic pulses  were focused at the depths of 50–100 μm under the sample surface  by 0.65-During the direct laser inscription in the polymer’s refractive properties of the materials in the focal volume is changing, following nanoscale structural transformations just in their molecular packaging , thus keThe initial and inscribed polymer samples were characterized regarding potential laser-induced surface ablative modification by atomic force microscopy AFM, , using aOne bulk diffraction grating with a period of 10 μm was inscribed by fs-laser pulses inside the thermoplastic PU sample a. Its heMeanwhile, the optical diffraction efficiency of the bulk PU diffraction gratings diminished versus the period (see below); very possibly, the structural relaxation occurred during the shrinkage, diminishing also the additional strong birefringence in the modified region, along with the main artificial stress birefringence.In the other thermoplastic PET sample, the initial bulk diffraction micro-grating with the period of 3 μm visualized by optical microscopy, SEM and 3D-scanning confocal Raman/photoluminescence micro-spectroscopy was transformed into the other one with the reduced period of 1.7 μm . SEM visIn contrast to the thermoplastic polymers, the elastomer VHB 4905 does not support the heat-shrinkage modality and for this reason it was anisotropically and mechanically pre-stretched in two orthogonal directions. As a result, the laser-inscribed bulk grating period could be then increased or decreased by the following external deformation. In Interestingly, the exposure of the elastomer VHB 4905 at the threshold fs-laser pulse energy of 28 nJ results in the irreversible multi-micron mechanical disturbance of the modified region, accompanying its 2.5-fold vertical and 1.5-fold horizontal shrinkage. Meanwhile, no considerable changes in Raman scattering intensities were observed in the non-modified and modified (inscribed) regions inside the VHB 4905 elastomer and the PU thermoplastic polymer at the 532 nm laser excitation , thus inIn the end, in this study, we utilized for the laser inscription in the polymers just the available 515 nm wavelength, the 0.3-ps laser pulse width and the very limited range of pulse energies, as well as the 0.25-NA and 0.65-NA focusing optics. Meanwhile, some observations reported in the literature indicate that other ultrashort-pulse laser wavelengths, shorter or longer pulse widths, spatial, temporal and spatiotemporal focusing systems, as well as other pulse-energy ranges, could be advantageous for delicate and precise micromachining inside bulk polymers in case-specific applications , related to mechanical relaxation of the pre-stretched elastomer or thermal shrinking of the thermoplastics along with the inscribed bulk micro-scale structures. Using as tests laser-inscribed bulk one-dimensional diffraction gratings, the scalability of their periods and diffraction efficiencies through the deformation relaxation was studied, revealing the non-linear dependence between the shrinkage and grating periods and the corresponding non-trivial dependences of their optical diffraction efficiency on the shrinkage magnitude—raising for the elastomer, constant for the polyethylene terephthalate, while diminishing for the polyurethane. The absolute optical diffraction efficiency values approach 10%, being comparable to the current holographic fabrication technologies. The bulk inscription character was demonstrated by scanning electron microscopy at 30-keV electron energy (top-view grating picture), 3D-scanning confocal photoluminescence/Raman micro-spectroscopy (photo-luminescent and Raman 3D-images) and atomic force microscopy (no surface grating relief). The obvious advantage of our method is the potentially controllable direct laser inscription of the phase profile of the diffraction element independently at each point of the magnified (micrometer) scale in the pre-stretched or pre-shrunk states. Moreover, owing to the pre-stretching and shrinkage steps, this method enables fs-laser inscription of bulk optical diffraction elements even smaller than the achieved period of 0.35 μm. Overall, this novel few-step method paves the way for facile and robust ultrashort-pulse laser inscription of bulk functional optical elements in polymeric materials for diffraction, holographic and virtual reality devices.


We report a case of recurrent ST-segment elevation myocardial infarction (STEMI) due to a previously implanted under-expanded stent with in-stent thrombosis refractory to traditional interventional techniques. We underscore the utility of bail-out shockwave intravascular lithotripsy to tackle previously under-expanded stents in this acute setting. However, this may be technically difficult since the device is physically impeded by the stent in situ2 and may not address issues of deeper vessel wall calcification. Intravascular lithotripsy (IVL) is an attractive alternative to circumferentially disrupt severely calcified coronary lesions contributing to significant luminal gain. It mitigates the risk of stent under-expansion, in-stent stenosis, and thrombosis.Percutaneous coronary intervention on heavily calcified coronary plaque is an interventional challenge associated with a lower success rate and a higher risk of complications. Heavy calcification leads to incomplete stent expansion with subsequent stent apposition and failure. Stent under-expansion can predispose patients to acute stent thrombosis and premature in-stent restenosis.A 54-year-old male with coronary artery disease and multiple recent percutaneous coronary interventions (PCIs), hypertension, hyperlipidemia, and tobacco use presented with severe chest pain. Fourteen days prior, he had undergone PCI at an outlying hospital, where a stent was implanted in his right coronary artery (RCA) for unstable angina .2 The patient was discharged on aspirin 81 mg daily, ticagrelor 90 mg twice daily, and rivaroxaban 2.5 mg twice daily as his antiplatelet regimen.The angiogram of the first intervention was unavailable to our facility. However, the interventional details were as follows. A 3.5- x 38-mm drug-eluting stent was deployed in the proximal-mid RCA, which was post-dilated using a 4.0- x 12-mm noncompliant balloon at 24 atmospheres (atm). Intravascular imaging after post-dilating the stent revealed a minimal stent area of 4.3 mm.Four days after this procedure, the patient presented to our facility with acute inferior STEMI due to acute stent thrombosis . BalloonTen days after the procedure, the patient presented with recurrent inferior STEMI due to acute stent thrombosis . After bGiven these findings, bail-out IVL was performed successfully with a 3.5- x 12-mm Shockwave C2 Coronary IVL balloon  at 4 atm (80 pulses). This yielded the lesion angiographically, and the IVUS catheter revealed fragmentation of the calcification and expansion of the stent . This wa1 Conventional lesion preparation strategies utilize high-pressure non-compliant balloons, modified balloons (cutting/scoring), or atheroablative technology to improve stent deployment in coronary calcifications. However, these interventions are associated with a high risk of strategy failure and coronary artery injury (dissection/perforation).3 Shockwave IVL (S-IVL) is a novel calcium modification device that emits sonic pressure waves that circumferentially fracture superficial and deep coronary calcific lesions to improve vessel compliance and facilitate stent implantation. The Disrupt CAD I-IV studies emphasized the high procedural success rates and safety of S-IVL in lesion preparation of severely calcified de novo coronary stenoses, paving the way for US Food and Drug Administration approval in these patients.5Coronary artery calcification is a challenging entity associated with poor long-term outcomes if not adequately treated. Calcified lesions predispose to device-related adverse events such as stent under-expansion and subsequent failure.7 Data from a multicenter French registry (n = 65) revealed a relatively lower angiographic success rate with in-stent use (73.1%) compared to use in native coronary arteries (94.9%) but similar clinical outcomes in their cohort.5 CRUNCH registry data (n = 70) showed a device success rate of 92.3% with no complications or major adverse cardiac events in their cohort of patients with stent under-expansion due to coronary calcification.7 In a similar cohort, SMILE registry data (n = 39) exhibited a device success rate of 87.1%, with only one patient with a complication of nonfatal periprocedural STEMI secondary to balloon rupture. All other patients had no complications or major adverse cardiac events.8 In addition, there appears to be a common concern among researchers on the effect of acoustic energy on stent drug-polymer coating, potentially increasing the risk of future in-stent lesions. S-IVL has a high safety index and impressive efficacy for in-stent lesions. However, the role of the technology in modifying coronary calcium in acute coronary syndrome-related stent under-expansion is unclear.Few studies have explored the off-label use of S-IVL in stent under-expansion and failure.2 Dimitriadis et al. used S-IVL  for non-STEMI in a similar patient and successfully treated the patient with no complications.9 Agrawal et al. used S-IVL  for non-STEMI in a similar but unstable patient in cardiogenic shock with Impella support.10 All three authors performed intravascular imaging by OCT or IVUS to assess the calcified coronary arteries. Intravascular imaging can help provide more information on stent under-expansion and help identify associated incomplete stent apposition, absence of strut endothelization, or stent fracture. Moreover, both cases highlighted the safety and efficacy benefits of the off-label use of S-IVL to manage stent failure in calcified coronaries. Importantly, S-IVL is probably best reserved for lesions with stent under-expansion related to dense, deep, circumferential, or nearly circumferential calcification.There is no clear direction on the optimal revascularization strategy for acute coronary syndrome related to under-expanded stents secondary to calcified plaques. The data on the utility of S-IVL in this setting is limited to case reports as a bail-out technique when conventional methods fail. Salazar et al. managed STEMI associated with stent under-expansion with S-IVL . They discussed the drawback of traditional calcium modifying devices physically impeded by the stent metallic matrix during lesion preparation, preventing rapid, crucial luminal gain.Our case highlights the successful utilization of S-IVL for “stent-release”  and 3 inS-IVL is a safe modality to circumferentially disrupt severely calcified coronary lesions to improve vessel compliance and promote luminal gain before angioplasty. Further studies are required to establish the safety and efficacy of S-IVL in acute coronary syndrome patients with stent under-expansion or failure.


