Besides using our labelled dataset for model training, we also employed the Global Wheat Head Detection dataset to incorporate varietal features into the DL models, facilitating us to perform reliable yield-based analysis from hundreds of varieties selected from main wheat production regions in China. Finally, we employed the SNpM2 and performance traits to develop a yield classification model using the Extreme Gradient Boosting (XGBoost) ensemble and obtained significant positive correlations between the computational analysis results and manual scoring, indicating the reliability of CropQuant-Air. To ensure that our work could reach wider researchers, we created a graphical user interface for CropQuant-Air, so that non-expert users could readily use our work. We believe that our work represents valuable advances in yield-based field phenotyping and phenotypic analysis, providing useful and reliable toolkits to enable breeders, researchers, growers, and farmers to assess crop-yield performance in a cost-effective approach.As one of the most consumed stable foods around the world, wheat plays a crucial role in ensuring global food security. The ability to quantify key yield components under complex field conditions can help breeders and researchers assess wheat’s yield performance effectively. Nevertheless, it is still challenging to conduct large-scale phenotyping to analyse canopy-level wheat spikes and relevant performance traits, in the field and in an automated manner. Here, we present CropQuant-Air, an AI-powered software system that combines state-of-the-art deep learning (DL) models and image processing algorithms to enable the detection of wheat spikes and phenotypic analysis using wheat canopy images acquired by low-cost drones. The system includes the YOLACT-Plot model for plot segmentation, an optimised YOLOv7 model for quantifying the spike number per m Yield performance is in the heart of breeding, crop research and agricultural practices . The abiTriticum aestivum) as our model plant, a key staple food in China and many countries around the world. Global wheat consumption reached 793 million tons in 2021/22 (2), grain number per spike (GNpS), and thousand grain weight (TGW) were often utilised  based plant phenotyping has been developed rapidly in the past decade . Due to The above research made valuable progresses in yield-based aerial phenotyping. Still, much research aimed to establish relationships between physiological parameters  with yield production, which were useful proxies but did not provide a direct yield-based measure . Due to The above methods verified that DL-based approaches could bring unique values to the detection of key yield components such as wheat spikes under field conditions. Nevertheless, due to the complex field conditions and the large-scale nature of field trials, ground-based stationed phenotyping devices were rather limited if hundreds of plots needed to be examined. Consequently, drone-based field phenotyping was likely to bridge the gap between accuracy and scalability in yield-based studies . While t2 trait. Moreover, we have included a range of image processing algorithms in CropQuant-Air to conduct canopy-level trait analysis using spectral and textural features possessed by the aerial images. To verify the CropQuant-Air system, we applied it to a field experiment studying 210 wheat varieties  selected from main wheat production regions in China. Besides the analysis of the SNpM2 and canopy-level traits, we also developed the Extreme Gradient Boosting (XGBoost) ensemble , Shandong (North China), and Henan . These lines were known for their dissimilar yield performance and different spike morphologies , which w2 (GPpM2), and thousand grain weight . The yield data was manually classified into three groups  according to protocols previously published , which could control small drones . After verifying the image resolution for AI-powered detection as well as the speed of drone phenotyping, we chose to fly the drone to image wheat canopy from an overhead perspective at a 4-m altitude during late flowering and early grain filling stages, so that we could accomplish the aerial imaging within 30 minutes and with AI-compatible wheat imagery , where an open and diverse dataset of wheat spikes were labelled from RGB images for developing and benchmarking ML/DL models. In order to improve the generalisation and accuracy of our AI-powered wheat spike detection algorithm, we combined GWHD and our wheat-spike training data with image augmentation techniques to train the YOLOv7  based whWe developed a three-step algorithmic workflow to incorporate computer vision and DL algorithms into the plot-based trait analysis: (1) a YOLACT-Plot segmentation algorithm .The YOLACT++ model was an enhanced fully-convolutional model built for real-time instance segmentation. We adopted its learning architecture and built the YOLACT-Plot model to identify wheat plots within aerial images. The YOLACT++ network was composed of a ResNet101 backbone network to extract features from input images, generating five feature maps  to the Res2Net module . The CBAwhere The spatial attention component used the input feature map where k-prototype masks with varying regional responses from the P3 feature map  and the above attention mechanism, P3-P7 sub-feature maps were fed into two parallel branches to perform plot detection: (1) the ProtoNet branch . As a result, we chose the Standard version of YOLOv7 due to the easiness of the software deployment and reasonable computational cost. The detailed implementation of other versions of YOLOv7 (e.g. Tiny and W6) can be found via We built a workstation  to conduct the DL training. Both PyTorch (v1.11) framework  and PythWe selected average precision (AP) as the performance metric to evaluate the segmentation result. AP was calculated using Eqns. 9-11. To ensure a comprehensive evaluation of the performance of the DL models, AP50 , AP75 (IoU = 0.75), and the mean Average Precision (mAP) were employed since the selection of IoU could influence the precision and recall scores.TP denotes the number of samples where the predicted category of the model matches the true labelled category; FP indicates the number of samples where the predicted category does not match the true labelled category; FN denotes the number of samples where the predicted category is the background, but the true labelled category are other categories.where FLOPs). Since the activation functions and biases affect the calculation of FLOPs, different calculations were performed. To ensure consistency of our analysis, we used PyTorch’s third-party library, Thop  for nonexperts. The CropQuant-Air GUI followed a modular architecture and implemented using the Python programming language. The cross-platform GUI (in EXE) integrated the above trained AI models and trait analysis algorithms into a stepwise software system and was developed using the Tkinter library . To impl2, NDYI, ExR, VARI, canopy coverage, ASM and GLCM dissimilarity) as input parameters and the manually measured yield production (i.e. GPpM2 and TGW) as targets. After testing a range of supervised ML models, we chose a stochastic gradient boosting algorithm, extreme gradient boosting (XGBoost) ensemble, as it provided the best performance compared with other supervised ML classifiers. When training the model, we fine-tuned the hyperparameters of the XGBoost model, including the number of trees, tree depth, learning rate, the number of samples, and the number of features. A grid-based search was employed to fine-tune the model to yield optimised hyper-parameters, followed by a combination of parameters with reasonable ranges of parametric values to simplify the procedure. Finally, k-fold cross-validation was adopted to evaluate the model performance, based on which the model with the best accuracy was selected. The above algorithmic steps and software implementation were performed using the Scikit-Learn library and saved in a separate executable Jupyter notebook, which can be downloaded from our GitHub repository.In order to train a ML-based model to classify yield production, we used the seven traits produced by the CropQuant-Air , covering the 210 varieties. During post-harvest handling, plot-based yield production, GPpMst and 2nd experiments suggested that the introduction of the Res2Net module in the backbone network improved the mAP of the prediction frame (2.35%) and mask (1.76%); whereas the 2nd and 3rd experiments indicated that the Res2Net-CBAM module improved the mAP of the prediction further , with slightly decrease in speed .We applied the YOLACT-Plot model to identify the central plot in a given aerial image , which cFLOPs before and after the optimisation, suggesting that the