Patients with schizophrenia suffer from increased mortality rates equivalent to 15-20 years shorter life expectancy. Up to 60% of this excess mortality can be explained by preventable, somatic conditions like cardiovascular, metabolic, and respiratory comorbidities. As forensic psychiatric (FP) patients often experience the triple stigmatization of mental illness, substance misuse and criminal conviction, the risk of suboptimal diagnosis and treatment may be high. Although benefits from the addition of general practitioner (GP) services to non-FP wards have been shown elsewhere, this cross-sectoral approach has never been attempted in a Danish FP ward.One purpose of this project is to evaluate the associations between self-reported quality of life and objective measures of somatic health.A clinical intervention in which a GP consults patients in all medium secure wards in the Central Denmark Region (N=72). The consultation includes a physical examination, medication review, and evaluation of blood samples. Data is collected from: electronic patient files and questionnaires regarding quality of life (SF-12), lifestyle, and attitude towards GP services.The population will be described in regards to socio-demographic, clinical, and forensic characteristics. Associations will be made between quality of life (SF-12), metabolic syndrome, blood markers, and heart-SCORE risk. Risk profiles for endocrinologic and coronary illness will be examined.Results may guide future health interventions and will be used as a basis for adjustments to the current project.No significant relationships.


Obesity could paradoxically improve prognosis in patients with heart failure (HF), termed the “obesity paradox.” Whether HF etiology could modify the “obesity paradox” is still controversial. In the present study, we aimed to assess the relationship between obesity and death in patients with heart failure with preserved ejection fraction (HFpEF) with non-ischemic versus ischemic etiologies.We analyzed 3,360 HFpEF patients from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. Cox regression models were used to assess the association of obesity assessed by body mass index (BMI) with short-term and long-term death risk.2 in non-ischemic versus ischemic HFpEF. In the short-term follow-up, the beneficial effects of overweight and obesity on survival were consistently observed in all the BMI categories, with the nadirs of all-cause death risk at class III obesity category both in non-ischemic and ischemic subgroups.Overweight and obesity were associated with a lower risk of long-term all-cause death in patients with non-ischemic HFpEF, even in those with class III obesity . However, in the ischemic subgroup, as obesity advanced, this paradoxical relationship was gradually attenuated and disappeared in class III obesity . Restricted cubic spline analyses confirmed the differential relationship of baseline BMI with risk of long-term death with a BMI higher than 30 kg/m“Obesity paradox” was evident both in non-ischemic and ischemic HFpEF during short-term follow-up, even in those with class III obesity. However, the beneficial effect of class III obesity disappeared during long-term follow-up in ischemic HFpEF.https://clinicaltrials.gov], identifier [NCT00094302].[ Obesity is a well-established independent risk factor for developing cardiovascular (CV) diseases such as heart failure (HF) in the general population , 2. HoweIn the last several years, the potential confounders of the obesity-related survival benefit in HF population have been broadly explored in different clinical conditions  . HoweverBased on data from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial, our current study sought to explore the relationship between obesity (defined by BMI) and death in a large cohort of HFpEF patients with non-ischemic versus ischemic etiologies.2 (n = 85), resulting in a final sample size of 3,360.The present study used data from the TOPCAT trial. The selection criteria and study design of TOPCAT have been described in detail previously –15. BrieN = 1,767). Also, patients with missing information regarding BMI and potential confounders, as well as BMI <18.5 kg/m2 were excluded (n = 60), resulting in a final sample size of 1,707.Given the previously reported significant differences in population characteristics and outcomes by region observed in TOPCAT , a sensi2). In the present study, patients were categorized according to the World Health Organization BMI classifications: normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), Class I obesity (30.0–34.9 kg/m2), Class II obesity (35.0–39.9 kg/m2), and Class III obesity (≥40.0 kg/m2)  .Outcomes in the TOPCAT trial were adjudicated by a clinical endpoint committee, as described previously . In our 2 as reference in patients with non-ischemic versus ischemic HFpEF. Second, we conducted Cox regression analyses with time-updated BMI to examine the short-term impact of BMI on outcomes in non-ischemic versus ischemic HFpEF  in patients with non-ischemic versus ischemic HFpEF. To explore the short-term and long-term effect of BMI on outcomes in HFpEF patients with non-ischemic versus ischemic etiology, we assess the relationship of death with baseline BMI, as well as time-updated BMI, which represented the most recent available BMI value for each patient at each visit during the course of the trial. First, Cox regression analyses were performed to calculate hazard ratios (HRs) and their confidence intervals (CIs) of baseline BMI category in HFpEF according to HF etiology. To flexibly evaluate the associations of the continuous variable of baseline BMI with death, restricted cubic spline analyses with three knots  were performed using 30 kg/mic HFpEF . BecauseThe covariates in the Cox regression model included randomization arm (spironolactone or placebo), age, gender, race, region of enrollment (Russia/Georgia versus the Americas), New York Heart Association (NYHA) functional class, heart rate, systolic blood pressure (BP), diabetes, stroke, atrial fibrillation, and serum creatinine. These variables were selected because of their well-established prognostic significance as CV risk factors and previous prognostic implication in the TOPCAT. In time-updated Cox regression models, we controlled for time-updated heart rate, time-updated systolic blood pressure and time-updated NYHA functional class at each visit instead of the baseline ones. We also adjusted for weight change during follow-up when modeling for baseline BMI; whereas, we replaced weight change with baseline BMI when modeling for time-updated BMI. In multivariate Cox regression models, we first fit a cox regression model with all covariates and used stepwise selection with the AIC method to produce a final set of potential confounders. This selection process was performed to produce a global model and then plus BMI levels to construct the final Cox proportional regression models.p-value of <0.05 was considered statistical significance.Statistical analyses were performed using R version 4.0.3 software . A two-tailed The baseline characteristics of the study group subdivided according to HF etiology are presented in p < 0.05). After adjustment for multiple clinical covariates, compared with normal-weight, overweight and obesity remained to be associated with lower risk of long-term all-cause death in patients with non-ischemic HFpEF, with the lowest risk in class III obesity category  (p = 0.798), with the lowest risk of all-cause death in class I obesity category . There was no significant interaction between BMI and HF etiology. Similar association patterns were observed with CV death. The paradoxical survival benefits were continually observed in all of the overweight and obesity categories in non-ischemic HFpEF, but disappeared in class III obesity in ischemic HFpEF . Likewise, the nadir of CV death risk occurred in class III obesity  in non-ischemic HFpEF, but in class I obesity  in ischemic HFpEF.During a median follow-up of 3.4 years, a total of 502 subjects (14.9%) died, of whom 317 were adjudicated as CV death. There were 174 (8.1%) and 143 (11.8%) CV deaths in the non-ischemic and ischemic subgroups, respectively. Crude death rate and Kaplan–Meier survival curves for all-cause death and CV death across all baseline BMI categories are shown in = 0.038) . In pati2, and continue to decrease gently with a BMI higher than 30 kg/m2  but not in ischemic HFpEF . Smooth spline plots demonstrate similar inverse relationship of baseline BMI and long-term death in non-ischemic and ischemic HFpEF with a BMI lower than 30 kg/m2. However, at BMI higher than 30 kg/m2, the inverse relationship was limited to the non-ischemic subgroup , demonstrated that obesity was not associated with increased morbidity or mortality, however, patients with BMI >40 kg/m2 was independently associated with increased risks of adverse postoperative outcomes. A prior meta-analysis by Sharma et al.  had lower risk of in-hospital mortality, compared with those not morbidly obese  or after coronary revascularization –33. Hencly obese . Subsequly obese , which ply obese . In linely obese  and tolely obese , which cly obese , which wly obese , which mly obese  and Li ely obese  consistely obese  during tly obese , 44 may It was not completely known why the lowest risk of short-term mortality occurred in different obesity categories between all-cause death and CV death, with the former in class III obesity and the latter in overweight/class I obesity, irrespective of HF etiology. A possible explanation is that obesity may be a sign of less preexisting illness or underlying chronic non-cardiovascular disease, thus favorable for the overall survival. However, as obesity advanced, the prevalence of CV risk factors and CVD markedly increased . In thisThe major strengths of our study are that we extend previous observations by demonstrating the impact of ischemic etiology on the association of BMI and mortality in HFpEF patients during the short-term and long-term follow-up, respectively. Specifically, overweight and obesity-related survival benefit were both evident in non-ischemic and ischemic HFpEF patients in the short-term follow-up. However, we found the survival benefit of class III obesity in ischemic heart failure group was time-dependent, which was present in the short-term follow-up but disappeared during the long-term follow-up. A possible explanation for this decrescendo effect might be related to the underlying atherosclerotic risk and high burden of comorbidities, as well as the increased risk for thrombosis after PCI or re-stenosis in grafting vessels after CABG in severe obese patients with ischemic HF. All of these conditions were associated with a greater likelihood of cardiovascular death, and the prognosis of patients during the long-term follow-up duration are more likely to be affected by this problem.Our study has several potential limitations as follows. First, the ability of BMI to evaluate the distribution and degree of adiposity appeared to be limited; also, BMI is unable to differentiate between body fat and lean mass. Therefore, we could not determine the interplay of fat-but-fit paradigm and HF etiology in the study population. Second, given that the prevalence of most diseases is increased in older people, and data about weight changes prior to the trial enrollment is not available, we could not eliminate the risk of reverse-causation bias. However, our study took into account weight change during the follow-up when analyzing the long-term effect of various BMI categories on death, and controlled for baseline BMI when analyzing the short-term effect of various BMI categories on death, which may help to reduce the susceptibility to reverse-causation bias. Third, the number of underweight subjects is relatively small and were not included in the analysis, potentially limiting the extrapolation of our findings to the general population of HFpEF patients. We did not adjust all CV risk factors (such as LVEF and brain natriuretic peptide) in the multivariate analyses because of the relatively limited data, thus could not rule out the possibility of residual confounding effects in our analysis. Likewise, we could not perform multivariate adjusted cox regression analysis to elucidate the impact of ischemic etiology on the association of five BMI categories and mortality in patients with EF higher than 50% or different levels of natriuretic peptides because of the relatively small sample size of patients with available EF or brain natriuretic peptide data. Finally, although we did not observe a protective effect of class III obesity on long-term death in ischemic HFpEF patients, it is not clear whether targeted weight loss in morbidly obese patients is beneficial or not. Large randomized control trials evaluating the impact of intentional weight reduction or weight gain in various BMI categories may help to resolve this issue.Overweight and obesity defined by BMI confer survival benefits both in non-ischemic and ischemic HFpEF patients. This paradoxical relationship persists in all BMI categories in patients with non-ischemic HFpEF. However, in patients with ischemic HFpEF, although an obesity paradox was noted during short-term follow-up for all BMI categories, class III obesity was not associated with better survival during long-term follow-up.