COVID-19 has disproportionately affected socially vulnerable communities characterized by lower income, lower education attainment, and higher proportions of minority populations, among other factors (https://stacks.cdc.gov/view/cdc/129934). Community-level COVID-19 vaccination coverage and incidence data from March 2020 through September 2021 were obtained from the Los Angeles Times COVID-19 data repository, which is populated with California Department of Public Health data.Eighty-one communities in Los Angeles with available vaccination and incidence data  were included in the analysis  . A significant interaction was observed between median household income and vaccination coverage on COVID-19 incidence (p<0.001). Within each income stratum, vaccination coverage was inversely associated with COVID-19 incidence; however, the effect was largest in the lowest-income communities. A 20% increase in community vaccination coverage was predicted to result in an additional 8.1% (95% CI = 7.7%–8.4%) reduction in COVID-19 incidence in the lowest-income communities compared with the highest-income communities (p<0.001)  and January 2021   Table 1Table 1.†This study adds to the body of evidence showing the disproportionate impact of COVID-19 on the lowest-income communities early in the pandemic and the impact of vaccination in reducing these disparities. These disparities were mitigated during the third pandemic surge, after COVID-19 vaccines became widely available. Although vaccination coverage was inversely associated with disease incidence during the third surge in all income groups, the estimated impact of vaccination on COVID-19 incidence was largest in the lowest-income communities, despite lower overall vaccination coverage in these communities. The higher impact of vaccination in those communities might be due to the higher risk for SARS-CoV-2 exposure in lower-income communities, potentially related to higher population density, more use of public transportation, and increased likelihood of working in service industries in which remote work might not be feasible  early in the vaccine rollout    was higher in lower-income communities compared with higher-income communities. During the first surge after vaccines became available (September 2021), a disparity in COVID-19 incidence between the highest- and lowest-income communities was not observed. The impact of vaccination on COVID-19 incidence was highest in the lowest-income communities despite their lower vaccination coverage.Addressing barriers to vaccination within lower-income communities is critical to reducing disparities in disease incidence and COVID-19–related illness in the United States.


Unlike B cell malignancies, the progress on generating an adoptive T cell therapy for relapsed/refractory acute myeloid leukemia (AML) remains insufficient. This review focuses on the main challenges in the field and novel strategies to overcome them.Despite exhaustive studies, researchers have made little progress in the field of adoptive cellular therapies for relapsed/refractory acute myeloid leukemia (AML), unlike the notable uptake for B cell malignancies. Various single antigen-targeting chimeric antigen receptor (CAR) T cell Phase I trials have been established worldwide and have recruited approximately 100 patients. The high heterogeneity at the genetic and molecular levels within and between AML patients resembles a black hole: a great gravitational field that sucks in everything. One must consider the fact that only around 30% of patients show a response; there are, however, consequential off-tumor effects. It is obvious that a new point of view is needed to achieve more promising results. This review first introduces the unique therapeutic challenges of not only CAR T cells but also other adoptive cellular therapies in AML. Next, recent single-cell sequencing data for AML to assess somatically acquired alterations at the DNA, epigenetic, RNA, and protein levels are discussed to give a perspective on cellular heterogeneity, intercellular hierarchies, and the cellular ecosystem. Finally, promising novel strategies are summarized, including more sophisticated next-generation CAR T, TCR-T, and CAR NK therapies; the approaches with which to tailor the microenvironment and target neoantigens; and allogeneic approaches. Since the early studies in the eighteenth century on the development of the first vaccines, researchers have attempted to eliminate tumors by harnessing the immune system. One strategy, adoptive cell therapy, uses T cells that can recognize tumor antigens through tumor-specific receptors. Since the 1980s, chimeric antigen receptor T cells (CAR T cells) have revolutionized the treatment algorithms of patients with lymphoma, acute lymphoblastic leukemia, and multiple myeloma [There are distinct considerations in acute myeloid leukemia (AML), the most common acute leukemia in adults. AML is an aggressive blood cancer characterized by a collection of immature cells of myeloid lineage that exhibit partial or complete arrest of maturation . The hetMany in vitro and in vivo studies have shown that CAR T cells against surface proteins, such as CD33, CD123, CLL-1, CD13, CD7, NKG2D ligand, CD38, CD70, and TIM3, effectively eradicate AML cells . HoweverNormal hematopoietic stem cells give rise to mature cells of the myeloid, lymphoid, and erythroid/megakaryocyte lineages. Single-cell RNA sequencing (scRNA-seq) analyses have shown that normal hematopoietic stem cell (HSC) commitment proceeds through a series of increasingly lineage-committed progenitor states . AML conAML is a highly heterogeneous disease between patients due to the presence of specific chromosomal abnormalities, gene mutations, or gene fusions. Seventeen genetic subtypes have been discovered so far in ELN risk stratification, but the number of molecular entities may increase over time . Not allFurthermore, a crucial problem in patients with relapse or treatment resistance is intratumoral heterogeneity, formed with different subclones of leukemia cells, with distinct genetic and epigenetic features coexisting within a single patient ,24. HighCAR T cells can bind to cell surface molecules without requiring any antigen processing or HLA expression . The choCD33 is a common transmembrane protein of the sialic acid-binding immunoglobulin-like lectin (SIGLEC) family found on normal progenitor cells, myeloid cells, monocytes, tissue-resident macrophages and more than 90% of leukemic blasts . Severe LSCs reside in a specialized niche that promotes their survival and chemoresistance, through which they can alter their microenvironment . LSCs seThe interactions are reciprocal: the niche cells also foster LSC growth. In vitro 3D bone marrow microenvironment models have elucidated these interactions . The AMLAssessment by scRNA-seq, the cellular indexing of transcriptomes and epitopes by sequencing (CITE-seq), or single-cell assay for transposase-accessible chromatin (ATAC) sequencing has paved the way for the