YOLACT-Plot model improved in the network parameters (9.8%), model size (1.06%), and FLOPs (6.7%) compared with a standard YOLACT++ model.With an improved backbone network, features from different channels of the same feature layer were combined for multiple times, facilitating the extraction of semantic information while leading to an increase in the size and parameters of the model. To further evaluate the YOLACT-Plot model in instance segmentation, we compared the model with several state-of-the-art instance segmentation DL algorithms such as Mask R-CNN, SOLOv2, and YOLACT++ . Our whe2) was computed to evaluate correlations between the CropQuant-Air-derived and manually scored spike numbers together with root-mean-square error (RMSE), resulting in R2 = 0.981  in a table at the bottom of the workspace  that enables non-expert users to perform plot-based trait analysis using an aerial image selected through a unified workspace. A user selects the image selection section , Eastern  and Northern wheat varieties , the distribution for Northern varieties was much more diverse  also had a much broader distribution in the selected Northern varieties  and textural traits . The dataset together with the variety-based yield production data  was then divided into 7:3 ratio, with 70% (147 lines) for training and 30% (63 lines) for testing. When applying the XGBoost learning model to classify yield production, we performed cross-validation in each round of Boosting iteration, enabling the optimal iteration number  for the SNpM2 trait, spike density of high-yield varieties largely located in the 375-500 region, whereas medium- and low-yield groups had a more diverse spike density; also, low-yield varieties on average had a lower SNpM2 value with many low values absent from the other two groups  from an aerial image, within which spikes were detected. This progressive algorithmic approach helped us establish an effective workflow to batch-process aerial image series, improving the productivity of the analysis solution presented here. More interestingly, we incorporated spectral and textural features and semantic information of wheat spikes into the model training, which achieved the best detection accuracy compared with seven state-of-the-art DL models, demonstrating a valuable attempt that combined plot- (i.e. the YOLACT-Plot model for instance segmentation) and spike-level (i.e. the optimised YOLOv7 model for semantic segmentation) DL techniques with traditional image processing algorithms to quantify key yield components. To verify the AI-powered trait analysis, we further evaluated the computational results with both manually scored spike number and yield production, resulting in highly significant correlations and thus the reliability of our phenotypic analysis pipeline.In our study, we demonstrated that low-cost drones could be utilised to perform standardised aerial imaging to collect canopy-level wheat spikes at key growth stages, whose quality was sufficient for AI-powered plot and spike detection, as well as yield-based classification. To quantify the SNpMTo enable non-experts to use our solution, we developed an open-source software system called CropQuant-Air, which integrated DL models and image processing algorithms to perform plot-based spike detection, as well as spectral and textural trait analysis with a batch-processing mode. Due to limited toolkits available for nonexperts to examine multigenic traits and develop markers , we deve2 trait contributed the most in yield classification and hence the most important factor for yield-related prediction in wheat. Also, subsequent improvements to the ensemble model could include spikelet density, historic yield records, growth stages, and key environmental factors such as ambient temperature and accumulated temperature  of the system, which required us to publish new versions of the executive file if new functions or dependencies were updated. As a result, a community-driven solution might be valuable to develop and improve CropQuant-Air, promoting open and easy-to-use software solutions jointly via the GitHub platform, which could also maximise the impacts of open scientific software R&D in a collaborative manner.Besides the desktop implementation of CropQuant-Air, we could consider deploying the analysis pipeline onto the cloud-based and/or edge computing, so that the software solution could be utilised for different breeding and crop research scenarios. New hardware is also likely to support near real-time analysis based upon our phenotypic analysis solution, providing more economic and powerful tools for agricultural practitioners and researchers. So, key yield-related analysis could be obtained to benchmark yield potential, comparing the performance of different crop varieties and identifying varieties with higher yields under field conditions.This could also be valuable when identifying crop varieties that were better adapted to local environmental conditions, leading to less water, fertilisers, and other agronomic inputs, which will help growers and farmers reduce the environmental footprint while still maintaining yields. Finally, through big data analytics and cost-effective hardware, much labour-intensive crop surveillance activities could be greatly benefited, facilitating Agri-Food and Agri-Tech companies, policymakers to determine the economic viability of recommended varieties in changing environments, which could also help assess the potential commercial value of the selected varieties so that sound and affordable agricultural production could be promoted.https://github.com/The-Zhou-Lab/CropQuant-Air/releases/tag/v1.0. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Other data and user guides are openly available on request.The testing datasets, Jupyter notebook, and CropQuant-Air software used in this paper are available at the Zhou lab’s GitHub repository: JiZ and JC wrote the manuscript with inputs from all the authors; QL, HL, YX, and RJ conducted field experiments and aerial phenotyping under JiZ, GZ, and DJ’s supervision; JiZ, GD, RJ, QL, and JC performed data analysis and statistical analysis; JieZ, JC, GS, and QL built and tested the deep learning models, trait analysis, and the yield classification model under JiZ and DJ’s supervision. JieZ and JC developed the GUI of the CropQuant-Air system with help from GS. JC, JieZ, and QL contributed equally to this work. All authors contributed to the article and approved the submitted version.


There is limited understanding of barriers to participation in pediatric qualitative research, particularly for studies seeking to understand diseases primarily affecting marginalized and hard-to-reach populations.We conducted a retrospective cohort study of participants and non-participants invited to enroll in a qualitative study of pediatric tuberculosis (TB) infection care. Potential participants in the initial study were adult caregivers of children diagnosed with TB infection between 2016-2021 in Boston. Most children were immigrants or children of immigrants, and all caregivers were English- or Spanish-speaking. We sent letters in English and Spanish to patients’ primary caregivers, and followed up with up to 2 phone calls. Enrolled participants completed a virtual qualitative interview. We compared characteristics of individuals who participated vs did not participate, and summarized reasons for non-participation.Of 61 invited caregivers, 19 (31%) enrolled in the initial qualitative study. Table 1 compares characteristics of participants and non-participants. The primary reason for non-participation was inability to contact caregivers . A total of 11 (26%) caregivers declined participation, and 4 (10%) participants were unable to join or complete interviews after initially agreeing to participate. Non-completion of TB infection care was significantly associated with non-participation in the qualitative study (P=0.049). We did not observe significant differences by language, insurance, relationship of caregiver to patient, or time from diagnosis to study invitation between participants and non-participants.Inability to contact potential participants, participants’ lack of time, and lack of shared illness understanding posed barriers to recruitment in this qualitative study. Our findings suggest that alternative contact strategies , use of short interviews, and strategies to rapidly communicate illness scripts should be studied to improve inclusion in similar studies. While we were able to enroll participants who had not completed TB infection care, additional methods are needed to obtain qualitative perspectives from individuals who disengage from care.Jessica Haberer, MD, MS, Merck: Advisor/Consultant