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Porcine reproductive and respiratory syndrome (PRRS), caused by PRRS virus (PRRSV), is a highly contagious disease that brings tremendous economic losses to the global swine industry. As an intracellular obligate pathogen, PRRSV infects specific host cells to complete its replication cycle. PRRSV attachment to and entry into host cells are the first steps to initiate the replication cycle and involve multiple host cellular factors. In this review, we recapitulated recent advances on host cellular factors involved in PRRSV attachment and entry, and reappraised their functions in these two stages, which will deepen the understanding of PRRSV infection and provide insights to develop promising antiviral strategies against the virus. As intracellular obligate pathogens, viruses infect host cells to complete their replication cycles, including attachment, entry, replication, synthesis, assembly, and release . AttachmNidovirales, family Arteriviridae, and genus Betaarterivirus.1Porcine reproductive and respiratory syndrome (PRRS) is a highly contagious swine disease characterized by reproductive failures in sows of late-term gestation and respiratory diseases in pigs of all ages . Since iin vivo  in vivo , and Afrin vitro . Multiplin vitro , such asin vitro , sialoadin vitro , vimentiin vitro , CD163  . It is ain vitro and in vivo  down-regulates CD163 expression and hinders PRRSV entry in vitro  family, namely Siglec-1. It is a macrophage-restricted molecule with an extracellular domain consisting of one N-terminal V-set Ig-like domain and 16 C2-set domains, a transmembrane domain, and a short cytoplasmic tail . Sn was via interaction with PRRSV glycoprotein (GP) 5 dependent on its sialic acid-binding activity of V-set Ig-like domain in vitro , is a subunit of non-muscle myosin IIA (NM-IIA) . MYH9 pavia interaction with PRRSV GP5 dependent on its C-terminal domain by Professor Zhou’s group , resulting in antagonized antiviral pro-inflammatory responses. More importantly, the MYH9-DAP12-Syk pathway plays a negative regulatory role in pro-inflammatory responses upon recognizing sialylated RNA viruses or sialic acid mimics .As mentioned above, PRRSV particles also contact MYH9 during intracellular transport along with other cytoskeleton components .in vitro and in vivo demonstrated by Professor Zhou’s group  on the envelope as viral apoptotic mimicry, which is recognized by PS receptor TIM-1 or TIM-4 to trigger the downstream signaling pathway and macropinocytosis as an alternative entry pathway for PRRSV into MARC-145 cells and PAMs, respectively .in vitro  (in vitro and in vivo)   and rottin vivo) . Chinesein vivo) . UnfortuIn conclusion, recent advances on host cellular factors involved in PRRSV attachment and entry have laid a strong basis for developing multi-target antiviral strategies. Intensive investigation in this field is still necessary to elucidate PRRSV infection, which is beneficial for preventing and controlling PRRS.RL recapitulated recent advances on host cellular factors involved in PRRSV attachment and entry and wrote the review. SQ and GZ provided guidance and modified the review. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study explored post-traumatic growth among preschool teachers during COVID-19 and investigated associations among post-traumatic growth, perceived crisis management, and risk perception. The participants were 2921 Chinese preschool teachers (96.5% women). Teachers’ reports of post-traumatic growth, perceived crisis management, and risk perception were analyzed by multivariate techniques. The results revealed that preschool teachers’ post-traumatic growth was at an intermediate level, and there was no significant difference in post-traumatic growth by risk level area. Post-traumatic growth was significantly related to risk perception and perceived crisis management, and risk perception appeared to moderate the relationship between perceived crisis management and post-traumatic growth. Our findings highlight the importance of considering the roles of perceived crisis management and risk perception in preschool teachers’ post-traumatic growth. Related suggestions for preschool teachers’ mental health are discussed. Preschool teachers work with young children and have major responsibilities, including children’s care and safety and teaching organization. They often face high levels of stress in their work, which highlights the emotionally challenging nature of the teaching profession ,2,3. A sThe outbreak of COVID-19 caused various psychological changes, such as increased stress, anxiety, panic attacks, and depression . The menAlthough the negative effects of COVID-19 on preschool teachers were evident around the world, positive psychology suggests that disasters may also trigger positive psychological changes and growth. A positive psychological change experienced by people following traumatic events is defined as post-traumatic growth ,15. SomeDuring COVID-19, positive actions by governments to fight the pandemic may have alleviated negative emotions, promoted patriotic enthusiasm, and increased people’s trust in society ,23. TherFew studies have analyzed post-traumatic growth among preschool teachers and its relationships with risk perception and crisis management by the government in the context of COVID-19. Research focused on Chinese preschool teachers remains scarce. This study explored post-traumatic growth among preschool teachers in China, including differences in post-traumatic growth among preschool teachers living in areas with differing COVID-19 risk levels. Moreover, we tested the moderating role of risk perception in the association between post-traumatic growth and perceived crisis management.With the spread of COVID-19 globally, the public were immersed in fear, anxiety, and sadness . Travel Preschool teachers’ mental health problems were a concern in the context of COVID-19. For example, some preschools faced economic difficulties and the risk of bankruptcy. Challenges such as these led to falling wages among preschool teachers . Most prIn China, preschool teachers provide education and care for children aged 3–6 years whose physical and mental development is immature. Preschool teachers’ mental health has a huge impact on children’s lifelong development . TherefoPost-traumatic growth refers to positive psychological changes experienced by individuals following traumatic events ,15. It iWith the outbreak of COVID-19, researchers explored post-traumatic growth among people living in affected areas. Stallard et al. (2021) found that most caregivers of children reported experiencing post-traumatic growth, including improved interpersonal relationships, a better appreciation of life, and positive mental changes . Other sPreschool teachers are indispensable in the life of children and paying attention to their post-traumatic growth is particularly meaningful in the context of COVID-19. If teachers experienced post-traumatic growth during COVID-19, their mental state may have changed in a positive direction ,36. UnfoFurthermore, different threat levels and different traumatic events have differing effects on post-traumatic growth ,37. ThisCrisis management refers to a process of planning, decision-making, and resolution carried out by government departments to deal with various crisis situations, and crisis management is a part of the government’s responsibility . Its purRestrictions on local and international travel and in-house isolation were the most common measures enforced by governments worldwide to contain the virus during the COVID-19 pandemic . In ChinCrisis management is closely related to post-traumatic growth. The public’s assessment of governmental crisis management is a problem of public sentiment and psychology ,42. DuriRisk perception refers to people’s assessments about the risks associated with various stimuli based on personal subjective and intuitive judgments . The sevRisk perception is closely related to post-traumatic growth. Traumatic events affect people’s basic cognitive schema and trigger painful emotions; people reflect on these traumatic events repeatedly to alleviate the negative impacts . These pIn addition, risk perception may moderate the relationship between post-traumatic growth and external factors. Armeli et al. 2001) and Stockton et al. (2011) noted that this growth depends on an individual’s cognition of stress events, and the cognition of traumatic events is the main reason for post-traumatic growth 01 and St. Zhou anIdentifying factors that affect post-traumatic growth may be necessary to protect preschool teachers’ mental health and promote their post-traumatic growth . HoweverMoreover, we investigated the moderating role of risk perception in the relationship between perceived crisis management and post-traumatic growth. In terms of the moderating role, we hypothesized that no relationship would be found between post-traumatic growth and perceived crisis management at higher levels of risk perception. In contrast, we expected that there would be a positive relationship between post-traumatic growth and perceived crisis management at a relatively moderate level of risk perception.Therefore, this study explored the following questions. (a) What is the profile of post-traumatic growth among preschool teachers in China in the context of COVID-19? (b) What are the characteristics of post-traumatic growth among preschool teachers living in different risk areas during COVID-19? (c) What are the relationships among crisis management, post-traumatic growth, and risk perception?Currently, COVID-19 continues to spread worldwide and affects preschool teachers’ mental health. Teachers’ mental health has a huge impact on children’s development. The post-traumatic growth of preschool teachers has not received attention. Therefore, it is urgent to consider the post-traumatic growth among preschool teachers and related factors. In this context, we believe that this study contributes to confirming the factors affecting post-traumatic growth among preschool teachers, which would help government departments and preschools formulate targeted practical measures to improve teachers’ well-being and minimize mental health risks during COVID-19. To our knowledge, this is the first study focused on post-traumatic growth and related factors among preschool teachers in the context of COVID-19. This study will enrich academic research on preschool teachers’ mental health.To make up a representative sample, three geographical and economical divisions were selected because they contained variability among eastern, central, and western China. Meanwhile, when we selected the provinces in the three divisions, we considered their epidemic risk. Specifically, Shandong and Hainan province in the eastern, Hubei and Jilin in the central, and Xinjiang, Gansu, Guizhou, Qinghai, and Ningxia province in the western regions were selected in this study. Participants in these provinces were randomly recruited from the National Training Program for Preschool Teachers during the COVID-19 epidemic in 2020 in China. All respondents were 2921 preschool teachers, 96.5% were women, 32.1% were aged 29 years or below, 47.4% had finished up to 3 years of college, 40.8% had more than 6 years of work experience, and 66.3% were from public preschools. In addition, 23.1% of preschool teachers lived in low-risk areas (0–199 COVID-19 cases), 41.5% were in medium-risk areas (200–9999 COVID-19 cases), and 35.4% were in high-risk areas  .Post-Traumatic Growth. The measure used to assess post-traumatic growth was the Chinese version of the Post-Traumatic Growth Inventory (PTGI) . Its relRisk Perception. The measure used to assess risk perception was adapted from an index of questions about risk perception used in a previous study . This quPerceived Crisis Management. The measure used to assess perceived crisis management was adapted from an index of questions