study of cellular heterogeneity and intercellular hierarchies and for the obtaining of insights into the cellular ecosystem of malignant and normal cells. Galen et al. showed that primitive AML cells had dysregulated transcriptional programs with the co-expression of stemness and myeloid priming genes and that differentiated monocyte-like AML cells suppressed T cell activity in vitro by immunomodulatory genes . FurtherSome potential targets appear more reliable in terms of off-tumor toxicity, especially on normal hematopoietic cells, but none of them has proven to be an ideal target in AML. C-type lectin-like molecule-1 (CLL-1) is a type II transmembrane glycoprotein overexpressed in over 90% of AML patients on AML blasts, LSCs, and differentiated myeloid cells that are absent in normal CD34+CD38- hematopoietic stem cells. Tashiro and colleagues reported that CLL-1 CAR T cells can eliminate mature normal myeloid cells but spare healthy HSCs in vitro . The CARmTCR CAR T cells that were cytotoxic to HLA-A2 restricted AML cells in vitro and in vivo without an impact on normal hematopoiesis [CD70, a ligand for CD27 identified as a type II transmembrane glycoprotein, was reported to be expressed on AML bulk cells and leukemic stem cells but not on normal hematopoietic stem cells. It showed a promising anti-tumor effect without toxicity on healthy HSCs . Later, opoiesis . Jetani opoiesis .The efforts to discover efficient targets for immunotherapeutic strategies accelerated following technical progress in proteomic and transcriptomic assays. These assays helped in the understanding of cellular behavior on the protein level instead of immunophenotyping malignant cells. Hoffman et al. described the mass-spectrometry-based phenotyping of HL60 and NB4 cell lines . Perna eUnacceptably severe or prolonged toxicities, especially cytopenias and infections, can occur more frequently than in clinical trials with CD19 CAR T cells in lymphomas due to older and therapy-resistant patient populations. It is crucial to maintain anti-cancer immune surveillance and clinical efficacy while avoiding toxicity. Safety or suicide genes are widely used to alleviate the toxicity from CAR T cells ,70,71. AMany cell engineering approaches have attempted to improve safety when designing CARs, such as with the logic gating of T cell recognition and SnyNotch receptors . MutatioCombinations of CARs against different AML targets might be a promising solution due to the lack of a leukemia-specific target antigen . PreviouThe combinatorial antigen-targeting strategy has already been applied in AML. Bicistronic CD123 and CD33 CAR T cells showed significant anti-tumor activity in artificially created cell lines  and in vivo . In a phNeoantigens are limited to malignant clones that arise from somatic mutation ,93. Beca+ AML patients, and the healthy CD8 T cells showed lysis when transduced with the same TCR [The major difficulty in identifying neoantigens was resolved following MS HLA-ligand profiling with whole-exon sequencing and RNA-sequencing techniques . An adeqsame TCR . CD 8+ Tsame TCR .T cell receptor (TCR) engineered T cells act through their modified TCRs and the tumor-associated antigens (TAAs) presented by human leukocyte antigen (HLA) molecules on the surfaces of leukemic cells. The target protein can be expressed intracellularly or on the cell surface. TCR-T cells have less stringent antigen requirements for T cell activation than CAR T cells . TCR-T cTCR-T cells against WT1, PRAME, and HA-1 demonstrated anti-leukemic effects in vitro and in a clinical setting in AML ,112,113.C4) from HLA-A2+ normal donor repertoires (WT-1 TCR CAR T cells) following allogeneic hematopoietic stem cell transplantation , inserted TCRC4 into Epstein–Barr virus-specific donor CD8+ T cells to minimize graft-versus-host disease and infused them prophylactically post-allo-HSCT. This strategy achieved 100% relapse-free survival at a median of 44 months [In order to promote graft-versus-leukemia (GVL) reactivity after HLA-matched allogeneic stem cell transplantation, Chapuis et al. isolated WT-1 TCR  generated from healthy donors will provide a valuable solution since the CAR T cell products are pre-manufactured without the need for customized manufacturing for a specific patient. Two major issues of allogeneic production—graft-versus-host disease and alloreactivity—can be overcome by various strategies . While tDNA transposon systems are sophisticated systems for stable genetic modification that can deliver large genetic cargos and can be used to reduce cost . ClinicaThere are several approaches described to modulate an immunosuppressive microenvironment. Immune evasion such as that with upregulating immune checkpoint proteins has proven to be a way which can dampen the anti-tumor response and limit the efficacy of CAR T cell therapy. Although immune checkpoint blockade in AML has not proven beneficial, ,137,138 Targeting immunosuppressive cells such as Tregs (with anti-CD25 antibodies) and MDSCs (anti-Gr-1 antibodies) in the tumor microenvironment may enhance anti-tumor immunity. CD33 is also present in MDSC; so, targeting CD33 will mediate anti-tumor activity through direct cytotoxicity of CD33+ blasts and also through inhibition of CD33+ MDSCs . In an AWhen and how to combine allo-HSCT with adoptive immunotherapy in AML is still being debated. The mechanisms of resistance to T cell-mediated anti-tumor effects after allo-HSCT are well defined in sophisticated murine models of allo-HSCT . CombiniThe tremendous advances in understanding the molecular and cellular mechanisms of AML have made it possible to manipulate the immune system and BM niches. Treating AML with CAR T cells is still in an immature stage. Experience with allogeneic stem cell transplantation, which is the most effective immune cellular therapy for AML, is guiding other directed therapies. One of the major challenges in developing CAR T cell therapy for AML is the lack of a suitable antigen that is expressed uniquely on AML cells. Identifying and isolating target antigens that are homogeneously and stably expressed in all leukemic blasts and leukemic stem cells with limited on-target off-tumor toxicity, investigating complex interactions in the AML microenvironment, and seeking a suitable cell source will all improve the fine-tuning of CARs.Sophisticated methods for ex vivo manufacturing are now changing the in vivo dynamics and the character of the final product . In AML,