Among patients with a history of ESBL infection, uncertainty remains regarding whether all of these patients require ESBL-targeted therapy when presenting with a subsequent infection. We sought to determine the risks associated with a subsequent ESBL infection to help inform empiric antibiotic decisions.Escherichia coli or Klebsiella pneumoniae (EC/KP) receiving medical care during 2017 was conducted. Risk assessments were performed to identify factors associated with subsequent infection caused by ESBL-producing EC/KP.A retrospective cohort study of adult patients with positive index culture for P = .428). Factors associated with subsequent infection caused by ESBL-producing EC/KP include history of ESBL-producing index culture, time ≤180 days between index culture and subsequent infection, male sex, and Charlson comorbidity index score >3.In total, 200 patients were included in the cohort, 100 with ESBL-producing EC/KP and 100 with ESBL-negative EC/KP. Of 100 patients (50%) who developed a subsequent infection, 22 infections were ESBL-producing EC/KP, 43 were other bacteria, and 35 had no or negative cultures. Subsequent infection caused by ESBL-producing EC/KP only occurred when the index culture was also ESBL-producing (22 vs 0). Among those with ESBL-producing index culture, the incidences of subsequent infection caused by ESBL-producing EC/KP versus other bacterial subsequent infection were similar (22 vs 18; History of ESBL-producing EC/KP culture is associated with subsequent infection caused by ESBL-producing EC/KP, particularly within 180 days after the historical culture. Among patients presenting with infection and a history of ESBL-producing EC/KP, other factors should be considered in making empiric antibiotic decisions, and ESBL-targeted therapy may not always be warranted. Klebsiella pneumoniae and Escherichia coli, are common gram-negative bacterial pathogens that produce ESBLs. ESBL-producing Enterobacterales confer resistance to third-generation cephalosporins, extended-spectrum penicillins, and aztreonam. An increasing amount of ESBL-producing bacteria are also associated with resistance to other antimicrobial classes such as fluoroquinolones, aminoglycosides, and tetracyclines. In 2019, the US Centers for Disease Control and Prevention (CDC) reported that ESBL-producing Enterobacterales are associated with nearly 197,000 healthcare-associated infections and 9,100 deaths each year. In a recent study of meropenem versus piperacillin-tazobactam in the treatment of bloodstream infections caused by ceftriaxone nonsusceptible K. pneumoniae or E. coli, noninferiority of 30-day mortality was not achieved, with results favoring meropenem. For these reasons, infections caused by ESBL-producing Enterobacterales are increasingly difficult to treat empirically. They contribute to the use of broad-spectrum antibiotics, and they are considered a national and global health concern.Extended-spectrum β-lactamase (ESBL) enzymes are characterized as a clinically relevant resistance mechanism produced by gram-negative bacteria. Enterobacterales, such as  Once a patient is infected with an ESBL-producing Enterobacterales, the likelihood of subsequent infection caused by ESBL-producing Enterobacterales is unknown, although history of antibiotic resistance has been shown to confer risk of the same antibiotic resistance in subsequent infections. If a patient has a history of ESBL-producing EC/KP, empiric therapy with a carbapenem has become common practice in hospitals. With rising rates of infection caused by ESBL-producers, there is concern that overuse of carbapenems will contribute to escalating rates of resistance. In this study, we evaluated the microbiology of infections among patients with a history of ESBL-producing EC/KP. Specifically, we sought to determine the likelihood of having a subsequent infection caused by ESBL-producing E. coli or K. pneumoniae.Prior studies have identified risk factors associated with infection caused by ESBL-producing Enterobacterales, such as major surgery, previous antimicrobial exposure, indwelling catheters, intubation or tracheostomy, prolonged hospital or intensive care unit (ICU) stays, residency in long-term care facilities, and cancer.E. coli and/or K. pneumoniae (EC/KP) during calendar year 2017 were eligible. These patients were randomly selected and evaluated for inclusion from a report generated by the EMR software up to 100 patients that met criteria. For analysis purposes, an equal number (100) of patients were identified who had a clinical specimen culture in 2017 positive for EC/KP and negative for ESBL production. These cultures were considered the index cultures for these patients.This retrospective cohort study was conducted at Wake Forest Baptist Health (WFBH), a health system that includes an 885-bed, academic, tertiary-care hospital in Winston-Salem, North Carolina, 4 affiliated community hospitals, and a network of clinics. Inpatients and outpatients at least 18 years of age receiving care within the WFBH system and whose electronic medical record (EMR) included a clinical specimen culture positive for ESBL-producing Patients were excluded if they had a culture positive with EC/KP within 1 year prior to the index culture, regardless of ESBL result. Each patient was included only once. If a patient had EC/KP isolated on multiple occasions in 2017, the first episode in the calendar year was deemed the index culture. Data were collected by review of the EMR for a 1-year follow-up period after the date of index culture, including information about any subsequent infections, antibiotics administered, demographic information, immune status, Charlson comorbidity index score, and laboratory information, including culture and susceptibility data. Subsequent infections were considered clinically significant and included in the analysis only if the treating provider prescribed an antibiotic. Patients with index cultures positive for ESBL-producing EC/KP were compared to those with index culture positive for EC/KP but negative for ESBL. or Fisher exact test. The Mann-Whitney U test or Student t test was utilized for ordinal and continuous data, depending on the distribution. A 2-sided P ≤ .05 was considered statistically significant. In univariate analysis, patients with subsequent infection caused by ESBL-producing EC/KP were compared to all other patients, a combined group of those with subsequent infection caused by a different pathogen and those without subsequent infection. Factors analyzed included age, sex, Charlson comorbidity index score, time from index culture to subsequent infection, and antibiotics received in the 90 days before subsequent infection. In analyzing time from index culture to subsequent infection, patients without subsequent infection were censored at the end of the observation period (365 days).Comparisons for categorical data were performed using the χMultivariable logistic regression analysis was performed to determine risk factors independently associated with subsequent infection caused by ESBL-producing EC/KP. To assess the likelihood of subsequent infection caused by ESBL-producing EC/KP among those with ESBL-producing index culture, a logistic model was fit using maximum likelihood. Restricted cubic splines were used to relax the linearity assumptions on the effect of time. Covariates were selected from a prespecified list to optimize the c-index of the model, and 500 bootstrap samples were used for model validation and calibration. Statistical analyses were performed using R software version 4.0.2 software.To further explore the risk of developing a subsequent infection caused by ESBL-producing EC/KP, we performed time-to-event analyses. An event was defined as subsequent infection caused by ESBL-producing EC/KP. Study participants were censored at day 365 if no subsequent infection caused by ESBL-producing EC/KP occurred. To investigate the unadjusted incidence of subsequent infection caused by ESBL-producing EC/KP, we utilized a Kaplan-Meier approach, and a log-rank test was performed to assess differences between the groups.In total, 8,560 patients with a culture containing ESBL-negative EC/KP in 2017 and 629 patients with a culture containing ESBL-producing EC/KP in 2017 were initially identified. Furthermore, 144 of the 629 patients with ESBL-producing EC/KP, and 117 of the 8,560 patients with ESBL-negative EC/KP underwent screening for inclusion. However, 43 patients with cultures positive for ESBL-producing EC/KP and 12 patients with ESBL-negative cultures were excluded due to having a positive EC/KP culture within the prior year. Also, 1 patient with ESBL-positive culture and 5 patients with ESBL-negative culture were excluded due to age <18 years at the time of specimen collection, leaving 200 patients selected for