about crisis management during COVID-19 . This asWe adapted preexisting questionnaires that collected information on preschool teachers’ post-traumatic growth, risk perception, and perceived crisis management. The risk perception and perceived crisis management tools were originally developed in English. We used the following measures to ensure the accuracy and readability of our translation. First, two doctoral students majoring in preschool education completed the translation separately. Second, we compared the two translations and discussed the differences, and reached consensus to form a draft. Third, experts in preschool education and mental health education, including a university faculty, a kindergarten manager, and an education expert, were consulted on the appropriateness and accuracy of the item wording. Finally, we revised the draft according to this feedback.The preschool teachers in this study worked in preschools that enrolled children aged 3–6 years in China. In the formal stage of data collection, we recruited participants from the National Training Program for Preschool Teachers during the COVID-19 epidemic in 2020 in China. The preschool teachers provided consent to participate in this study after receiving information about the research objectives. Participants were assured that the information collected would be used solely for research purposes. We distributed electronic questionnaires (e-questionnaires) to participating preschool teachers from September to December 2020 using Wenjuanxing, a professional online questionnaire collection platform.To ensure the objectivity of the data, we defined clear submission principles: the same participant and questionnaires from the same IP address could not submit the e-questionnaire repeatedly. To ensure participants answered questions openly and honestly, the e-questionnaire was sent directly to participants via anonymous links. The research was carried out in accordance with ethical standards for the treatment of human participants, and the study was approved by the Institutional Review Board at the study’s home institution.We used IBM SPSS version 26.0  for the statistical analyses. First, we divided the classification of COVID-19 risk levels into low-risk, medium-risk, and high-risk based on previous research ,54. Datap < 0.05), indicating that preschool teachers’ perceived crisis management may have had a potential impact on post-traumatic growth. However, the exact relationships among these variables needed to be further explained by the moderation analysis.The descriptive statistics and bivariate correlations for the key study variables are shown in 2partial < 0.2). The multiple comparative analysis showed that in high- and medium-risk areas, preschool teachers’ risk perception was significantly higher than that among teachers in low-risk areas. Furthermore, teachers’ risk perception in high-risk areas was significantly higher than that among teachers in medium-risk areas. Teachers’ perceived crisis management in high-risk areas was significantly higher than that among teachers in low-risk areas, and perceived crisis management in medium-risk areas was marginally higher than that among teachers in low-risk areas. However, teachers’ perceived crisis management in high-risk areas did not significantly differ from that among teachers in medium-risk areas.The results of the one-way ANOVA are shown in p < 0.05). Risk perception significantly moderated the relationship between perceived crisis management and post-traumatic growth . We conducted a simple slope test to further explore the moderating role of risk perception in the relationship between crisis management and post-traumatic growth. There was a positive relationship between post-traumatic growth and perceived crisis management when risk perception was lower than one SD of the mean  = 0.032, 95% CI: 0.008, 0.135; p < 0.05). No relationship was found between post-traumatic growth and perceived crisis management when risk perception was higher than one SD of the mean   See .In this study, we found that preschool teachers’ post-traumatic growth in the context of COVID-19 was at an intermediate level, and there was no difference in different risk areas. However, preschool teachers’ post-traumatic growth was significantly related to risk perception and perceived crisis management, and risk perception had a significant moderating effect on the relationship between perceived crisis management and post-traumatic growth.We found that preschool teachers’ post-traumatic growth during COVID-19 was at an intermediate level, and “appreciation of life” had the highest score among all subscales. These results were consistent with a previous study . Our resOur study found a positive correlation between perceived crisis management and post-traumatic growth among preschool teachers. Previous studies showed that social support was positively related to post-traumatic growth . Our resWe found a positive correlation between post-traumatic growth and risk perception among preschool teachers. This was consistent with the results reported by Calhoun et al. (2000) and Yang et al. (2021) ,49, and We found that risk perception moderated the relationship between perceived crisis management and post-traumatic growth among preschool teachers. Perceived crisis management had a significant positive impact on post-traumatic growth when the level of risk perception was appropriate. However, it had no significant impact on post-traumatic growth when the level of risk perception was high. This confirmed that post-traumatic growth is a cognitive process, and individual cognitive factors are more critical than external factors ,27. PostThis study explored a basic profile of post-traumatic growth among preschool teachers during COVID-19 and the moderating role of risk perception in the relationship between perceived crisis management and post-traumatic growth. This study found that preschool teachers in China had an intermediate level of post-traumatic growth, and there was no significant difference in post-traumatic growth by risk level area. Post-traumatic growth was significantly related to risk perception and perceived crisis management, and risk perception moderated the relationship between perceived crisis management and post-traumatic growth. These results contribute to developing targeted practical measures to improve preschool teachers’ mental health in the context of COVID-19.This study explored the relationships among post-traumatic growth, risk perception, and perceived crisis management in preschool teachers during COVID-19 and confirmed the moderating role of risk perception. These findings deepened our perspectives on the mechanism of preschool teachers’ post-traumatic growth and potential strategies for improving their mental health during a public health emergency. We put forward the following suggestions based on our results. First, local governments and preschool managers should pay attention to preschool teachers’ post-traumatic growth. This not only affects the mental health of teachers but also has an important effect on children’s growth ,12,30. SThis study had several limitations. First, our findings were obtained from cross-sectional data. The occurrence of post-traumatic growth takes a certain amount of time, and its positive effect is achieved over time , whereas


Background: Although previous studies indicate that chronotype might be associated with risk-taking behavior, the specific mechanism has not been thoroughly discussed. This study aimed to fill this gap by exploring the mediating role of self-control and the chain mediating role of self-control and emotional stability between chronotype and risk-taking behavior. Methods: A total of 547 Chinese college students between 18 and 24 years old were selected to complete the Morningness–Eveningness Questionnaire (MEQ), Self-Control Scale (SCS), Eysenck’s Personality Questionnaire-neuroticism (EPQ-N), and Adolescent Risk-Taking Questionnaire: Risk Behavior Scale (ARQ-RB) to assess chronotype, risk-taking behavior, self-control, and emotional stability, respectively. Hayes’ PROCESS macro for SPSS was used to test the relationships among these variables. Results: Our result showed significant positive correlations among chronotype, self-control, emotional stability, and significant negative correlations between self-control, emotional stability, and risk-taking behavior. We also found that chronotype had a significant predictive effect on risk-taking behavior in the chain mediation model. Specifically, chronotype affected risk-taking behavior through two pathways: the separate mediating role of self-control and the serial mediation pathway of self-control → emotional stability. Conclusions: Our study provides direct evidence that chronotype is associated with risk-taking behavior. The results showed that the predictive function of chronotype was mediated by self-control and emotional stability. This study provides a new perspective on preventing and reducing risk-taking behavior. Risk-taking behavior is defined as either a socially unacceptable volitional behavior with probably undesirable consequences without preventive measures, such as speeding, drinking and driving, etc., or a relatively socially accepted behavior in which the danger is acknowledged, for instance, competitive sports, skydiving, etc. . A consiSeveral factors, including personality traits , sex difA person with a morning preference who prefers morning activities, gets up easily and is more alert in the morning than in the evening, whereas a person with an evening preference prefers afternoon-evening activity, is more alert at night, and sleeps late into the morning . InvestiOne potential underlying mechanism of the association between chronotype and risk-taking behavior might be self-control. Existing evidence highlighting the association between chronotype and self-control showed a significant and positive correlation between Morningness–Eveningness Questionnaire (MEQ) score and the Self-Control Scale score, indicating a relationship between evening-type and low self-control  and a reEmotional stability has been defined as the extent to which individuals can remain calm and stable under pressure, and has been described in the literature as an individual’s degree of self-confidence, tolerance of stress, optimism, and self-consciousness . A signiAlthough previous studies have indicated that chronotype might be associated with risk-taking behavior, the specific mechanism of the relationship between chronotype and risk-taking behavior has not yet been thoroughly discussed. This present study was designed based on a previous study to reveal the simple mediating role and the chain mediating role of self-control and emotional stability between chronotype and risk-taking behavior. Specifically, we proposed the following hypotheses:Hypothesis 1.Chronotype would directly and positively affect self-control.Hypothesis 2.Self-control would directly and positively affect emotional stability.Hypothesis 3.Emotional stability would directly and negatively affect risk-taking behavior.Hypothesis 4.Chronotype would indirectly and negatively affect risk-taking behavior through self-control and emotional stability.https://www.wjx.cn, accessed on 6 April 2021), during 3 March 2021 to 26 March 2021. All participants provided informed consent prior to the electronic questionnaire.The study participants comprised 547 students  from Nantong University . Their ages ranged from 18 to 24 years. Using a convenience sampling method, the data were sampled by administering an anonymous electronic questionnaire on the WenJuanXing public online platform .Chronotypes were categorized with the Morningness–Eveningness Questionnaire (MEQ) . The ChiThe revised version of Self-Control Scale (SCS) for Chinese college students  was usedThe 24-item Eysenck’s Personality Questionnaire-neuroticism (EPQ-N) revised by Gong et al. was used to assess college students’ emotional stability . The scaThe Adolescent Risk-Taking Questionnaire, developed by Gullone et al. , consistTo test correlations among variables, descriptive statistics and Pearson correlation analysis were inspected in SPSS 21.0 .To examine the mediation effect of self-control and emotional stability, Model 6 of the PROCESS macro in SPSS21.0 was utilized . We condTo avoid common methodological deviations, the Harman single-factor method was used for statistical control . The resThis cross-sectional study included 547 adult college students comprising 197 males (36%) and 350 females (64%). The questionnaire survey involved four dimensions: chronotype, risk-taking behavior, self-control, and