The clinical benefit of anti-spike mAbs for prophylaxis and treatment of SARS-CoV-2 is now well established ; However, the evolution of SARS CoV-2 due to immune pressure has compromised the utility of all previously approved mAbs which target the variable, immune dominant receptor binding domain of the Spike protein. Despite the success of vaccination protecting the general population, the immunocompromised and elderly remain at high risk of serious disease and mortality from SARS CoV-2 infection. Therefore, there is a need to develop mAbs that remain active across current and emergent SARS CoV-2 variants for such populations.The Generate Platform uses machine learning (ML) models to generate therapeutics with desirable properties. We used this platform to explore the amino acid sequence landscape compatible with the binding conformation and breadth of neutralization for mAbs targeting the conserved S-2 stem helix of Spike. While S-2 directed antibodies can broadly neutralize diverse coronaviruses, they are generally limited by potency. We employed an iterative computation- experimentation loop to design antibodies that bind to the S-2 stem helix, optimizing for potency, breadth and developability.The Generate Platform was employed to identify S-2 targeted Spike antibodies with high potency and breadth of neutralization resulting in GB-0669. GB-0669 exhibits sub-nM neutralization against all SARS-CoV-2 variants and Omicron sublineages including the highly immune evasive strain XBB. GB-0669 also displays sub-nM neutralization against sarbecoviruses associated with previous epidemics (SARS-CoV-1) and those of pandemic potential . The GB 0669 epitope was mapped by co-crystallization and is consistent with the observed breadth; all key interactions are >99% conserved with no evidence of immune escape.GB-0669, a novel mAB targeting the conserved S-2 region of Spike, is hypothesized to be effective for prophylaxis of COVID-19 across all Omicron sublineages and future variants as well as CoVs with pandemic potential.Francesco Borriello, MD PhD, Generate Biomedicines: Employee Gevorg Grigoryan, PhD, Generate Biomedicines: Chief Technology Officer|Generate Biomedicines: Ownership Interest|Generate Biomedicines: Stocks/Bonds Daria Hazuda, PhD, Generate Biomedicines: Employee|Generate Biomedicines: Stocks/Bonds|Merck and Co: Employee|Merck and Co: Stocks/Bonds Nathan H. Joh, PhD, Generate Biomedicines: Employee at Generate Biomedicines


Differential gene expression, pathway and network analyses demonstrated that the B-HOT panel captured biologically and clinically relevant genes , pathways  and networks reflecting the pathophysiological mechanisms underlying the AMR process previously identified in whole-transcriptome analysis. Our findings support the potential clinical use of the B-HOT-gene panel as a reliable proxy to whole-transcriptome analysis for the gene expression profiling of cardiac allograft rejection.The molecular refinement of the diagnosis of heart allograft rejection based on whole-transcriptome analyses faces several hurdles that greatly limit its widespread clinical application. The targeted Banff Human Organ Transplant gene panel  has been developed to facilitate reproducible and cost-effective gene expression analysis of solid organ allografts. We aimed to determine   While the incidence and clinical importance of acute cellular rejection has declined over time, antibody-mediated rejection (AMR) is now recognized as a major risk factor for patient death, graft loss and various allograft injuries . Even ifThe study cohort consisted of 137 heart transplant biopsies from 109 patients performed between 2006 and 2011 at four French referral institutions , that have been previously studied and published . . 9]. Allescribed .B-HOT gene annotations were defined according to the Banff 2019 meeting report . The B-Hp-value and highest fold changes , adjusting nominal p-values for multiple comparisons using the Benjamini-Hochberg method.Raw gene expression data were normalized using the Robust Multichip Average (RMA) expression measure algorithm. Low variance probesets were excluded using IQR<0.5 filtering, with a total of 24697 probesets left. Differential expression analysis was conducted by fitting a linear model to the normalized expression values for each probeset. Fold changes and t-statistics were computed for the contrast of interest AMR versus non-AMR biopsies. Standard errors were moderated using an empirical Bayes model to compute a moderated t-statistic and a log-odds of differential expression for each contrast and each probeset . Probesep-value lower than 0.05 and annotated according to Uniprot as well as GeneCards databases [We then compared differential expression analysis results derived from the whole-transcriptome or the targeted genes panel. Significant genes associated with AMR were filtered according to a false discovery rate atabases , 13.enrichplot package). Hierarchical clustering of enriched terms was implemented to account for pairwise similarities using Jaccard similarity index [The enrichment pathways were generated based on the differentially expressed genes (FDR <0.05) for the contrast of interest derived from whole-transcriptome genes or restricted to B-HOT genes using ReactomePA . Pathophty index . Statistn = 20, pAMR1(H+): n = 24; pAMR2/3: n = 27) and 66 biopsies without AMR (comprising 24 with acute cellular rejection (ACR) and 42 with non-rejection diagnoses).Patients’ characteristics  are shown in n = 71) compared to all biopsies without AMR (n = 66), considering whole transcriptome genes or only those included in the targeted panel. The differential expression analysis showed a high enrichment of B-HOT related genes . Major pathophysiological mechanisms related to antibody-mediated response and injury  identifiIn this study, we evaluate the B-HOT panel ability to capture the key features of the molecular signature of AMR through comparative analysis with the whole-transcriptome approach. Using differential expression, pathway, and network analysis, we demonstrate that the B-HOT panel captured clinically-relevant AMR associated genes in heart allografts, and that the derived enriched pathways and functional networks were highly comparable to the whole-transcriptome derived ones. Our results suggest that the targeted panel may be sufficient and sensitive enough to serve as a surrogate to whole-transcriptome analysis.In the last decade, whole-transcriptome based expression profiling has described the signature of allograft rejection in solid organ transplantation, and allowed the development of predicting models with good performance metrics , 16, 17.While the molecular refinement of the diagnosis of rejection based on whole-transcriptome approaches faces several hurdles that limit its clinical application , FFPE-based technology combined with a targeted panel has the potential to reduce experimental complexity, cost and turn-around time, thus refining rejection diagnosis and therapeutic decision-making in the framework of histo-molecular data contextualization. A first attempt to assess the B-HOT panel utility as a proxy for whole-transcriptome profiling on publicly available renal allograft expression data has been reported recently . Our stuThe Banff Human Organ Transplant panel accurately captured key molecular patterns of antibody-mediated rejection in heart allograft biopsies. Our study suggests that this specific targeted panel could be used as a proxy to whole-transcriptome profiling -based analysis after heart transplantation.