the study . A greater percentage of culture-positive subsequent infections caused by ESBL-producing EC/KP occurred within 180 days of index culture compared to subsequent infections not caused by ESBL-producing EC/KP: 21 (96%) of 22 versus 26 (60%) of 43, respectively (P = .003).Within 1 year of index culture, 100 patients (50%) developed a subsequent infection; 65 subsequent infections were positive upon bacterial culture. Among them, 22 were caused by ESBL-producing EC/KP, 43 were caused by bacteria other than ESBL-producing EC/KP, and 35 had a negative culture or no culture was performed in association with the subsequent infection . The mean times from index culture to subsequent infection caused by ESBL-producing EC/KP versus those caused by a bacteria other than ESBL-producing EC/KP were 85 days  and 140 days , respectively (P = .091) and had higher average Charlson comorbidity index score . Additionally, the mean days between index culture and subsequent infection was significantly longer in patients whose bacterial subsequent infection was not ESBL-producing EC/KP: mean, 140 days (95% CI ±104) versus 85 days .Table P < .0001).Figure The results of univariate and multivariable analyses are shown in Table E. coli and Klebsiella is rising throughout the United States. Carbapenems are generally considered the drugs of choice for serious infections caused by ESBL-producing Enterobacterales. However, mounting utilization of carbapenems to treat infections caused by ESBL-producers has led to increased prevalence of carbapenem-resistant Enterobacterales in the United States and worldwide. Many institutions restrict the use of carbapenems out of concern for the development of carbapenem resistance. Preference at these institutions is given to other broad-spectrum antibiotics such as piperacillin-tazobactam and cefepime. Yet, these antibiotics are not reliable as treatment of serious infections caused by ESBL-producing EC/KP, particularly bloodstream infections. It is imperative to describe what factors are important in determining which patients are most likely to have infection caused by ESBL-producing EC/KP so that optimal outcomes are preserved by appropriately selecting a carbapenem as empiric treatment, even if restrictions are in place, while minimizing unnecessary use of carbapenems to delay the development of resistance. This study has identified the factors that clinicians can use in making these difficult decisions about who should receive an empiric carbapenem.The incidence of ESBL-producing  However, we identified a timing effect that influenced the likelihood of having infection caused by ESBL-producing EC/KP. Specifically, the risk of having ESBL-producing EC/KP was significantly reduced if the historical infection was >180 days prior. Based on this information, it is reasonable to consider noncarbapenem antibiotics when choosing empiric therapy for those patients whose historical infection was >180 days prior. Male sex and Charlson comorbidity index scores >3 were also positively associated with infection by ESBL-producing EC/KP. The latter is not surprising because other studies have recognized the impact of comorbid conditions on risk of infection caused by resistant organisms. As such, empiric carbapenem therapy may be more appropriate for medically complex patients with multiple underlying disease states but particularly if the patient also has history of ESBL-producing EC/KP within the past 180 days.Prior infection with ESBL-producing EC/KP was a strong predictor of ESBL infection in our study. Certainly, it is considered best practice to review prior cultures and history of resistant organisms when deciding on empiric antibiotic therapy for patients presenting with signs and symptoms of infection. colonization with an ESBL-producing organism did not persist indefinitely. In fact, this study demonstrated a median duration of colonization that closely aligns with the 180-day time course identified in our study. Among patients with bloodstream infection, researchers have noted a steadily declining trend in the positive predictive value of historical, nonsurveillance ESBL cultures as time increases since the historical culture. It stands to reason that colonization with an ESBL-producing organism would precede infection with that organism and that any change in colonization status over time would result in a change in risk of infection by that organism.Why the risk of infection caused by ESBL-producing EC/KP decreases over time among patients with a prior ESBL-producing EC/KP culture is not obvious, but colonization may be an important contributor to this trend. In a study by Birgand et al, Additionally, inappropriate use of broad-spectrum antibiotics, such as carbapenems, leads to excess risk of C. difficile infections. For these reasons, many antimicrobial stewardship programs at hospitals either develop guidelines to direct the use of carbapenems or they limit use via prior authorization (restriction) processes. Results from this study have compelling implications for how hospital providers and stewardship team members approach clinical decision making regarding empiric carbapenems. It is not sufficient to say that all patients without a history of ESBL-producing EC/KP should not receive an empiric carbapenem. Indeed, we did not assess the risk of having an ESBL-producing EC/KP among patients presenting with their first EC/KP infection. Furthermore, as the incidence of ESBL-positivity among EC/KP continues to trend upward, the risk of having a first EC/KP infection that is ESBL-producing will also rise. However, results of this study add to our knowledge of patient-specific factors that influence risk of infection caused by ESBL-producing EC/KP. Clinicians may find these results useful as another tool in deciding which patients are most appropriate to receive an empiric carbapenem, ultimately with the goal of preserving the future utility of carbapenems, vis-à-vis preventing carbapenem resistance from developing.Indiscriminate use of carbapenems is associated with higher rates of carbapenem resistance among gram-negative bacteria. Similarly, this study included a significant proportion of outpatients. A health-system stewardship worker may not feel completely comfortable extrapolating these results to their patient population. However, a separate study analyzing usefulness of prior cultures to predict resistance among hospitalized patients with bloodstream infection documented declining positive predictive value over time since historical culture. The results of this study may not be applicable to locations where the rate of ESBL-producing EC/KP is significantly different from that of WFBH. In addition, we analyzed ESBL-producing E. coli and K. pneumoniae collectively and exclusive of other resistant bacteria. It is unknown whether our findings have implications for the management of other bacteria harboring ESBL enzymes or whether there is a difference specifically between ESBL-producing E. coli and ESBL-producing K. pneumoniae. Access to medical records outside of the WFBH system was limited. Therefore, it is possible that a patient had an infection and received treatment that was not reflected in the data collected. Lastly, the retrospective nature of this study relies on accuracy of documentation in the EMR.This study had several limitations. Although ESBL-producing bacteria are commonly isolated from the genitourinary tract, this study had relatively low representation of isolates from nonurinary sources. Future studies should aim to determine whether the findings of this study are applicable across all anatomic sources of infection because this may be a factor contributing to clinical outcomes.In conclusion, history of positive culture for ESBL-producing EC/KP is associated with subsequent infection caused by ESBL-producing EC/KP. However, the results of this study demonstrate that other factors should weigh in the decision to use an empiric carbapenem for these patients. Patients presenting >6 months after historical culture with ESBL-producing EC/KP have substantially lower risk of infection caused by ESBL-producing EC/KP. For this reason, clinicians and stewardship workers should consider noncarbapenem antibiotics for empiric therapy of these non–life-threatening subsequent infections. Other factors, such as male sex, comorbidities, and severity of illness should also be considered when making antibiotic decisions. Nonetheless, the categorical use of empiric carbapenems for all patients with historical cultures of ESBL-producing EC/KP is not warranted. An approach to choosing empiric antibiotic therapy in these patients based on the factors identified in this study serves as another avenue to limit the development of resistant bacteria.