emotional stability. Descriptive statistics of the sample are reported in p < 0.01) and emotional stability , but not significantly correlated with risk-taking behavior . Moreover, both self-control  and emotional stability  were negatively and significantly correlated with risk-taking behavior. The correlation outcomes supported the relationship between the variables included in the hypothesized model.Pearson’s correlations explored the relations between all the variables of interest. As indicated in p < 0.001, Hypothesis 1). Concerning the prediction of emotional stability, self-control was observed to show a significant and positive association with emotional stability . For predicting risk-taking behavior, self-control and emotional stability were found to be significantly associated with risk-taking behavior .p < 0.01), except for the association between chronotype and emotional stability . However, the direction of the indirect effect (ab = −0.019) was opposite to the direct effect (c’ = 0.106), indicating that there is a “suppressing effect” between chronotype and risk-taking behavior. The results showed that the positive relationship between chronotype and risk-taking behavior was significant, with self-control partially mediating the relationship between chronotype and risk-taking behavior and a significant chain mediating effect of self-control and emotional stability.This study was designed to explore the antecedents of risk-taking behavior by assessing the relationship between chronotype, self-control, emotional stability, and risk-taking behavior among Chinese college students. Unexpectedly, we did not find a significant correlation between chronotype and risk-taking behavior, indicating no simple linear correlation between them. Unlike the traditional mediating effect test, when the relationship between an independent variable and dependent variable is not significant, the indirect effect, called the “suppressing effect”, might still exist, generalizing the intermediary effect ,48. TherThe indirect effect results confirmed our hypothesis, showing that self-control plays a simple mediating role between chronotype and risk-taking behavior. Specifically, morning-type people have a higher level of self-control, which might play a role in counteracting or reducing their curiosity about inappropriate or negative events to establish the complete behavior patterns that reduce the likelihood of risk-taking behavior, while those with evening-type have a lower level of self-control and harm avoidance  and a loThe chain mediating role of self-control and emotional stability on the relationship between chronotype and risk-taking behavior was supported. Consistent with previous research, we found that self-control significantly and positively predicted emotional stability , which sConsidering the mediation variable, chronotype can positively predict risk-taking behavior, which was contrary to our expectations and previous findings. We speculated that this result could be because the college students are usually characterized by “getting up early and sleeping late”, which might have led to insufficient sleep, earlier daily routines, and worse sleep deprivation. In addition, an irregular sleeping schedule is also one of their characteristics; this observation is most likely due to conditions brought on by the COVID-19 pandemic. Students were likely to have a greater possibility to sleep at home during the COVID-19 pandemic, but their sleep schedules were still disturbed . SeveralThe results of this present study might represent an important step toward implementing psychological intervention for reducing risk-taking behavior and associated consequences. Since self-control and emotional stability might play a significant role in explaining the relationship between chronotype and risk-taking behavior, current evidence can be used to guide college students in preventing or reducing risk-taking behavior and the associated consequences by improving their self-control and emotional regulation skills. Although there is no intention of labeling evening-type individuals with negative behaviors, the present literature tends to show a certain correlation between evening-type individuals being more prone to enter such a vicious cycle. To fundamentally solve this issue, more awareness is needed for evening-type individuals to inform them about such risks to develop healthy sleeping habits. Workers in the psychological field should also pay more attention to the mental health of evening-type persons and promote activities that could guide them to maintain more effective social stability.Although the present study advances our understanding of the relationship between chronotype and risk-taking behavior, some limitations should be addressed. First, we relied on cross-sectional data; thus, conclusions regarding the cross-sectional findings must be interpreted cautiously. Additionally, the data were cross-sectional and could not be used to test causality. Future research might implement prospective and longitudinal designs, for example, monitoring these variables and their interactions in the post-pandemic period . Second,This study found a positive and significant association between chronotype, self-control, and emotional stability. Further, there was a negative and significant association between risk-taking behavior, self-control, and emotional stability. In addition, the relationship between chronotype and risk-taking behavior was partially and sequentially mediated by self-control and emotional stability.


Beta-lactam (BL) antibiotic “allergy” labels are common, but often overdiagnosed. Although much research has been focused on the BL allergy and the delabelling process in the West, studies from other parts of the world remain sparse. This review outlines the contrasting global epidemiology, shifting clinical practices and disparities of BL allergy in the Asia-Pacific region compared with the West. Innovative strategies to overcome barriers in BL allergy workup are discussed and potential directions for future research and service development are also proposed. Antibiotics can result in a plethora of adverse drug reactions presenting as both immune-mediated  and non-immune mediated manifestations  . AlthougClostridioides difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus)  –11. Thesococcus) , 11, 12.ococcus) , 14.From a public health perspective, suboptimal therapy because of mislabelled BL allergy can be a waste of efficiency and healthcare resources. BL allergy labels are also associated with higher mean antibiotic costs, as well as higher cost during hospital admission and discharge, wherein lengthier hospital stays increase healthcare expenditure up to ten-fold . BL alleIdentifying genuine BL allergy, i.e., delabelling the mislabelled, is thus vital for healthcare optimization at both individual and institutional levels. However, existing practices on BL allergy and delabelling are widely substantiated based on inputs and experience from “the West”, which includes Europe, North America, Australia and New Zealand in this article, warranting attention to this predicament from an Asia-Pacific perspective.The prevalence of BL allergy varies across regions. Global estimates derived primarily from United States and European studies report an approximate 10% (8%–15%) prevalence within the general population , 24. TheAcross Asia-Pacific countries , the regional prevalence of BL allergy labels in both the general population and hospitalized patients are generally lower although the disease burden is still considerable. Regional figures in hospitalized patients from mainland China, Hong Kong and Japan range from 4% to 5.6% –33. In HFurthermore, there is a higher rate of documented allergic reactions to second-line broad-spectrum BL in Asia-Pacific. A study comparing patients referred for suspected BL allergies in Hong Kong and the United Kingdom found significantly more referrals in the Hong Kong cohort for suspected hypersensitivity to broad-spectrum antibiotics, including amoxicillin-clavulanate, piperacillin-tazobactam and meropenem . Recent Reasons for these observed regional variations are likely multifactorial, whether it be more robust electronic health record documentation , or genuSensitization patterns to penicillin allergic determinants also vary through time and space. For example in Australia, the sensitization rate to only penicillin determinants (benzylpenicilloyl polylysine (PPL) ± minor determinant mixture (MDM) ± benzylpenicillin (BP)) was 9.5% while in the UK, only 8% of patients were monosensitized to PPL or MDM . In a 13Variability in the use and availability of skin test reagents will also determine differences in sensitization patterns. For example, in the United States, there is no commercially available MDM so many centers did not comprise that as a component in penicillin skin test but only use PPL and BP . Even foFurthermore, testing patterns may reflect regional policy differences. For instance, regulations of mainland China mandate routine intradermal test prior to penicillin prescription even in patients with no clinical history of penicillin-induced hypersensitivity reaction , 55. ConSeverely limited allergy services and overburdened medical infrastructure seems ubiquitous amongst many Asia-Pacific countries. While the Asia-Pacific represents the majority of the world population and likely the biggest burden of mislabelled “allergy”, there remains a limited supply of Allergists to meet the overwhelming demand . SeverelA popular and important tactic adopted in many clinical settings is to stratify and triage patients into different groups according to their risk of a genuine allergy. Various clinical predictors have been validated to identify low, medium and high-risk features of genuine BL allergy , 53, 57.With proper risk stratification, further drug allergy workup strategies may be adopted to incorporate a multidisciplinary team with collaboration between Allergists, non-allergists and allied health professionals. Various clinical models that have gained popularity in the past decade include multidisciplinary collaborations with pharmacists, nurses, and non-allergist physicians to implement BL allergy workup among low-risk patients –18, 68. There is great potential for telemedicine growth in the implementation of delabelling, especially in Asia-Pacific regions where accessibility to Allergist services and facilities may be limited . TelemedThe epidemic of BL allergy overdiagnosis is a global problem. More robust epidemiological data to determine and understand the burden and differences of BL allergy, especially in Asia-Pacific, are urgently needed. The outcome and enduring impact of delabelling should not just be limited to the delabelling process and it is important to recognize the clinical, psychosocial, and economic impacts beyond the initial delabelling process. Important data long-term clinical outcomes, which are especially scarce among Asian populations, include patterns of microbial resistance, patient quality of life and overall cost-effectiveness in the years following delabelling. Multi-centre, multi-cultural, international prospective studies are needed for better representation in the Asia-Pacific region.As mentioned, HLA genetic variations might partially explain the discrepancies between BL allergies between Asia-Pacific and the West and may carry powerful diagnostic potential. However, regional differences in HLA-gene frequency, accessibility of screening facilities, and local availabilities of drug alternatives for high-risk individuals would likely affect the cost-effectiveness and feasibility of prescreening for BL allergy by HLA-genotype in different countries . Large iNonetheless, various large-scale studies within the Asia-Pacific region have demonstrated clinical and economic benefits of BL allergy delabelling. The gains from successful BL allergy delabelling programs demonstrated in these Australian studies provide forays into the potential benefits that could be generated across the Asia-Pacific with widespread implementation of BL delabelling programs in the region.In conclusion, overdiagnosed BL allergy is a significant public health challenge to be tackled globally. In view of the substantial geographical differences, it is in urgent need for Asia-Pacific to establish more evidence and customize its own delabelling practice to best fulfil its huge and unique demand. Collaborations among disciplines and countries are direly called for. After all, it is the effort and responsibility of every one of us to tackle the global burden of misdiagnosed BL allergies.