Culture-based studies have shown that acquisition ofextended-spectrum β-lactamase-producing Enterobacterales is commonduring international travel; however, little is known about the role of thegut microbiome before and during travel, nor about acquisition of otherantimicrobial-resistant organisms. We aimed to identify (1) whether the gutmicrobiome provided colonisation resistance against antimicrobial-resistantorganism acquisition, (2) the effect of travel and travel behaviours on thegut microbiome, and (3) the scale and global heterogeneity ofantimicrobial-resistant organism acquisition.mcr-mediated colistin-resistantEnterobacterales), and underwent DNA extraction and shotgun metagenomicsequencing. We profiled metagenomes for taxonomic composition,antibiotic-resistant gene content, and characterised the Escherichiacoli population at the strain level. We analysed pre-travelsamples to identify the gut microbiome risk factors associated withacquisition of the three targeted antimicrobial resistant organisms.Pre-travel and post-travel samples were compared to identify microbiome andresistome perturbation and E coli strain acquisitionassociated with travel.In this metagenomic analysis, participants were recruited at three UStravel clinics  beforeinternational travel. Participants had to travel internationally between Dec8, 2017, and April 30, 2019, and have DNA extractions for stool samples bothbefore and after travel for inclusion. Participants were excluded if theyhad at least one low coverage sample (<1 million read pairs). Stoolsamples were collected at home before and after travel, sent to a clinicalmicrobiology laboratory to be screened for three targetantimicrobial-resistant organisms  increase inburden (reads per kilobase per million reads). This increase includedantibiotic-resistant genes previously classified as threats to publichealth, which were 56%  higher in abundance after travel than before.Fluoroquinolone antibiotic-resistant genes were aquired by 97 (54%) of 181travellers with no detected pre-travel carriage. Although we found thatvisiting friends or relatives, travel to south Asia, and eating uncookedvegetables were risk factors for acquisition of the three targetedantimicrobial resistant organisms, we did not observe an association betweenthe pre-travel microbiome structure and travel-relatedantimicrobial-resistant organism acquisition.A total of 368 individuals travelled between the required dates, and296 had DNA extractions available for both before and after travel. 29travellers were excluded as they had at least one low coverage sample,leaving a final group of 267 participants. We observed a perturbation of thegut microbiota, characterised by a significant depletion of microbialdiversity and enrichment of the E coli andantimicrobial-resistant organism acquisition by US travellers not apparentfrom previous culture-based studies, and suggests that strategies to controlantimicrobial-resistant organisms addressing international travellerbehaviour, rather than modulating the gut microbiome, could beworthwhile.This work highlights a scale of  Previousculture-based studies have identified travel-associated acquisition ofcarbapenem-resistant and mcr-mediated colistin-resistant organismsin addition to ESBL-producing organisms,15 while whole-metagenomic shotgun sequencing has been used toshow widespread AMR acquisition during travel;16 however, the organisms associated with this AMR burden haveyet to be well characterised.Acquisition of AMR organisms requires exposure to relevant microbialreservoirs and successful colonisation by the organism, with geographical and hostfactors both having a role. Geographical factors probably reflect local AMRprevalence, whereas travellers’ diarrhoea and antibiotic use are factors thatcould increase susceptibility to colonisation. The gut microbiota are increasinglyrecognised as a source of colonisation resistance; perturbation of a healthy gutmicrobiome can diminish this effect.Escherichia coli strain carriage.Here, we use stool samples collected from a large cohort of US internationaltravellers to evaluate the role of the pre-travel gut microbiome in susceptibilityto AMR organism acquisition and the effect of travel on the gut microbiota, thetotal burden of AMR-associated genes (referred to as the resistome), and17 as partof a previously described study.15 Study approval was obtained from institutional reviewboards at each participating site. Recruitment and sample processing began onNov 27, 2017, at the Boston site; on Aug 15, 2018, at the New York site; and onSept 10, 2018, at the Salt Lake City site, and were done on a rolling basis. Weimplemented a cutoff date of April 30, 2019, for inclusion in this metagenomicanalysis at all three sites.In this metagenomic analysis, we recruited US international travellersat three travel clinics affiliated with Global TravEpiNet, a pre-travel health-careconsortium,Participants were required to have travelled internationally between thestudy recruitment dates and to have DNA extractions available for stool samplesfrom both before and after travel. Individuals who had at least one low coveragesample (<1 million read pairs) were excluded. Research staff approachedtravel clinic visitors to offer participation in the study. Health-careproviders used a structured questionnaire to collect demographic information,clinical histories, and travel details; no inclusion or exclusion criteria werespecified including for age. Participants or their guardians provided writteninformed consent. Institutional review board approval was obtained at each ofthe participating sites.18 Samplestransported in Cary-Blair medium were screened for the presence of three targetAMR organisms: ESBL-producing Enter obacterales, carbapenem-resistantEnterobacterales, and mcr-mediated colistin-resistantEnterobacterales, using US Food and Drug Administration-approved or internallyvalidated culture-based methods, as previously described.19 Ethanol samples were stored at −80°C untilDNA extraction and metagenomic sequencing.Travellers collected stool samples before departure and after return andcompleted a post-travel questionnaire regarding travel-related behaviours andillnesses  p4. DetE coli strain content wascharacterised using StrainGE (version 1.1.4).20 Resistance gene content was profiledusing ShortBRED (version 0.9.5),21 with AMR-associated genes classified as high risk if theywere classified as “Rank I - current threat” by Zhang andcolleagues.22 Usingthe vegan (version 2.6–4) package in R, microbiome diversity wasquantified with the Shannon index, and perturbation was measured as the BrayCurtis index between the pre-travel and post-travel samples, using the vegdistfunction.DNA extraction was done with the PowerFecal DNA/RNA kit . We used a NovaSeq 6000 system  with 151bp paired-end reads to yield a median of 14 million paired-end reads per samplefor sequencing. Metagenomic libraries were prepared using the Nextera XT DNALibrary Preparation kit (Illumina) and data were processed with the Broad PicardPipeline. Further details on DNA extraction, sequencing, and metagenomicanalysis are described in t test or Wilcoxon signedrank test. Differences in count measures  before and after travel were compared using an exact Poisson test.Exact binomial tests were used to assess the non-randomness of changes . Traveller questionnaireresponses were categorised into travel factors , host factors , and behaviouralfactors  before and aftertravel were tested using a paired e burden  p 2.mcr-mediated colistin-resistant Enterobacteralesindividually, since acquisition of carbapenem-resistant Enterobacterales, andmcr-mediated colistin-resistant Enterobacterales was rare,and only two individuals acquired a targeted AMR organism without also acquiringan ESBL-producing Enterobacterales. We report odds ratios (ORs) and 95% CIs forall outcomes, with the exception of microbiome perturbation, where we estimatethe change in Bray Curtis dissimilarity. Benjamini-Hochberg correction wasapplied to adjust for multiple hypothesis testing, with a two-sided thresholdfor significance of p<0·05.We considered acquisition of targeted AMR organisms together rather thanESBL-producing Enterobacterales, carbapenem-resistant Enterobacterales, andThe study funders collaborated with co-investigators to design the studyand were involved in data interpretation and writing of the manuscript. Thestudy funders had no involvement in data collection or data analysis.15 368 hadcompleted travel by the cutoff date, and DNA extractions were available for bothpre-travel and post-travel samples for 296 travellers. 29 travellers were excludedas they had at least one low coverage sample. We studied the pre-travel andpost-travel faecal metagenomes of 267 travellers (15 Post-travelstool samples were collected a median of 11 days (IQR 7–16) after return. Atotal of 101 (38%) travellers acquired at least one of the three targeted AMRorganisms, based on culture; 99 (98%) of these travellers acquired an ESBL-producingorganism, 18 (18%) acquired mcr-mediated colistin-resistantEnterobacterales, and 3 (3%) acquired carbapenem-resistant Enterobacterales. Alltravellers acquiring an ESBL-producing organism acquired an ESBL-producing Ecoli; three (3%) additionally acquired ESBL-producingKlebsiella pneumoniae. 