Accurate localization of multi-focal ground-glass opacities (GGOs) is crucial for successful video-assisted thoracoscopic surgery (VATS). Electromagnetic navigation bronchoscopy (ENB) provides a minimally invasive and dependable approach for precise localization. This study assessed the accuracy and safety of ENB-guided localization in cases involving multi-focal GGOs.This retrospective study presents a single-center investigation into ENB-guided localization, utilizing methylene blue, for multi-focal GGOs assisting VATS. Clinical, surgical, and pathological data were collected from patients who underwent ENB-guided localization between 23 December 2019 and 31 August 2022.The study examined 57 patients with multi-focal GGOs who underwent ENB-guided localization and VATS. A total of 150 GGOs were treated, with ENB-guided localization taking a median time of 65 min. Following localization, all patients proceeded to VATS, with a median duration of 170 min. The median lesion size measured 7.8 mm, with a 5-mm distance between GGO and pleura or fissure. When the distance between GGO and pleura/fissure exceeded 1 cm, an additional location point was introduced below the pleura or fissure based on GGO location. No complications related to localization were observed. The overall malignancy rate stood at 66%. Location precision was confirmed by measuring the marker-to-GGO lesion distance, resulting in a 94% (141/150) accuracy rate for GGO localization.ENB-guided methylene blue injection is a safe and precise method to treat multi-focal GGOs, potentially minimizing operation time and simplifying lesion detection. With the development of high-resolution chest CT, it has become evident that a large population of patients is being diagnosed with multi-focal ground-glass opacities (GGOs) . The prePreoperative localization of pulmonary nodules, especially GGO, has been widely used in clinical practice, for video-assisted thoracic surgery in particular . The useThis study was approved by the Ethics Committee of Tongji Medical College of Huazhong University of Science and Technology . Informed consent was waived because of the retrospective nature of the study. We retrospectively collected clinical data from consecutive patients with multi-focal GGO who had undergone ENB-guided localization combined with VATS in the Thoracic Surgery Department of Tongji Hospital from 23 December 2019 to 31 August 2022. Inclusion criteria were as follows: more than two GGOs on chest CT; the predominant lesion, with highly suspicious imaging signs of malignancy, should fulfill either of the following criteria: i. diameter exceeding 10 mm for pure GGO and ii. no size alteration or growth over a minimum of 3 months; residual GGOs’ diameter over 6 mm; without any intra-pulmonary or organ metastasis evidences and surgical candidacy; agreement to receive ENB-guided localization; more than two GGOs located using ENB and then resected using VATS. Clinical, radiographic, surgical, and pathological data were collected. Details on a located GGO including its size, distance to the pleura, time for localization, accuracy of localization, and pathological diagnosis were obtained for analysis.All ENB procedures used the superDimensionTM navigation system version 7.0 with manufacture’s instruction. Patients underwent chest CT within 1 week before surgery  for continuous variables and as the total number (percentage) for categorical variables. All statistical analysis was performed using SPSS (version 27).A total of 57 patients received ENB-guided localization and VATs from 23 December 2019 to 31 August 2022. In this cohort, all 57 patients had multiple GGOs, and more than two GGOs were resected in each case under the localization of ENB. Patient characteristics are shown in Information on the nodules is shown in in situ, 23 of atypia, and 28 were benign lesion or negative for malignancy.Pathological results are shown in Information on postoperative complication is shown in Each lesion was cut open to judge the accuracy of localization. When there was no overlap between the dye-mark and the lesion, mislocalization was assigned. Data on localization accuracy are shown in in situ, and R4 was a minimally invasive adenocarcinoma.A 50-year-old patient was diagnosed with multi-focal GGOs in his right lung. ENB-guided localization of multi-focal GGOs has been demonstrated as a safe and effective diagnostic technique, as recent studies suggest. Performing ENB during VATS yielded good diagnostic results in the preoperative phase, according to the study. ENB-guided localization was not only highly accurate (94%) but proved not to carry, so common in thoracic surgery, such severe complications as persistent pain, pleural reaction, subcutaneous emphysema, hemorrhage, pneumothorax, or hemothorax. Moreover, accurate localization of lesions enables the resection of each, even the deepest multi-focal GGOs. Our results suggest that ENB-guided localization combined with VATS could be a reliable treatment for multi-focal GGOs.The rampant advancement of high-resolution CT has led to a great increase in the number of primary lung cancer cases diagnosed within the population . HoweverIdentification and localization of GGOs are one of several challenges presented by the surgical treatment for patients with multi-focal lesions. Detecting and precisely pinpointing multi-focal GGOs can be intricate, particularly when they are small or widely distributed. Accurate localization is critical to the complete removal of pathological lesions and minimizing the risk of spreading to adjacent tissues . VariousThe inaccuracy rate of CT-guided localization ranges from 0% to 10.3%, according to several studies , 22–24. Overall, a highly supportive role of ENB-guided localization in uni-portal VATS is greatly corroborated by our results. The median time of VATS was only 170 min, for resecting multiple GGOs. We sharply reduced the time during which the surgeon could find the exact GGO for resection. Even in mislocated GGOs, surgeon usually spent less than 2 min on finding the specific lesion. Likewise, the aforementioned observation that multi-focal GGOs would indicate a synchronous primary NSCLC was substantiated by the results of the postoperative pathological evaluation in our study. The overall malignant rate in all 150 nodules was 66%.Our findings seem to make a significant impact on the widely approved operative mode for multi-focal GGOs. To the best of our knowledge, this is the most extensive study to date that assesses preoperative ENB-guided localization of multi-focal GGOs combined with uni-portal VATS. There are also some limitations to our study. First, this is a retrospective study with inevitable intrinsic shortcomings. Second, the cost of ENB-guided localization is greater than that of CT-guided localization, which may be an inhibitory effect on promoting this technique in clinical practice. Third, although high-resolution chest CT may support ENB-guided localization to increase the accuracy, ENB may still mislocalize GGOs as many lesions do not have a CT bronchus sign. Hence, the whole procedure of ENB-guided localization should be performed carefully so that to increase the accuracy, which is crucial in uni-portal VATS. Although the findings of our study corroborated the theory of a useful role of ENB-guided localization during VATS, a further study carried out on more multi-focal GGO would confirm diagnostic value of using the two techniques simultaneously during one procedure.Our study demonstrated that ENB-guided localization of multi-focal GGOs has a great enhancing effect on the performance of uni-portal VATS, with no related complications. This is an effective technique to sharply reduce the operation time and to aid in the “blanket” resection and effective treatment for multi-focal GGOs as well as to make the accurate pathological evaluation of specific lesions. Our results are of promising clinical relevance and should be validated by a larger sample size. Further investigation and clinical practice are needed to increase the efficacy of ENB-guided localization of multi-focal GGOs during VATS.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The studies involving humans were approved by the ethic committee of Tongji Medical College of Huazhong University of Science and Technology. The studies were conducted in accordance with the local legislation and institutional requirements. The 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.CZ: Writing – original draft. GY: Writing – original draft. LW: Project administration, Writing – review & editing. JHW: Project administration, Writing – review & editing. XW: Data curation, Writing – review & editing. FY: Data curation, Writing – review & editing. XF: Project administration, Writing – review & editing. YC: Conceptualization, Writing – review & editing. JNW: Conceptualization, Writing – review & editing.