Obsessive-Compulsive Disorder (OCD) is an incapacitating Neuropsychiatric condition characterized by the presence of obsessions and/or compulsions. Although the disorder’s phenotype is well described, its pathophysiology remains elusive . Over the last decade, techniques to noninvasively study the brain’s neurophysiology, such as Transcranial Magnetic Stimulation (TMS), have found widespread use in psychiatric research. For OCD, single- and paired-pule TMS protocols have been used to explore abnormalities in motor cortex excitability and cortical neuroplasticity. Here we propose to systematically review and, where possible, metanalyse existing case-control studies that compared such measures in patients and healthy subjects.To systematically review and meta-analyse published case-control studies comparing cortical excitability measures, as measured by single- or paired-pulse TMS, in subjects with OCD and healthy controls.We have conducted a systematic review of published literature (PROSPERO registration CRD42020201764) reporting measures of cortical excitability as measured by single or paired-pulse TMS, in patients with OCD and healthy controls. We searched 4 different electronic libraries . The resulting list of articles was reviewed, separately, by two researchers. Disagreements were discussed and resolved by consensus, until a final list of eligible articles was obtained.13 studies reporting motor cortex excitability measures were included in our final list. The total number of participants included in our analyses is 615 A sufficient number of studies was found to allow for metanalyses, currently ongoing.


Sonographic mesenteric pattern in celiac disease (CD) suggests a hyperdynamic circulation. Despite the well-known CD-related neurological involvement, no study has systematically explored the cerebral hemodynamics to transcranial Doppler sonography.Montreal Cognitive Assessment (MoCA) and 17-item Hamilton Depression Rating Scale (HDRS) were assessed in 15 newly diagnosed subjects with CD and 15 age-, sex-, and education-matched healthy controls. Cerebral blood flow (CBF) velocities and indices of resistivity (RI) and pulsatility (PI) from the middle cerebral artery (MCA), bilaterally, and the basilar artery (BA) were recorded. We also assessed cerebral vasomotor reactivity (CVR) through the breath-holding test (BHT).Worse scores of MoCA and HDRS were found in patients compared to controls. Although patients showed higher values of CBF velocity from MCA bilaterally compared to controls, both at rest and after BHT, no comparison reached a statistical significance, whereas after BHT both RI and PI from BA were significantly higher in patients. A significant negative correlation between both indices from BA and MoCA score were also noted.These treatment-naïve CD patients may show some subtle CVR changes in posterior circulation, thus possibly expanding the spectrum of pathomechanisms underlying neuroceliac disease and in particular gluten ataxia. Subclinical identification of cerebrovascular pathology in CD may help adequate prevention and early management of neurological involvement. It is known that, within the wide spectrum of gluten-related disorders , the typRegarding extra-intestinal symptoms, neuropsychiatric and neurological manifestations still represent a challenge for diagnosis, since they can co-occur or precede CD, or even exist in isolation without any gastrointestinal symptoms . In the in vivo assessment of cerebral blood flow (CBF) vessel velocity and resistance on a prolonged period and with high temporal resolution  represents a non-invasive ultrasound method using a ≤2 MHz (low-frequency) probe transducer to insonate cerebral basal arteries through some specifically thin skull windows. TCD is used for an solution . Most ofsolution , subaracsolution , stroke solution , monitorsolution , intensisolution , right-tsolution . Recentlsolution  or demensolution .2 inhalation) determines a hemodynamic reaction which correlates with the brain metabolic response secondary to the stimulus itself  . SplanchTo date, however, no study has systematically explored cerebral hemodynamics in CD. We evaluated TCD in newly diagnosed CD patients with respect to normal individuals. The hypothesis was that TCD might identify even preclinical CVR or CBF differences in CD compared to controls.A group of 15 treatment-naïve consecutive patients , with the diagnosis of CD based on the European Society for Pediatric Gastroenterology Hepatology and Nutrition guidelines , were reWe excluded the following subjects: age <18 years; any neurological  or psychiatric disorders ; acute or chronic not compensated medical illnesses , as well as any condition causing a hyperdynamic state ; alcohol dependency or illicit drug intake; use of any drug affecting CBF or CVR; bilateral insufficient acoustic bone windows. Since iron-deficiency anemia may be a common presenting manifestation of CD, we have excluded subjects with a moderate-to-severe anemia, whereas those with mild anemia , especially without low hematocrit values, were considered for possible inclusion.Demographic and clinical evaluation included: sex, age, education, handedness, neurological and general examination, any comorbidity. A global test of the overall cognitive functioning through the Montreal Cognitive Assessment (MoCA), adjusted for education and age of every participant , and a qThe Ethics Committee of “G. Rodolico-San Marco” Policlinico University Hospital of Catania  approved the study (Prot. n. 103/694). Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article. Every procedure was conducted according to the in Declaration of Helsinki (1964) and later amendments, in a fully equipped Lab and by using the same system and under the same experimental conditions.® X digital . CBF velocities of the proximal tract of the middle cerebral artery (MCA), bilaterally, and of the basilar artery (BA) were obtained through a 2 MHz pulsed-wave Doppler ultrasound handheld probe from the transtemporal and suboccipital bone windows, respectively. All recordings were obtained both at rest and at the depth providing the optimal signal . The measures of interest were: mean blood flow velocity (MBFV), peak systolic velocity (PSV), end-diastolic velocity (EDV), RI [according to the formula: (PSV–EDV)/PSV)], and PI [which was equal to: (PSV–EDV)/MBFV)] (An expert sonographer (R.B), who was blind with respect to the participants’ status as control or patient, performed all the procedures through a dedicated TCD Compumedics DWL, Multi-Dop)/MBFV)] . These i)/MBFV)] .2-induced hypercapnia is able indeed to identify an altered vasomotor reserve of the brain, and an impaired reaction can detect an increase in the risk of cerebrovascular diseases  was utilized to assess correlations existing between variables. P-values were statistically significant when <0.05.All statistical analyses were performed by using the GraphPad Prism v.8. Data distribution was evaluated by means of the Shapiro-Wilk and Kolmogorov-Smirnov tests. Mann–Whitney test or Unpaired p = 0.004) and HDRS  scored significantly worse in patients compared to controls.p = 0.042) and PI  were significantly higher in patients compared to controls . Although patients showed an overall trend toward higher values of CBF velocities from MCA bilaterally compared to controls, both at rest and after BHT, none of these comparisons reached a statistically significance; the same holds true for TCD measures of CBF velocity from BA at rest. Conversely, after BHT, both RI  investigation in a restricted sample of CD subjects with cerebral calcifications and epilepsy demonstrated hypoperfusion of the occipital lobes, which extended to the temporo-parietal or frontal areas in most of them . Neverth2 partial pressure changes. As such, PI provides information on downstream vascular resistance  and an exhaustive battery of neuropsychological tests, which was restricted to MoCA, which is however a comprehensive test of global cognitive functioning.Third, given the cross-sectional study design, it needs to be acknowledged that, at this stage, a direct correlation between CD and TCD cannot be drawn, but only an association between gluten exposure and specific hemodynamic indices. Follow-up studies in gluten-restricted patients will further clarify their clinical and pathophysiological impact.Finally, it is known that anemia with low hematocrit value may influence TCD parameters . HoweverLastly, TCD parameters were not measured from the anterior cerebral artery and the posterior cerebral artery; nevertheless, BA and MCA irrorate most of the posterior and anterior brain areas, respectively, and are standardized for TCD examination, thus providing a satisfactory and reliable evaluation of cerebral resistance and velocities.Transcranial Doppler sonography in CD may disclose some subtle CVR changes in the posterior circulation of these neurologically asymptomatic patients, thus possibly suggesting its role as an additional tool to non-invasively probe the cerebrovascular correlates of CD. Follow-up investigations, which correlate neuroimaging and clinical results, both at the time of diagnosis and after the gluten restriction, should be encouraged to confirm this finding and to gain further insights on the fascinating connections between gut and brain.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by The Ethics Committee of “G. Rodolico-San Marco” Policlinico University Hospital of Catania  (Prot. n. 103/694). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.FF and MP: conceptualization. RB: methodology, investigation, and project administration. GL, CD’A, and MP: validation. MC: formal analysis and data curation. CD’A: resources. FF and GL: writing—original draft preparation. GP and MH: writing—review and editing. MH: visualization. GP: supervision. All authors have read and agreed to the published version of the manuscript.