88 (33%) of 267 travellers reportedtravellers’ diarrhoea, of whom 16 (18%) reported antibiotic treatment(ciprofloxacin n=7 or azithromycin n=9). An additional 14 (5%) travellers tookantibiotics (including doxycycline n=6) for other reasons.Of the 608 travellers comprising the previously described fullcohort,avellers .15 Post-To determine gut microbiome risk factors for acquisition of the targeted AMRorganisms, we first fit logistic regression models with acquisition as a function oftravel, host, and behavioural risk factors  p 1. Adjt test p=0·0003; t test p=0·041); travellers who took antibiotics totreat travellers’ diarrhoea had the greatest loss of diversity (t test).164 (61%) of 267 travellers had a loss of microbial diversity after travel, whereas consumption of unfiltered tap water was unexpectedlyassociated with significantly smaller perturbations, meaning greater microbiomestability . These results remained significant after adjusting for selecteddietary and travel behaviours  p 4. TheEscherichia spp was elevated in asignificant proportion of travellers after travel relative to before travel (−10). Several related genera within theEnterobacteriaceae family were also significantly elevatedafter travel, including Klebsiella, Enterobacter,and Salmonella (Alistipes (Rickenellaceaefamily) was observed to be depleted after travel. Similar patterns were observed ingenus acquisition (defined as present in post-travel microbiomes but not pre-travelmicrobiomes); 33% of travellers acquired Klebsiella spp, 26%acquired Shigella spp , 25% acquired Enterobacter spp, 24% acquiredCitrobacter spp , and 22% acquired Escherichia spp than did pre-travel samples , and most travellersreturned with more strains than were present before travel . 178 (67%) of the 267 travellersacquired at least one new E coli strain, defined as a straindetected in the post-travel sample but not in the pre-travel sample. Of 187travellers with an increase in E coli relative abundance, 159 (85%)acquired at least one E coli strain, compared with 19 (24%) of the80 individuals who had no increase, suggesting that strain acquisition, rather thanexpansion of the pre-travel population, was driving the increase in Ecoli abundance after travel. Notably, acquired strains werephylogenetically distinct from those carried pre-travel; although most (83 [65%] of127) pre-travel strains belonged to E coli phylogroups B2 and D,most acquired strains (215 [70%] of 306) belonged to phylogroups A and B1  was identifiedas a risk factor for acquisition, whereas consumption of unfiltered tap water wasfound to decrease the risk of E coli strain acquisition, as was pre-traveladministration of any typhoid vaccine . These associations remained significant in a multivariable modeladjusting for additional selected dietary and travel factors  acquired targeted AMR organisms . Although travel to most destinations was associated with an increase in theoverall AMR-associated gene burden, the magnitude of change varied by destinationincrease in overall AMR-associated gene burden, measured as reads per kilobase permillion reads . A total of 72AMR-associated genes were acquired at significant rates (22 including genes encoding trimethoprim(dfrA) and fluoroquinolone (qnrB andqnrS) resistance and the ESBL-encoding gene cluster CTX-M group1. Although high-risk AMR-associated genes were significantly enriched after travelamong all travellers , we observed the largest gains amongthose travelling to south Asia , and southAmerica . Among travellers who did not acquirea targeted AMR organism, the increase in the burden of cephalosporin,fluoroquinolone, aminoglycoside, and peptide resistance remained significant, as didthe increase in high-risk AMR-associated genes .Although we could not definitively link specific AMR-associated genes to theirbacterial host, 36 of the 50 most commonly acquired AMR-associated genes werestrongly correlated with E coli relative abundance  ofthe 72 AMR-associated genes that were significantly elevated in our study did notincrease significantly in abundance in the earlier Dutch study: two high-riskfluoroquinolone resistance-associated genes, qnrB59 andqnrB41, and the polymyxin resistance genepmrE. Conversely, seven (9%) of the 76 significantly elevatedAMR-associated genes in the Dutch study did not increase significantly in abundancein our study: two high-risk β-lactamase-encoding genes,OXA-31 and CTX-M-110, andcepA, LAP-2, lsaE,AAC(3)-IIa, and SAT-2.Finally, we compared our resistome data with results from a 2014 cohort ofDutch individuals who travelled to similar regions of the world as our study  p 11.16,Enterobacteriaceae organisms, and acquisitionof multiple AMR-associated genes, including several that have previously beenidentified to pose the greatest risk to public health.22 Although a third of travellers acquiredESBL-producing organisms during travel, over two-thirds acquired new Ecoli strains. Previous culture-based studies have shown that travel tosome regions, including south and southeast Asia, are associated with an elevatedrisk of acquiring ESBL-producing organisms.5 Our untargeted metagenomic approach shows thatESBL-producing organisms represent only a fraction of travel-acquired AMR organisms,and that similar geographical heterogeneity exists in the risk of acquiring otherAMR-associated genes that pose a public health risk.We found that international travel, across a range of destinations and avariety of travel, host, and behavioural factors, is associated with a perturbationof the gut microbiome characterised by a reduction in microbial diversity, a surgein the abundance of 14 Our larger study allowed us to account for a wide range ofpotential confounders, and we conclude that the pre-travel microbiome probably playsa considerably lesser role than the travel, host, and behavioural risk factorsidentified here. However, it is possible that perturbations to the microbiome duringtravel facilitate targeted AMR organism acquisition. We note that antibiotic use anddiarrhoea, two frequently identified risk factors for acquisition of the targetedAMR organisms,24affected the microbiome in this and other studies.25Although we cannot disentangle causative factors without longitudinal samplingduring travel,27 this evidence is suggestive of a temporaryloss of colonisation resistance during travel.Notably, we did not find any microbiome risk factors to predict targeted AMRorganism acquisition or travellers’ diarrhoea based on pre-travel samples,which contrasts with the results of two previous, smaller studies.E coli strains inthe gut after travel, with over two-thirds of travellers acquiring a new strain.Understanding risk factors for travel-associated E coli acquisitioncan help to disentangle the roles of local prevalence of drug resistance andindividual exposure. For instance, the low rate of acquisition for the targeted AMRorganisms in southern Africa suggests a lower prevalence of drug resistance, ratherthan a smaller exposure to bacterial reservoirs, based on the similar rates ofE coli acquisition seen in this region compared with otherregions. Our study highlights the potential utility of studying travellers assentinels to identify AMR reservoirs and prevalence in countries that do not have arobust surveillance framework. We observed elevated levels of fluoroquinoloneresistance-associated gene acquisition relative to an earlier study of Dutchtravellers;23 this finding is also concordant with arecent study of travellers from China.28 Ongoing surveillance could robustly identify such temporalchanges in resistance-acquisition patterns as global antibiotic consumption patternsand the prevalence of AMR organisms change.We observed a significant enrichment of E coli phylogroup A and B1 strains werecommonly acquired during travel, whereas phylogroups B2 and D were dominant beforetravel. We observed little difference in phylogroup pattern across travel regions. Although outcomes among travellersrecruited from smaller sites were broadly similar, our results might not begeneralisable to the US traveller population. Finally, the collection of onlypre-travel and post-travel samples prevents examination of the persistence ofacquired AMR organisms and gut perturbation. We believe improved insights into riskfactors for acquisition, rather than persistence, will be more valuable fordesigning interventions to limit the public health effects of the spread of AMRorganisms, although future studies exploring persistence will be complementary tothis goal.Our study has limitations. Strain detection within metagenomic samples islimited by sequencing depth and the typically low relative abundance ofEnterobacteriaceae strains and AMR-associated genes. Ourability to untangle resistant and general E coli acquisition herehighlights a new model to evaluate the risk of, for example, ESBL-producing organismacquisition as a product of behavioural risk factors for E coliacquisition and local prevalence of ESBL-producing organisms. Our findings alsohighlight the potential utility of targeting preventive strategies to internationaltravellers, including pre-travel education and minimising unnecessary antibiotic useduring travel, with the aim of restricting the global dispersal of AMR.Our study is the first detailed metagenomic evaluation of the gut dynamicsof US international travellers, revealing frequent acquisition of novelAppendix 1Appendix 2