Viral hepatitis, the most common cause of inflammatory liver disease, affects hundreds of millions of people worldwide. It is most commonly associated with one of the five nominal hepatitis viruses (hepatitis A–E viruses). HBV and HCV can cause acute infections and lifelong, persistent chronic infections, while HAV and HEV cause self-limiting acute infections. HAV and HEV are predominantly transmitted through the fecal-oral route, while diseases transmitted by the other forms are blood-borne diseases. Despite the success in the treatment of viral hepatitis and the development of HAV and HBV vaccines, there is still no accurate diagnosis at the genetic level for these diseases. Timely diagnosis of viral hepatitis is a prerequisite for efficient therapeutic intervention. Due to the specificity and sensitivity of clustered regularly interspaced short palindromic repeat (CRISPR)/CRISPR-associated sequences (Cas) technology, it has the potential to meet critical needs in the field of diagnosis of viral diseases and can be used in versatile point-of-care (POC) diagnostic applications to detect viruses with both DNA and RNA genomes. In this review, we discuss recent advances in CRISPR–Cas diagnostics tools and assess their potential and prospects in rapid and effective strategies for the diagnosis and control of viral hepatitis infection. E. coli in 1987, followed by the identification of CRISPR-dependent proteins. Subsequent research has shown that CRISPR serves as a defense mechanism in prokaryotic cells against exogenous genetic elements, including viral pathogens and plasmids, by precise and specific degradation of their sequences [Viral hepatitis, an infection that causes inflammation of the liver, is a significant global health-care problem. There are numerous viruses known to cause liver inflammation, including Herpes simplex virus (HSV), Cytomegalovirus (CMV), Epstein–Barr virus (EBV), and varicella-zoster virus (VZV) . Howeverequences . The CRIequences . Class Iequences –16. In tViral hepatitis is one of the most common causes of human morbidity and mortality, both due to acute infection and chronic complication , 18. AltHAV was first identified in 1973. It is a non-enveloped, icosahedral, single-stranded RNA virus belonging to the picornavirus family. At present, HAV can be divided into three genotypes including I, II, III, with two subtypes including subtypes A and B, which can infect humans. It is usually transmitted through the fecal-oral route, either by person-to-person contact and eating or drinking contaminated food or water. HAV is endemic in many countries, especially countries with limited health care resources . The preHBV is a prototype member of the Hepadnaviridae family. It is an enveloped viruses which contains relaxed, circular, partial double stranded DNA . AlthougHCV, a member of the Flaviviridae family, has a positive-sense single-stranded RNA genome coding three structural and seven non-structural proteins. The high mutation rate of HCV leads to marked genomic heterogeneity. HCV is classified into seven confirmed genotypes and at least 67 confirmed subtypes. Meanwhile, genotypes 1–3 are globally distributed, while genotypes 4–6 are concentrated in a certain area. HCV genotype 4 and subtype 5a are endemic in the Middle East and northern parts of South Africa, respectively. HCV genotypes 6 and 7 are mainly observed in Southeast Asia and the Democratic Republic of Congo, respectively , 40. TheDeltavirus, is an enveloped, circular, single-stranded negative-sense RNA virus that encodes two kinds of proteins; the small protein (S-HDAg) and the large protein (L-HDAg), which are 24 kDa and 27 kDa in size, respectively. S-HDAg is required for viral RNA replication, while the L-HDAg is essential for viral assembly [HDV, a member of the genus assembly . HDV is assembly . Currentassembly . Like HBassembly . Globallassembly , 49. Theassembly .Hepevirus genus of the Hepeviridae family. [HEV was first discovered in 1983 when scientists were looking for the cause of the outbreak of non-A, non-B (NANB) hepatitis, which is transmitted enterically . HEV bel family. , 53. Thr family. . HEV gen family. . Genotyp family. . HEV gen family. . HEV gen family. . HEV inf family. . Both se family. . However family. . Current family. .s solid-phase enzyme immunoassays (EIAs) and enzyme-linked immunosorbent assay (ELISA) technology, in particular, have revolutionized diagnostic virology and are now widely used for detecting different viruses [As infectious agents of potentially all types of living cells, viruses are the most abundant biological entities in the environment, that can cause an epidemic which threaten the life and health of humans and animals and cause significant economic loss. The occurrence of a serious outbreak often leads to irreversible losses or damage, so an early and rapid dignosis of the viral infectious is particulary important . The tra viruses , 62. Cur viruses .Cas) proteins has led to transformative advances in molecular biology [cas proteins facilitate adaptive immunity through the multistep process which comprises adaptation, CRISPR RNA (crRNA) biogenesis, and interference. During adaptation which is the first stage of CRISPR immunity, foreign genetic elements are recognized, processed and selected for integration into the CRISPR array, providing a recall element during recurrent infection. During the expression stage, also known as crRNA biogenesis, the CRISPR array is transcribed into a long precursor (pre-crRNA), and processed into mature form as crRNA. In the last stage, the mature crRNAs guide Cas proteins to cleave complementary sequences of foreign DNA (interference) and eliminate those elements. By uncovering the structural and functional components of these diverse systems, new tools, including those applicable to molecular diagnostics, are emerging [The key discoveries that prokaryotic cells like bacteria and archaea have heritable adaptive immunity against foreign genetic elements mediated via CRISPR and CRISPR-associated  and Class 2 . Class 1 systems are characterized by a complex of multiple effector proteins, and class 2 systems encompass a single crRNA-binding protein . Most ofOwing to the programmable nature of CRISPR-Cas systems, they have been exploited in many different fields of biology and medicine and, in fact, have revolutionized these fields. An increasing number of studies have shown that CRISPR/Cas technology can be integrated with biosensors and bioassays for molecular diagnostics. CRISPR-based diagnostics has attracted much attention as highly specific and sensitive sensors with easily programmable and device-independent capabilities. This technique has been used for the sensing of nucleic-acid-based biomarkers of infectious and non-infectious diseases and for the detection of mutations and deletions indicative of genetic diseases. With further research, it holds promise for detecting other biomarkers such as small molecules and proteins , 72. In Mycobacterium tuberculosis, Staphylococcus aureus, Listeria monocytogenes, Pseudomonas aeruginosa and Salmonella enteritidis [Plasmodium parasite responsible for malaria [The main goal of CRISPR-based diagnostics approaches are the identification of specific pathogens, such as the DNA or RNA viruses, bacteria and parasites. RNA viruses which detected with CRISPR-based approach include parvovirus B19, Zika virus (ZIKV), Dengue virus (DENV), Japanese encephalitis virus, Ebola virus (EBOV) and Corona virus. Besides RNA viruses, DNA viruses such as cytomegalovirus (CMV), Epstein–Barr virus, BK virus (BKV) and human papillomavirus (HPV) have also been sensed with CRISPR-based diagnostics . CRISPR/eritidis . Moreove malaria .CRISPR-Cas-based diagnostics technologies have also been implemented for the detection of genetic material relevant to non-infectious diseases. For example, this system was used to sense abnormal levels of human CXCL9 mRNA, an indicator of acute cellular kidney-transplant rejection, in order to detection of graft-versus-host disease in kidney transplants . Apart f(EGFR) and BRAF [A key strength of CRISPR-based diagnostics is the single-nucleotide specificity of Cas enzymes, which permits the discrimination of point mutations (SNPs) and small deletions. Single-nucleotide specificity of CRISPR-based detection has made possible this system to sense markers of antimicrobial resistance, deletions and mutations in the epidermal-growth-factor-receptor gene and BRAF , mutatioand BRAF  and SNPsand BRAF .Accurate, sensitive, and rapid diagnosis of viral infections is the critical first step toward accurate and timely treatment of viral infections. CRISPR-Cas-based diagnosis of pathogens has gained tremendous popularity over the past few years, mainly due to the high specificity, sensitivity, and rapid diagnosis of this system . NumerouIn 2016, Pardee et al. introduced the first CRISPR/Cas-based diagnostic method able to recognize dsDNA. They developed a rapid and inexpensive diagnostic method for detecting Zika virus using CRISPR type II, called nucleic acid sequence-based amplification-CRISPR cleavage (NASBACC). The NASBACC system consists of three parts: nucleic acid sequence-based amplification for the isothermal preamplification of targets, protospacer adjacent motif (PAM)-dependent target DNA recognition by the Cas9, and a toehold detector for the readout. Briefly, a toehold switches triggered binds to a NASBA-amplified RNA fragment via reverse transcription. If the PAM sequence is available in the RNA fragment, Cas9-mediated cleavage causes a short RNA without the trigger sequence. In the absence of the PAM sequence, the trigger containing the full-length RNA activates the toehold switch, indicated by a color change . HoweverThe first applicable platform based on the CRISPR–Cas type VI (Cas13) system, SHERLOCK, was developed in 2017 by the Zhang Lab based on the activity of Cas13 nuclease from Leptotrichia wadei . SHERLOCRecently, a