We showcase improved PlaqView functionality, backend data processing, user-interface, and capacity. PlaqView brings new or improved tools to explore scRNA-seq data, including gene query, metadata browser, cell identity prediction, ad hoc RNA-trajectory analysis, and drug-gene interaction prediction. PlaqView serves as one of the largest central repositories for cardiovascular single-cell datasets, which now includes data from human aortic aneurysm, gene-specific mouse knockouts, and healthy references. PlaqView 2.0 brings advanced tools and high-performance computing directly to users without the need for any programming knowledge. Lastly, we outline steps to generalize and repurpose PlaqView's framework for single-cell datasets from other fields.Single-cell RNA-seq (scRNA-seq) is a powerful genomics technology to interrogate the cellular composition and behaviors of complex systems. While the number of scRNA-seq datasets and available computational analysis tools have grown exponentially, there are limited systematic data sharing strategies to allow rapid exploration and re-analysis of single-cell datasets, particularly in the cardiovascular field. We previously introduced PlaqView, an open-source web portal for the exploration and analysis of published atherosclerosis single-cell datasets. Now, we introduce PlaqView 2.0  Named “Method of the Year” in 2013, single-cell RNA sequencing (scRNA-seq) technology has now been used in virtually every field of biology and medicine, including cancer biology and cardiovascular medicine , have distilled large bulk RNA-seq datasets, made them accessible to everyone, and provided multiple query functions, but none are designed for single-cell datasets . Oth. Oth(wwwdatasets  10). As. As, users can open the scRNA-seq portal (APOE for humans and Apoe for mice)  , 21. TheTo facilitate functional interpretation within a given single-cell dataset, PlaqView conducts automated Pathway Enrichment Analysis with the queried genes, powered by EnrichR –24. AlthCell identity prediction remains one of the most time-intensive and critical steps in the single-cell analysis pipeline . PreviouPlaqView enables users to run and compare several methods of cell annotation and compare them against other databases, as well as exporting the entire differential gene expression matrix for manual exploration of rare cell types. In many areas of the application and specifically under the “Cell Labeling” tab, users have the ability to explore the cell identities as provided by the original authors (when available), by SingleR , and by T-cells” with the reference cluster “Effector memory CD8 T cells”, with a 75.5% precent positive correlation in gene signature . CI. CI30). ignature . Lastly,Currently, no systematic convention exists in sharing single-cell metadata that are essential for reproducible analysis and future meta-analysis. These important metadata, such as sex, age, sample location, and author-provided cell-type annotations, are often omitted when submitting data to public repositories. It is estimated that fewer than 25% of current single-cell studies have provided cell-level metadata . PlaqViep-values of singleR annotations. PlaqView will output appropriate feature maps when these data are available. Furthermore, we introduce the ability to query gene expression based on factor-type variables. We demonstrate its use by querying the genes APOE, COL1A1, FBLN1, and FBLN2 in the Tucker et al. (FBLN1 and FBLN2) are more highly expressed in the right atrium (RA) and left atrium (LA), compared to ventricular samples, most likely due to the differential behavior of atrial and ventricular fibroblasts  with PlaqView , 39. In We are committed to bringing the most updated and relevant cardiovascular datasets to PlaqView. Currently, we plan to update the PlaqView database at least once monthly as more datasets and studies are published. Furthermore, we are currently developing other multi-modal portals suited for data such as single-cell Assay for Transposase-Accessible Chromatin (scATAC-seq), spatial RNA-seq, and a separate portal to compare healthy and diseased tissues in a systematic manner.One of the major challenges of reproducible single-cell analysis is the lack of standardization in data-sharing format. We have found that the most commonly used methods are: (1) sharing processed data as matrices , (2) sharing raw FASTQ files, (3) sharing processed Seurat objects as .rds files or equivalent, such as .h5ad files. We have found that sharing single-cell data as .rds or equivalent is the most convenient and reproducible method as the metadata are matched at the cell-level. However, as noted above, fewer than 25% of published single-cell RNA-seq studies provide this cell-level metadata.(https://github.com/cellgeni/sceasy), manual effort is still required to standardize analysis input for PlaqView. Depending on the incoming file type, they are converted or updated into the latest Seurat object class in R, and are saved as .rds files. These processed files, along with their raw formats, are made publicly available on the PlaqView homepage at https://plaqview.com/data. Systematic processing script is available in in the PlaqView DataProcessing Github page (https://github.com/MillerLab-CPHG/PlaqView_DataProcessing) and can be used as a reference for other single-cell applications to readily convert datasets into R-readable formats.For PlaqView, each dataset curated or submitted is standardized and is ready to be read by the application. Although some efforts have been made to allow interconversions between file formats, such as sceasy Once the datasets are converted into the raw Seurat objects, we process them in the same manner to generate several output files to be read by PlaqView . First, To infer cell identity using automatic methods, the scaled RNA matrix is extracted using the GetAssayData function and fed into SingleR as a new singleR object using the SingleR function. The identities called by singleR are added into the metadata slot within the Seurat object.Similarly, we use Seurat's label transfer function FindTransferAnchors and TransferData to predict cell identity using the Tabula Sapiens and Tabula Muris  referencTo enable trajectory analysis, we used custom scripts to extract Seurat data and place them into a Monocle3 CDS object using the new_cell_data_set function. The new CDS object is preprocessed using the following functions: preprocess_cds, reduce_dimension, cluster_cells , 34. A c(https://github.com/MillerLab-CPHG/PlaqView_DataProcessing).Finally, we compute the entire differential expression for all cell types labeled by different methods  using the FindAllMarkers function. This is the most time-consuming and memory intensive part of the preprocessing pipeline and we use the Future package to parallelize this step. The full R script for the preprocessing pipeline is located in our Data Processing Github page Raw human sequencing data often require specialized secured storage both due to their size and institutional review board (IRB) compliance regulations. Currently, PlaqView 2.0 only requires the downstream count matrices and does not use any raw sequencing. When data are submitted to PlaqView as raw sequences (such as FASTQ or BAM files), they are processed offline in a dedicated high-performance computing platform and only the count matrices are transferred to PlaqView storage, which is protected under an institutional firewall .PlaqView.com under “Data.” Furthermore, researchers can directly and securely submit their dataset to PlaqView on the PlaqView homepage.Nonetheless, most datasets currently on PlaqView are already open-access and are deposited in different public storage spaces in various raw formats. All datasets available on PlaqView have undergone systematic preprocessing and are saved in .rds formats that can be requested directly on renv does not completely enable a reproducible environment and only records the versions of tools in an R computing environment (https://rstudio.github.io/renv/articles/renv.html). Recently, the combination of Docker and R gave rise to the Rocker Project (https://www.rocker-project.org/), which utilizes the image building capability of Docker in conjunction with R. Essentially, a predetermined set of R tools are installed on top of a basic operating system, such as Ubuntu. This enables programmers to capture the entire computing environment- including the base operating system, R, and all dependent packages- and can be downloaded to any computing platform reliably and in isolation. This has an advantage over other tools such as renv in that Docker images contain the actual packages and operating system, therefore in the event of version changes or deleted repositories, it will not break with the computing environment. Based on Rocker, we have built a custom Docker image that enables users to run the exact analysis pipelines with all dependencies already installed, and is available via DockerHub at millerlab/plaqviewmaster. This Docker image has two major utilizations: as a stable environment for feature development and as a base for the PlaqView application deployment, as it contains all the necessary packages and serves as a backbone for the web application  to regulate the amount of memory and processor each user can access. DC/OS also automatically handles the workload demand to scale up more service instances in response to increased user access. Furthermore, this infrastructure allows for isolated, or “sticky,” instances so each user is given a dedicated R instance and cannot access other users' instances. This is commonly referred to as “stateless programming.” Currently, PlaqView supports up to 32GB of memory per user . In the near future, we plan to further scale up using Kubernetes on large commercial-grade infrastructures such as Google Cloud Computing.Typically, PlaqView development occurs in several stages: edit source code (app.r file), test locally and update Docker images, deployment, and bug fixes . The stavia GitHub as well as through internal runtime log reviews.Once the app is live, we begin to capture user feedback and fix any additional bugs. We implement bug fixes and feature requests PlaqView was originally developed for atherosclerosis-related cardiovascular datasets, but the underlying structure was designed to be easily adapted to other fields of research. The entirety of the source-code has been made available on GitHub. Furthermore, each iteration of PlaqView comes with a containerized base image hosted on DockerHub (wfma888/plaqviewmaster), which allows for immediate and reproducible deployment in virtually any computing structure. Essentially, there are two major steps to adapt PlaqView to other fields: minimal processing of the user interface script and deploying to a suitable service structure.Shinyapps.io also provides a native and easy way to deploy Shiny apps for beta testing, however limitations in memory per instance and slow performance limits its usefulness in analyzing large datasets.Due to the size of the single-cell datasets, PlaqView and adapted versions are best hosted on dedicated, large high-performance clusters. Commercial solutions that would work well are Google Cloud Services as Google Run instances or Amazon Web Services. To date, very few single-cell portals like PlaqView exist for cardiovascular genomics research. ExpressHeart, a single-cell portal dedicated to non-cardiomyocyte cells, has several single-cell datasets but has limited scope and features for data re-analysis  42). Ot. Ot42). PlaqView helps to overcome many modern challenges in the single-cell field, such as the complex coding and computational knowledge needed to explore single-cell data and standardization for data sharing. Since its initial release, we have registered users from 35 countries, with the top being U.S., China, Germany, and the Netherlands. To our knowledge, PlaqView is the most comprehensive single-cell portal dedicated to