Perfluorodecanoic acid (PFDA), an enduring and harmful organic pollutant, is widely employed in diverse food-related sectors. Our previous studies have provided evidence that PFDA has the potential to facilitate obesity and hepatic fat accumulation induced by high-fat diet (HFD) intake. Epigallocatechin-3-gallate (EGCG), a polyphenol found in green tea, has been suggested to possess potential preventive effects against metabolic abnormalities and fatty liver. The purpose of this research was to investigate the effects of EGCG on PFDA-exacerbated adiposity and hepatic lipid accumulation in HFD-fed mice. The results showed that EGCG reduced body weight gain; tissue and organ weights; blood glucose, serum insulin, HOMA-IR, leptin, and lipid parameters; serum inflammatory cytokines ; and hepatic lipid accumulation in PFDA-exposed mice fed an HFD. Further work showed that EGCG improved liver function and glucose homeostasis in mice fed an HFD and co-exposed to PFDA. The elevated hepatic mRNA levels of SREBP-1 and associated lipogenic genes, NLRP3, and caspase−1 in PFDA-exposed mice fed an HFD were significantly decreased by EGCG. Our work provides evidence for the potential anti-obesity effect of EGCG on co-exposure to HFD and PFDA and may call for further research on the bioactivity of EGCG to attenuate the endocrine disruption effects of long-term exposure to pollutants. Perfluorodecanoic acid (PFDA), a noxious and enduring organic pollutant, is extensively utilized in various food-related domains, including food packaging and cookware ,2. Due tAs indicated by epidemiological studies ,11,12, wThe nucleotide-binding domain leucine-rich repeat and pyrin domain-containing receptor 3 (NLRP3) inflammasome is a multimeric cytosolic protein complex that assembles in response to cellular perturbations . As a reThere exists a discernible correlation between NLRP3 inflammasome activation and the accumulation of lipids, as well as an elevation in the expression of the sterol regulatory element-binding protein (SREBP) 1 . NLRP3 i(−)-Epigallocatechin-3-gallate (EGCG), the most abundant catechin of green tea, accounting for 50–80% of all catechins, has been found to have strong protective effects against obesity and NAFLD ,30,31,32Mice that were fed a low-fat diet (LFD) displayed typical fluctuations in body weight throughout the duration of the experiment; in addition, no significant changes in body weight were noted between the LFD-fed group and the LFD plus PFDA group A,B. Howep < 0.05) and kidney (p < 0.05) tissues. The administration of H-EGCG in response to HFD feeding plus PFDA exposure resulted in a significant decrease in liver weight (p < 0.05), while kidney weight remained unaffected. On the other hand, the HFD-fed group exhibited significant increases in the weights of the four types of adipose tissue  and total adipose tissue  compared to the LFD-fed group. In accordance with our previous study /22.5] was used to determine the HOMA-IR score. The areas under the curve (AUCs) for ITT and GTT were determined using GraphPad Prism 5.0 .The hepatic lipid contents and hepatic adipocyte morphology were assessed with Oil Red O staining and hematoxylin and eosin (H&E) staining as previously described . Lipid d−ΔΔCq.Total RNA was isolated from liver tissues using a TRIzol reagent  according to the manufacturer’s protocol. Total RNA was quantified using a NanoDrop Microvolume Spectrophotometer . cDNA was obtained using total RNA, oligo dT primer, and the PrimeScript RT Enzyme Mix following the manufacturer’s instructions . Relative gene expressions were quantified using RT-qPCR analysis  with a SYBR Green kit. The sequences are shown in p < 0.05.The results are presented as mean ± standard errors of the mean (SEM). One-way analysis of variance (ANOVA) followed by Tukey’s test was used for comparisons between multiple groups. For the results presented in Taken together, this study provides evidence that long-term PFDA exposure significantly increased body weight, increased hepatic lipid accumulation, impaired glucose homeostasis, and increased mRNA expression of SREBPs and their target genes as well as the NLRP3 inflammasome, thereby contributing partly to the exacerbation of steatohepatitis in HFD-induced mice at the doses indicated. Moreover, this study revealed the significant protective effects of EGCG against PFDA-exacerbated obesity and hepatic lipid accumulation in HFD-fed mice. As for the mechanism, EGCG possessed considerable lipid-lowering activity that enabled it to downregulate SREBP pathway expression by inhibiting NLRP3 inflammasome activation . Our fin


The underlying neurobiology of early-life stress (ELS)-induced major depressive disorder (MDD) is not clearly understood. miRNAs, a subclass of noncoding RNAs, are estimated to regulate 20-90% of genes in the genome. Previous studies identify differences in miRNA expression following MDD and ELS, but there is limited research on a direct link between changes in serotonin signaling and miRNAs in response to ELS.In this study, we used MS and environmental enrichment to study serotonin signaling in the PFC and its regulation by miRNAs. Because women are more likely to develop MDD, but there is no strong evidence of sex differences in the experience of ELS, we were interested to test for sex differences. We hypothesized that genes in the serotonin signaling pathway would be altered by ELS and potentially recovered by enrichment.We used maternal separation (MS) as a rodent model of ELS and tested whether microRNAs (miRNAs) target serotonin genes to regulate ELS-induced depression-like behavior and whether this effect is sex dependent. We also examined whether environmental enrichment prevents susceptibility to depression- and anxiety-like behavior following MS and whether enrichment effects are mediated through serotonin genes and their corresponding miRNAs.Slc6a4 and Htr1a were upregulated in the frontal cortex following MS. In male MS rats, enrichment slightly reversed Htr1a expression to levels similar to control rats. miR-200a-3p and miR-322-5p, which target SLC6A4, were decreased by MS, but not significantly. An HTR1A-targeting miRNA, miR-320-5p, was also downregulated by MS and showed slight reversal by enrichment in male animals. miR-320-5p targeting of Htr1a was validated in vitro using SHSY neuroblastoma cell lines.MS decreased sucrose preference, which was reversed by enrichment. Males also exhibited greater changes in forced swim climbing and escape latency tests only following enrichment. Altogether, this study implicates miRNA interaction with the serotonin pathway in ELS-induced susceptibility to depression-related reward deficits. Furthermore, because of its recovery by enrichment in males, miR-320 may represent a viable sex-specific target for reward-related deficits in major depressive disorder.None Declared


The 2021 US Preventive Services Task Force CRC recommendations state that positive results on stool-based screening tests require follow-up with colonoscopy,4 Thus, in an effort to promote higher CRC screening completion rates and reduce disparities, federal regulations require commercial insurers and Medicare to eliminate out-of-pocket costs for follow-up colonoscopy as of January 2023. The objective of this analysis was to estimate the clinical and financial outcomes of this policy change.Financial barriers are a likely contributor to low follow-up colonoscopy completion rates. A 2021 study reported that 48% of commercially insured and 78% of Medicare beneficiaries paid nontrivial out-of-pockets costs for follow-up colonoscopy.5 a cohort of average-risk individuals who received mt-sDNA or FIT at age 45 for commercially insured patients and at age 65 for Medicare beneficiaries was modeled. For only those simulated patients with a positive mt-sDNA or FIT test, 2 scenarios were analyzed: (1) received follow-up colonoscopy ($0 cost sharing) or (2) no follow-up colonoscopy. The payer costs of follow-up colonoscopy were assumed to be $2,057  for commercially insured patients and $1,118  for Medicare beneficiaries.6 The clinical inputs for colonoscopy, mt-sDNA, and FIT sensitivity, specificity, and complication risk, as well as cost and utility inputs are listed in Using the validated Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model,Commercially insured and Medicare patients undergoing follow-up colonoscopy after a positive stool-based screening test experienced more LYG per 1000 individuals (83 and 80, respectively, with mt-sDNA; 43 and 46, respectively, with FIT; The total lifetime cost per patient for those receiving follow-up colonoscopy compared with stool-test-positive patients who did not receive follow-up colonoscopy was $4,609–$6,439 less for commercially insured patients and $4,755 less for Medicare beneficiaries. Total spending for patients receiving follow-up colonoscopy after a positive stool-based test was cost-saving when compared with no follow-up colonoscopy as long as the colonoscopy costs were less than $6,448 for commercial plans and $5,652 paid by Medicare.These modeling analyses demonstrate that follow-up colonscopy after a positive stool-based test is an essential and necessary step in realizing the clinical and economic benefits of CRC screening. The findings that those who undergo follow-up colonoscopy are estimated to have improved CRC-related outcomes and lower total medical expenditures compared with those who do not receive follow-up colonoscopy should compel stakeholders to further invest in patient education, navigation, transportation, and other support services that facilitate completion of the overall CRC screening process, along with ensuring adequate and efficient access to follow-up colonoscopy. Such investments are urgently needed and will undoubtedly yield positive impacts at multiple levels.