second version of the SHERLOCK system called SHERLOCKv2 has been developed, which takes about 2 h to complete and also increases the detection sensitivity to two attomolar . In thisCas12a is another Cas enzyme with collateral activity that detects DNA molecules. One of the first Cas12a-based detection platforms developed in 2018 by Doudna et al. was DETECTR . In thisUntil now, many DNA and RNA viruses have been diagnosed using these methods. The CRISPR-Cas-based SHERLOCK system allows the detection of Zika virus, Ebola virus, and Dengue virus with a sensitivity of about 1 copy per microliter of sample. It has also enabled the detection of West Nile virus (WNV), Yellow fever virus (YFV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Similarly, DETECTR technology has also been employed to detect SARS-CoV-2. Furthermore, human papillomavirus (HPV) strains (HPV-16 and HPV-18) can be diagnosed by DETECTR technology. In the next section, the potential application of different CRISPR-Cas systems in the diagnosis of viral hepatitis are discussed .Achieving the World Health Organization’s goal of eliminating viral hepatitis by 2030 requires accurate diagnosis of the disease. As mentioned, the ideal diagnostic assay should provide accurate and sensitive identification of the viruses while being affordable, portable, and able to distinguish different variants. Developing new tools which meet the requirements of the WHO standard diagnostic test can completely reshape epidemiological surveillance and medical health care systems for the viral hepatitis in the world . In thisChen X et al. devised a CRISPR-Cas based detection platform, known as “CRISPRHBV”, for ultrasensitive and early detection of two major HBV genotypes (HBV-B and HBV-C) in clinical applications. CRISPR-HBV consists of three steps including multiple crossover displacement amplification (MCDA) for rapid pre-amplification, Cas12b-based detection to decode targets, and result readout with real-time fluorescence and lateral flow biosensors. This system is able to detect 10 copies of genomic DNA per test and has 100% specificity and also has no cross-reactivity in other HBV genotypes and pathogens. The entire assay process, which includes DNA template extraction, MCDA preamplification reaction, CRISPR-Cas12b-based detection, and readout of results can be completed in 60 min and does not require expensive equipment. Additionally, the feasibility of the CRISPR-HBV assay for HBV-B and -C genotyping was successfully confirmed by validation with clinical samples. Therefore, the CRISPR-HBV system has the potential to be a POC diagnostic test for the detection and diagnosis of HBV genotypes B and C in clinical applications, especially in countries with insufficient medical resources .Since the formation of an intranuclear reservoir of cccDNA in the hepatocyte is the main cause of persistent HBV infection, Zhang, X et al. developed highly sensitive and specific diagnostic tools for the detection of HBV cccDNA based on CRISPR-Cas13a technology. This technique includes the following steps: (1) using plasmid-safe ATP-dependent DNase (PSAD) and HindIII enzymes to digest circular rcDNA and linear double-stranded DNA, (2) amplification of specific HBV cccDNA fragments using rolling circle amplification (RCA) and PCR, and (3) target detection using the CRISPR-Cas13a system. This assay can detect 1 copy/µL HBV cccDNA by CRISPR/Cas13-assisted fluorescence readout. Furthermore, by performing ddPCR, qPCR, RCA-qPCR, PCR-CRISPR and RCA-PCR-CRISPR, this assay was validated for the detection of cccDNA in HBV-associated liver tissues, plasma, whole blood, and peripheral blood mononuclear cells (PBMCs) .Many studies revealed that drug-resistance mutations occurring in the HBV genome can increase the risk of HBV transmission or cause active replication of the viral genome, resulting in a lytic infection and other clinical problems in affected patients. One of the most important factors in antiviral drug resistance is the mutation in the YMDD motif of the HBV P gene. Therefore, Wang S. et al. developed a highly sensitive and practical method for the detection of HBV DNA and YMDD drug resistance mutation based on the CRISPR-Cas13a detection system and PCR amplification, and evaluated its diagnostic capability using clinical samples. This technique represents very high sensitivity for detecting HBV and identifying drug resistance mutations using conventional PCR. Given that PCR amplification is more stable than isothermal amplification techniques, PCR was used to target amplification prior to CRISPR-Cas13a detection. In terms of sensitivity, it was found that this technique can detect one copy per test for HBV DNA and YMDD drug resistance mutations . In anotThe genetic diversity of HCV and quasispecies generated during replication have led to viral resistance to direct-acting antivirals (DAAs), as well as obstacles to the development of a vaccine. The accurate and timely diagnosis of disease is a prerequisite for efficient therapeutic intervention and epidemiological surveillance . While tThese overall studies proved the potential of the CRISPR/Cas system as an effective diagnostic tool for viral hepatitis infections. Beyond these studies describe above, till now, no CRISPR-based diagnosis method has been developed for the detection of HAV, HDV, and HEV. However, Cas12a enzyme is the enzyme of choice for developing a CRISPR-based method for HAV detection. As well as, since HDV is an RNA-virus, Cas13a is the choice enzyme for CRISPR-based diagnosis method for HDV. Like HDV, HEV is an RNA-virus, so Cas13a is the choice enzyme for CRISPR-based diagnosis method for the detection of this virus. Uncertainty, the potential of the CRISPR/Cas system can soon become the leading diagnostic tool for different viral hepatitis infection.Within a few years, CRISPR-based molecular diagnostics system have been developed from an experimental tool for nucleic acid biosensing to a clinically viable diagnostic tests for the fast, affordable, sensitive, and specific detection of pathogens including viruses at the POC. Although this technology apparent many advantages, it has several challenges and limitations which needs to overcome for safe and efficient clinical application. The major limitations of most current CRISPR-Cas-based diagnostic tools including SHERLOCK and DETECTR is their dependence on preamplification of the target nucleic acids by either PCR or isothermal amplification processes . However, the isothermal amplification process often needs a set of proteins such as; polymerase, recombinase, or binding proteins and primers which includes 2 primers for RPA and 4 to 6 primers for LAMP and additional sample preparation steps, which greatly complicates and lengthen the assay time for 20 min to 2 h . To resoIn addition, the ease of use of CRISPR-based diagnostics is improved through optimized one-pot reactions and simple visualization of test results. However, sample preparation still requires a separate step and incubation temperatures higher than room temperature require heating devices. Furthermore, target concentrations close to the lowest analyte concentration (LOD) of the assay make it challenging to quantify the readout with certainty, especially when using a lateral flow assay. For home or point-of-care (POC) use, assay design should combine simple sample preparation protocols with robust detection methods to provide robust results in variable or challenging condition, such as long-term storage, limited user training, and harsh environmental conditions. In order to achieve this goal, the integration of sample preparation, measurement, and reporting into single, easy-to-operate units are becoming feasible using microfluidic techniques . Future Another disadvantage of CRISPR-Cas systems particularly Cas9 is the ‘off-target’ effect, in which Cas9 binds to unintended genomic sites for cleavage. Such off-target effect can potentially lead to false negative or positive results. This issue can be overcome with the use of bioinformatic software for designing an appropriate sgRNA .Automation and artificial intelligence can greatly strengthen the application of CRISPR-Cas systems in viral diagnostics. CRISPR-Cas-based diagnostic systems can be combined with artificial intelligence (AI) to provide an early warning system for rapid, affordable, accurate, and smart detection of an infectious agent. In particular, user-friendly and portable CRISPR-Cas-based diagnosis kits are provided to hospitals, health centers, communities, or even individuals for the fast and accurate detection of specific pathogens. Smartphone retrieval of the test result is achieved through an application. Data from various locations can be stored and processed in a cloud computing system via the 5G service, which can be accessed by restricted personnel for support decisions or publicly for research purposes. The cloud computing system calculates the risk of infection to generate an AI-equipped model by updating diagnostic items, and then warn policymakers and individuals –104. SucLimitations and drawbacks in traditional diagnostic techniques open new ways to use sensitive and efficient molecular diagnostic methods for the rapid diagnosis of viral infections. Type II (Cas9), V (Cas12), and VI (Cas13) CRISPR-based systems provide advanced diagnostic tools for the rapid detection and control of DNA and RNA viruses. The development of new CRISPR-based platforms for the molecular diagnosis of viral hepatitis promises to change healthcare and improve the epidemiological management of this infectious disease globally. Currently, developed CRISPR-based assays must be validated by clinical trials and assay validation should be monitored and maintained after clinical implementation to ensure their performance. Despite many successful developments in the CRISPR-Cas-based diagnostic platform, there is still a long way to go from the laboratory to practical or clinical use.