cardiovascular research. We are committed to the longevity of PlaqView and are working on furthering PlaqView's capability as multimodal datasets are released, such as spatial and scATAC-seq data. Our immediate goals are (1) including additional relevant single-cell datasets, (2) creating a subportal for live single-cell dataset integration and comparison, and (3) creating a subportal for multimodal single-cell data visualization.ad hoc RNA-trajectory calculations. We further improved the usability, speed, stability, and scale of the application. PlaqView serves both as a repository of single-cell data for cardiovascular diseases as well as a tool to rapidly visualize, renalayze, and share scRNA-seq data without the need to code or have specialized computing knowledge. PlaqView is an invaluable resource that bridges the gap between computational and experimental research to advance cardiovascular medicine.Single-cell data has always been challenging to share, analyze, and visualize. Typically, these datasets require specialized computing knowledge and high-performance computing tools not readily available. Previously, we presented PlaqView, a web-portal to allow lay scientists and benchtop researchers to rapidly view single-cell RNA-seq data for atherosclerosis. Here, we introduce PlaqView 2.0, a significant improvement to the PlaqView application. In this second major release, we introduce many new features, such as a metadata explorer, cell identity prediction, and www.plaqview.com.Publicly available datasets were analyzed in this study. This data can be found here: The studies involving human participants were reviewed and approved by Institutional Review Board (IRB) at the University of Virginia. The patients/participants provided their written informed consent to participate in this study.WFM designed, tested, and wrote the PlaqView application. AWT provided feedback, programming help, and application testing. CG provided back-end infrastructure and deployment aid. DW, YS, JVM, GA, CJH, and AP provided feedback and application testing. SWvL and CLM guided and helped in the development of PlaqView. HAE developed the CIPR module. All authors provided feedback and editing for this manuscript.Funding for this research was provided by National Institutes of Health (NIH) grants R00HL125912 and R01HL14823, a Leducq Foundation Transatlantic Network of Excellence (PlaqOmics) Young Investigator Grant, Netherlands CardioVascular Research Initiative of the Netherlands Heart Foundation , and the ERA-CVD program druggable-MI-targets (grant number: 01KL1802). SL was funded through EU H2020 TO_AITION (grant number: 848146).Author SL has received Roche funding for unrelated work. The remining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pharmacovigilance using real-world data (RWD), such as multicenter electronic health records (EHRs), yields massively parallel adverse drug reaction (ADR) signals. However, proper validation of computationally detected ADR signals is not possible due to the lack of a reference standard for positive and negative associations.This study aimed to develop a reference standard for ADR (RS-ADR) to streamline the systematic detection, assessment, and understanding of almost all drug-ADR associations suggested by RWD analyses.We integrated well-known reference sets for drug-ADR pairs, including Side Effect Resource, Observational Medical Outcomes Partnership, and EU-ADR. We created a pharmacovigilance dictionary using controlled vocabularies and systematically annotated EHR data. Drug-ADR associations computed from MetaLAB and MetaNurse analyses of multicenter EHRs and extracted from the Food and Drug Administration Adverse Event Reporting System were integrated as “empirically determined” positive and negative reference sets by means of cross-validation between institutions.The RS-ADR consisted of 1344 drugs, 4485 ADRs, and 6,027,840 drug-ADR pairs with positive and negative consensus votes as pharmacovigilance reference sets. After the curation of the initial version of RS-ADR, novel ADR signals such as “famotidine–hepatic function abnormal” were detected and reasonably validated by RS-ADR. Although the validation of the entire reference standard is challenging, especially with this initial version, the reference standard will improve as more RWD participate in the consensus voting with advanced pharmacovigilance dictionaries and analytic algorithms. One can check if a drug-ADR pair has been reported by our web-based search interface for RS-ADRs.RS-ADRs enriched with the pharmacovigilance dictionary, ADR knowledge, and real-world evidence from EHRs may streamline the systematic detection, evaluation, and causality assessment of computationally detected ADR signals. An increasing number of studies have reported serious postmarket adverse drug reactions (ADRs) that were not discovered in Phase III clinical trials. Clinical trials are inherently limited in reflecting real-world settings where patients with diverse demographics and comorbidities take a variety of concurrent medications . Real-woComputational methods for massively parallel detection of almost all drug-ADR interactions using real-world data (RWD), such as claims and multicenter electronic health records (EHRs), are emerging as relatively unbiased approaches -16. HoweColoma et al  developeIn silico ADR detection using RWD is much faster than reference standard development relying on expert curations. RWD analysis can potentially provide a reference standard for ADR signal evaluation. A systematic application of controlled vocabularies with rich semantics is essential for in silico pharmacovigilance (PV) using RWD. The controlled vocabulary–based ADR signal dictionary (CVAD) integrated controlled vocabularies with EHR data to improve PV . The devFor prevention and management in PV, a strategy for integrating multiple data sources is preferred. Wei et al ,25 combiA key challenge in drug-safety surveillance, regardless of data source, is that publicly available, reliable, and sufficiently large reference standards are needed. Although no definitive reference standard contains a complete set of ADRs, we intended to aggregate information from multiple data sources to constitute a set. In this study, we developed a reference standard for ADR (RS-ADR) for the comprehensive, efficient, and pragmatic evaluation of computationally detected massive ADR signals from RWD. RS-ADR integrates EHR term–related standard ADR terminologies, including those from the Medical Dictionary for Regulatory Activities (MedDRA) preferred terms (PTs), WHO Adverse Reactions Terminology (WHO-ART), Logical Observation Identifiers Names and Codes (LOINC), and International Classification of Diseases 10th Revision (ICD-10). We created the RS-ADR by aggregating massively parallel results of RWD and cross-validations for the positive and negative cases extracted from a multitude of health care organizations. Other PV resources, including OMOP and EU-ADR reference standards, the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) , and SIDGiven the lack of a “gold standard” to evaluate true and false ADR signals detected from PV studies, many researchers have attempted to compose ad hoc “gold standard” sets. The practical databases used in the study for constructing RS-ADRs were SIDER 4.1, OMOP, and EU-ADR. SIDER 4.1 contains the numbers of drugs, ADRs, drug-ADR pairs, and drug frequency entries from various references . In addiA reference standard is essential for the evaluation of analysis results and systematic accumulation of evidence from comprehensive PV studies -31. TherA comprehensive annotation of controlled vocabularies that encompass disease classifications, laboratory tests, medications, and clinical narratives enables extensive EHR data exploration. Laboratory results have been used the most frequently for ADR signal detection in many studies. CVAD facilitates the use of a variety of data sources to detect ADR signals . ClinicaOMOP also provides a reference set, which is composed of 165 positive and 234 negative drug-ADR signal pairs, covering 53% of the 756 (189 × 4) pairs between 189 drugs and 4 ADRs . The refWe mapped the 4 ADRs of OMOP and the 10 ADRs of EU-ADR to 4485 MedDRA terms in SIDER 4.1 using MedDRA synonyms . We created a reference standard matrix for 1344 drugs and 4485 ADRs returning 6,027,840 drug-ADR pairs. The value of each cell of the reference matrix was filled with 0 for negative controls, 1 for positive controls, and 2 for unknowns. Negative controls were those known to not cause the outcomes, using case reports, case series, or observational evidence in OMOP and EU-ADR. Positive controls were extracted from the product labels in the US FDA “Black Box Warning” section in SIDER 4.1, OMOP, and EU-ADR .We benchmarked the analysis data from various institutions for PV  and inteWe evaluated the drug-ADR pairs of the MetaLAB and MetaNurse analyses from multiple EHRs and compared with FAERS for causality assessments as follows: certain, probable/likely, possible, unlikely, or conditional/unclassified . We applThis study was approved by the Institutional Review Board of Konyang University Hospital (IRB no 2019-08-018).The RS-ADR contained 1344 drugs and 4485 ADRs in terms of MedDRA PTs  and 4. TThe process from part 1 to 4 for RS-ADR construction is briefly summarized as follows: first, the drugs and ADRs to be targeted; in part 1, term code confirmation; in part 2, the identification of contents described in the existing reference set; in part 3, analysis by data source; and in part 4, causality evaluation through meta-analysis. P value). Parts 3 and 4 of the RS-ADR have a structure that allows researchers to add and update their results to improve the RS-ADR.To provide a semantically enriched ADR dictionary for postmarket drug safety research and enable multicenter EHR-based extensive ADR signal evaluation, we developed a web-based search interface for RS-ADR to explore drug-ADR associations  Figure . Figure In this study, we demonstrated the possibility of creating an RWD-based RS-ADR. We integrated various standard vocabularies to facilitate the use of different institutional EHR databases along with other PV resources, such as SIDER 4.1, OMOP, and EU-ADR. Integrative analysis of heterogeneous real-world clinical information requires a standard vocabulary to correctly interpret study results.The reference sets of OMOP and EU-ADR ,16 are dOur study has some limitations. SIDER 4.1 provides inadequate information about postmarket ADRs as it comprises public documents and package inserts. The 4 ADRs of the OMOP and 10 ADRs of the EU-ADR project may emphasize ADRs of more frequently or chronically used drugs, which are also clinically important. The use of integrative ADR references such as SIDER 4.1, OMOP, and EU-ADR in the RS-ADR complements the limitations of each resource. Although the RS-ADR went through interevaluator agreement, expert evaluation was substantially limited, and continuous review and updates are required. When integrated with multicenter and multinational data, RS-ADR becomes a meaningful RWE-based reference standard for evaluating ADR signals. Underlying the use of a reference standard for method evaluation is the assumption that negative controls are exchangeable with positive controls . Adding RS-ADR enriched with the PV dictionary, knowledge, and RWE can streamline the systematic detection, evaluation, and causality assessments of computationally detected ADR signals. Through RS-ADR, evidence related to ADRs can be prepared as much as possible before the clinical evaluation stage, and we could identify more cases based on actual medical center data—RWD. In addition, since we considered the standardization of terms for drugs and ADRs, it is highly useful when adding medical center or other resources in the future. It is applicable not only to ADR studies but also to a variety of health outcomes and health care database utilization studies.