Aging is associated with a progressive decline of innate and adaptive immune responses, called immunosenescence. This phenomenon links to different multiple sclerosis (MS) disease courses among different age groups. While clinical relapse and active demyelination are mainly related to the altered adaptive immunity, including invasion of T- and B-lymphocytes, impairment of innate immune cell  function is the main contributor to disability progression and neurodegeneration. Most patients with MS manifest the relapsing-remitting phenotype at a younger age, while progressive phenotypes are mainly seen in older patients. Current disease-modifying therapies (DMTs) primarily targeting adaptive immunity are less efficacious in older patients, suggesting that immunosenescence plays a role in treatment response. This review summarizes the recent immune mechanistic studies regarding immunosenescence in patients with MS and discusses the clinical implications of these findings. Traditionally, multiple sclerosis (MS) is considered an immune-mediated inflammatory demyelinating disease of the central nervous system (CNS). However, it is well known that neurodegenerative processes are also involved and play a key role in cumulative disability. While current disease-modifying therapies (DMTs) effectively control inflammation, they do not fully stop disability progression, possibly due to inadequate targeting of neurodegeneration. The lack of clarity regarding the etiology of progression hinders the development of effective therapies for progressive disease. Immunosenescence has emerged as a possible mechanism .Immunosenescence is an age-related weakening of adaptative and innate immune responses with altered activation . As a reSome studies have demonstrated premature immunosenescence in MS  and expeIn this review, we summarize the current knowledge of immunosenescence, focusing on humans . We thenImmune cells are generated from hematopoietic stem cells (HSCs) in the bone marrow. They stepwise differentiate and undergo selection and proliferation upon antigenic exposure; thus, becoming prone to the senescence process. Telomere shortening and cell cycle arrest in aging HSCs result in fewer immune cells . SenesceProgressive thymus gland involution reduces the naïve T-cell pool and diversity of the T-cell receptor (TCR) repertoire. Reactive dendritic and B-cell homeostatic proliferation then leads to clonal expansion of memory T-cells, further depleting the TCR repertoire .+ T-cells and increase in CD8+ T-cells, causing an inversion of the CD4+/CD8+ ratio  production  B-cells decrease while exhausted double-negative (IgD−CD27−) B-cells increase  and A-proliferation-inducing ligand (APRIL), abruptly decreases after age 75 due to hematopoiesis. . Progenit of age . The memt of age . Naïve mincrease  and prodincrease . Immaturoduction .Serum IgM and IgD decrease with age, while concentrations of IgG and IgA increase due to a reduction in antibody class switching and affinity maturation in B-cells during clonal expansion . Althoug−CD27− (aka. double negative B-cell) and CD21−CD11c+ (aka. CD21low B-cell) (Age-associated B-cells (ABCs), including IgD B-cell)  are a su B-cell) . However B-cell) .+CD16+ inflammatory monocytes (Aging affects the innate immune response through impaired pathogen associated molecular patterns (PAMPs)-mediated response, decreased type I interferon production, and fewer plasmacytoid dendritic cells . Monocytonocytes . These aonocytes . Moreoveonocytes  and incrhigh NK cells, which augment cytokine and chemokine production, decrease with aging while cytotoxic CD56low NK cells increase  and vimentin  via tranChoroid plexus epithelium (CPE) also undergoes several senescent changes, which may contribute to inflammaging. Alterations in the CPE cytokine and chemokine profile, such as an increased IL-4:IFN-γ ratio, may contribute to a pro-inflammatory state by upregulation of CCL11, which has been implicated in age-related cognitive decline in murine models . Likewis+ memory T cells  . Additioin vitro and reduced susceptibility in rim lesions on magnetic resonance imaging . Although it could not be definitively concluded that discontinuing treatment was non-inferior to continuing, a salient takeaway is that new clinical relapses and new radiographic lesions were rare in both study groups . There iProgressive multifocal leukoencephalopathy (PML) is a severe adverse effect of DMTs, particularly natalizumab, for MS . Older aOlder age is associated with an impaired immune response to primary and booster vaccinations. T-cells favor the generation of short-lived effectors over memory cells , and B-cRegarding COVID-19 vaccines, mRNA vaccines (BNT162b2 and mRNA-1273) have demonstrated high efficacy and immunogenicity. The Ad26.COV2.S vector vaccine was designed as a single-dose vaccine to improve compliance, particularly for older people. This single dose of vaccine resulted in a strong humoral immune response independent of age. Another vector vaccine (ChAdOx1 nCoV-19) needs further investigation to determine the effect of age on immune responses . In patiOlder age is one of the most important risk factors for the development of cancer, and there is evidence that immunosenescent changes are necessary to promote tumorigenesis. Several changes in the innate and adaptive immune response described earlier in this paper, which occur in the natural aging process, are also induced by the tumor microenvironment. These include a loss of T cell CD28 expression, increased expression of program death ligand 1 by dendritic cells, and a reduction in pro-inflammatory cytokines, all of which contribute to an immunosuppressive state . DysfuncAutoimmune conditions and cancer are both a result of immune dysregulation. However, there remains conflicting research regarding whether patients with multiple sclerosis have protective effects against cancer due to increased immunosurveillance or whether they are at increased risk due to chronic inflammation. A higher total incidence of malignancy, as well as an increase in malignancy subtypes , among MS patients compared to the general population was suggested in one French cohort . RegardiAdditionally, the initiation of DMTs for treatment may lead to further immunomodulation or immunosuppression, increasing cancer risk . In prioAging is associated with immunosenescence, but the specific changes relevant to disease progression in MS are not well established. The timing of a future progression-targeted therapeutic intervention is crucial and may require non-invasive biomarkers for detection. Biological age measured by leukocyte telomere length  and ovarAlthough some DMTs, such as fingolimod  and glatImmunosenescence is an age-related loss of innate and adaptive immune system proficiencies, which influences the course of and accelerates MS. Thus, senescent immune cells may play an essential role in progressive MS. Some DMTs may induce similar immune system changes. Age-related changes in the immune system may contribute to the risk of adverse events, particularly infection, in older patients with MS. However, none of the available DMTs effectively target the immunosenescence process. Therefore, the development of treatment strategies to rejuvenate the immune system may be of hope for patients with progressive MS.