The clinical response to cancer therapies involves the complex interplay between the systemic, tumoral, and stromal immune response as well as the direct impact of treatments on cancer cells. Each individual's immunological and cancer histories are different, and their carcinogen exposures may differ. This means that even though two patients with oral tumors may carry an identical mutation in TP53, they are likely to have different pre-existing immune responses to their tumors. These differences may arise due to their distinct accessory mutations, genetic backgrounds, and may relate to clinical factors including previous chemotherapy exposure and concurrent medical comorbidities. In isolation, their cancer cells may respond similarly to cancer therapy, but due to their baseline variability in pre-existing immune responses, patients can have different responses to identical therapies. In this review we discuss how the immune environment of tumors develops, the critical immune cell populations in advanced cancers, and how immune interventions can manipulate the immune environment of patients with pre-malignancies or advanced cancers to improve therapeutic outcomes. The local and systemic immune status of the patient plays a role in the response to conventional therapy for head and neck cancer (HNSCC). Therefore, it is critical to understand how the tumor develops both genetically and immunologically. It is in this context that this review examines the developing immune biology of HNSCC. While head and neck cancers can be found in the mucosal epithelium of the oral cavity, larynx, and pharynx, the oral cancers are predominantly associated with tobacco and alcohol use while tumors in the larynx and pharynx have been increasingly associated with HPV infection . In addi+ T cells in both the invasive margin (IM) and center of the tumor (CT) were associated with lower stage (T1 and T2 tumors) and increased CD8+ and CD4+ T cells in the invasive margin predicted lower risk of axillary metastases . We mayal blood  and Tormal blood ]. Therapex vivo . A failn tumors . DC are n tumors , 68. We n tumors –73. Thusn tumors . When imoutcomes . When cooutcomes . Checkpooutcomes , rendersoutcomes . T cell outcomes , with exoutcomes . As discoutcomes  and receoutcomes , 79. Thede novo T cell responses following antigen challenge [de novo immune responses to tumor-associated antigens, our most popular cancer immunotherapies serve to bring suboptimal T cells into the anti-tumor immune response. These data indicate the importance of regulating the activation of pre-existing T cells and improving the response of sub-optimal T cells that were formerly unable to functionally participate. In addition to exploiting pre-existing immunity to alter immune responses to growing tumors, we can restore the function of failed responses to expand tumor immune control. As we will discuss, this may in part account for the beneficial effect of autologous/expanded TIL therapy, and/or repeated infusion of expanded TIL-derived cell products [Of course, antagonist anti-CTLA4 and agonists such as anti-OX40 can act as vaccine adjuvants expanding hallenge –82. Thushallenge , 84. Thihallenge –89  for T cell mediated eradication of HPV16-associated tumors (NCT02858310) [Promising results from an NCI group, first reported in late 2018, used a gene-modified TCR-transduced adoptive T cell therapy (TCR-T) targeting HPV16 E7 protein –122 vira2858310) . Complet2858310) . Among t*02:01 restricted TCR-T therapy in combination with pembrolizumab for first-line recurrent/metastatic, HPV-agnostic HNSCC. This trial has since closed due to slow accrual of MAGE-A4 expressing & HLA-matched eligible participants (NCT03132922) [*02:01 restricted TCR-T therapy for treatment-refractory advanced solid tumors (NCT03686124) [In 2020, Adaptimmune reported the ADP-A2M4 single-arm, phase II pilot trial of MAGE-A4 targeted, HLA-A3132922) . In 20213686124)  at the S3686124) , 128, OSSystemic delivery of CAR-T targeting HNSCC surface antigens, to date been shown to be unsafe due to the unacceptable risk of on-target/off-tumor toxicities , 130. CAex vivo and in vivo proliferative kinetics; TCR affinity and signaling enhancements, membrane-anchored cytokines to promote in vivo persistence; conversion switches to couple an inhibitory cell surface receptor with a stimulatory cytosolic tail, and thus armor the cells for trafficking, survival and effector function on entry to a hostile TME. These cell-intrinsic enhancements undoubtedly will increase therapeutic efficacy. Nevertheless, the foremost challenge to TCR-based cell therapy approaches remains ineffective antigen presentation without which T cell-dependent immunotherapy, whether through immune checkpoint inhibitor or adoptive cell therapy, cannot exert an effect. MHC class I down-regulation and alterations in antigen processing and presentation are prevalent in HNSCC  [via MHC-independent mechanisms, have been proposed to overcome this challenge in HNSCC. NK-92 cells [in vitro in a PD-L1-dependent fashion [in vitro was able to salvage response and prevent clonal outgrowth of escape variant tumor cells [n = 55) of this triplet combination in 2nd line recurrent/metastatic HNSCC (NCT04847466). A potential advantage of CAR-NK cell therapy over CAR-T therapy is a very reduced incidence of graft vs. host disease due to limited longevity. Tracking studies indicate that PD-L1 t-haNK cells persist in tumors for up to 72 h, suggesting that to ensure the maintenance of cells in situ, weekly or more frequent dosing may be necessary.With the advent of widely available tumor sequencing, tumor neoantigen redirected T cell therapies  such as. These hlesions)  and are lesions) –158. Sevlesions) , 159 andlesions) –162 and lesions) . NK cell92 cells  engineer92 cells  and a se92 cells  , it is worthy to note here that the non-myeloablative conditioning regimen of cyclophosphamide/fludarabine (Cy/Flu)—which has modest activity in HNSCC , 179—hasactivity . Using tutgrowth . Standarutgrowth , and wasutgrowth . Future ex vivo to enhance tumor infiltration. Moreover, while the tumor blocks T cell function, ex vivo engineering can build resistance into the transferred cells. Finally, where antigen presentation is a limitation, exploiting NK cell therapy or the effects of combination with conventional therapies may improve the visibility of tumors to the immune system [Together, these data indicate that even where tumors are poorly infiltrated with tumor-specific T cells, such cells can be engineered e system –187. At e system , 189. ThAlmost every category of immunotherapy has proven effective in controlling HNSCC tumors in pre-clinical models. These include innate adjuvants, T cell checkpoint inhibitors, T cell costimulators, adoptively transferred T cells, myeloid regulatory targets, vaccines, and a wide range of alternative immune focused therapies. Despite this, there are only a handful of approved immunotherapies for HNSCC in the clinic. It is normal to see promising pre-clinical therapies fail in clinical trials, but it is always valuable to understand the biology behind the wide difference between successes in pre-clinical models and clinical trials.Firstly, there is a significant impact of pre-clinical model selection. Some tumor models are more responsive to treatment than others. In part this is explained by immunogenicity , where sex vivo patient-derived modeling. Simple tumor explant models can provide a rapid readout of patient-specific responses to immunotherapy agents [ex vivo response of small fragments of fresh tumor tissue can have predictive power for patient responses to the same therapy [Due to the complexity and impracticality of testing multiple agents in patients to evaluate their ability to change the tumor immune environment from a negative to a positive state, we may need to turn to y agents –202. In  therapy , 204. WeAs we have discussed, pre-malignancy represents the first opportunity for intervention to alter the course of disease  and thisTD, MG, RL, and SS were jointly responsible for the preparation, writing, and editing of the manuscript and figures. All authors contributed to the article and approved the submitted version.This work was supported by NCI R01CA182311, NCI R01CA244142, and by the Providence Foundation.RL receives research funding from Clinigen, Incute, Celldex, and Bristol Myers Squibb. MG receives research funding from Bristol Myers Squibb and VIR Biotechnology. SS receives research funding from IMV Inc. and consulting fees from Stanford Burham Prebys Medical Discover Institute. Funders had no role in the preparation of the manuscript. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.