BackgroundIn the setting of the COVID-19 pandemic, the development of care processes that reduce the need for in-person clinic visits while maintaining low complication rates is needed. The purpose of this study is to assess the outcomes of patients undergoing trigger finger release with various suture and follow-up visit types to assess the feasibility of shifting towards telemedicine-based follow-up protocols.MethodsA retrospective review of 329 patients undergoing trigger finger release was performed. Patients were classified based on whether or not they received in-office follow-ups; whether they received absorbable or non-absorbable sutures; and whether they were treated using a telemedicine and absorbable suture protocol or other combination of sutures and follow-ups. Univariate statistics were performed to compare outcomes between groups.ResultsPatients who did not undergo in-office follow-up were more likely to experience residual stiffness or contracture  but had no significant differences in 30-day reoperation, emergency department (ED) returns, wound complaints, and Quick DASH  scores. When comparing chromic absorbable sutures to non-absorbable sutures, those with absorbable sutures were significantly more likely to have telemedicine visits but were also more likely to have wound complaints . There was no significant difference in two- and six-week pain scores, 30-day reoperation, ED returns, residual symptoms, and Quick DASH scores. When comparing patients treated using the absorbable suture and telemedicine protocol with those receiving any other type of suture and postoperative follow-up, no significant differences in any postoperative clinical outcome measures were observed.ConclusionThe results of this study demonstrate that the use of an absorbable suture and telemedicine protocol for patients undergoing trigger finger release yields similar outcomes as traditional methods of care. However, the use of absorbable sutures may result in decreased patient satisfaction with surgical wound healing. Trigger finger, also known as stenosing flexor tenosynovitis, is one of the most common causes of hand disability, with a lifetime prevalence of 2%-3% ,2. TriggTraditional approaches to wound closure in hand surgery primarily utilize non-absorbable sutures made from synthetic materials such as nylon, polybutester, polypropylene, or natural silk that require removal after placement . Non-absThe rapid expansion of telemedicine use during the COVID-19 pandemic presents an opportunity to pair this technology with absorbable sutures to realize the potential for remote follow-up after trigger finger release . TelemedThe purpose of this study was to assess the outcomes of patients undergoing trigger finger release with non-absorbable versus absorbable sutures and of those undergoing in-office versus no in-office follow-up. Based on these findings, we aim to assess the feasibility of an absorbable suture with a telemedicine follow-up protocol. We hypothesize that both absorbable sutures and telemedicine will yield similar outcomes as the traditional wound closure and follow-up approaches.This study was deemed institutional review board exempt by the institutional clinical research committee as a review of existing electronic medical records and previously collected data. A retrospective chart review of all patients undergoing trigger finger release by three board-certified surgeons at a single institution was performed. The timeline for inclusion was between July 1, 2019 and June 30, 2021. All patients undergoing surgery during this time period were included in the study; patients who underwent concomitant procedures were excluded. No other inclusion or exclusion criteria were used. The study time period was selected to coincide with the increased use of telemedicine and absorbable sutures during the COVID-19 pandemic. A manual chart review was performed to assess patient outcomes and utilization patterns.Perioperative protocolPrior to the incision, digital blocks were performed on the operative finger(s) using local anesthetic. Following this, the Esmarch bandage was used to exsanguinate the limb, and the tourniquet was elevated to 250 mmHg. A standard incision overlying the A1 pulley was then undertaken down through the skin and subcutaneous tissues. Blunt dissection was carried down to the level of the flexor sheath. The A1 pulley was identified and transected perpendicular to its fibers all the way down to the A2 pulley. Once this was completed under direct vision, the wound was copiously irrigated, and the tourniquet was released. Wounds were closed using 4-0 chromic absorbable or nylon non-absorbable suture in an interrupted fashion and covered with dry sterile dressings. Suture choice was at the discretion of the surgeon at the time of surgery based on a number of patient and facility factors. Patients were discharged with oral narcotics as needed for pain control and encouraged to elevate the hand and move fingers as allowed by the bandage. Patients receiving absorbable sutures were instructed to remove the bandage five days postoperatively, shower with the wound uncovered, and replace it with a dry adhesive bandage. In-office follow-up for suture removal was scheduled at 10-14 days postoperatively, with a six-week repeat follow-up scheduled as needed. Patients receiving absorbable sutures followed the same postoperative protocol but were given the option of having the 10- to 14-day postoperative wound check via telemedicine. Patients were instructed to return to the office for suture removal if they were still present four weeks postoperatively.Study populationA total of 329 patients underwent trigger finger release over the study period and were analyzed. Patients were classified by whether they had an in-office follow-up visit (n=241) or no in-office follow-up (n=88) and whether they used telemedicine for follow-up care . Patients were also classified based on whether they received chromic absorbable (n=106) or non-absorbable sutures (n=223). Using these variables, patients were then classified based on whether they were treated using the absorbable suture and telemedicine protocol . Fifty-six patients (17%) were treated using this approach, while 273 (83%) were not.Study outcomesPostoperative outcomes of interest included a two-week follow-up and pain score, six-week follow-up and pain score, 30-day reoperation, and a 30-day emergency department (ED) return. The number of follow-up visits and rates of wound complaints and residual symptoms were assessed over the six-week postoperative period. Wound complaints and residual symptoms were further classified by the specific type of issue encountered. Patient-reported outcomes during the postoperative period were evaluated using the Quick DASH  instrument.Statistical analysisBased on a priori power analysis, 51 patients per group were deemed necessary to detect a medium effect size (d=0.5) between continuous endpoints evaluated using two-sided independent samples t-tests at α=0.05 and 80% power. For categorical endpoints, 44 patients per group were needed to detect a medium effect size (w=0.3) using the chi-square test at α=0.05 and 80% power. Therefore, the study was deemed adequately powered to detect medium effects when comparing both suture types and types of follow-up visits. Statistical analyses were used to determine the impact of office visits, absorbable sutures, and utilization of the absorbable suture and telemedicine protocol on patient outcomes. Univariate analysis, including chi-square tests and two-sided independent samples t-tests, was used to determine differences between groups. Fisher’s exact test was performed when the assumptions of chi-square testing were not met. All statistical analyses were performed using R Studio . Statistical significance was assessed at p<0.05.Of the 329 patients, 106 (32.2%) received chromic absorbable sutures. For the two-week follow-up, 69.0% did so in-office, 26.1% did so via telemedicine and 4.9% did not follow-up. For the six-week follow-up, 23.7% did so in-office, 14.6% did so via telemedicine, and 61.7% did not follow-up. In total, there were 499 follow-up visits, 70.3% in-office and 29.7% via telemedicine. Overall, the mean time to the last follow-up was 34.0 days  and six-week follow-up pain score . Those who did not undergo in-office follow-up had a higher proportion of patients with residual stiffness or contracture  and a greater number of follow-up visits . There was no significant difference in 30-day reoperation, ED returns, wound complaints, and Quick DASH scores between those who followed up in-office and those who did not  and six weeks postoperatively . In addition, the chromic absorbable suture group was more likely to have wound complaints . There was no significant difference in two- and six-week pain scores, 30-day reoperation, ED returns, residual symptoms, Quick DASH scores, and number of follow-up visits between those who had chromic absorbable sutures and those who had non-absorbable sutures (Table Finally, when comparing patients treated using the absorbable suture and telemedicine protocol with those receiving other combinations of suture type and postoperative follow-up, no significant differences in any postoperative clinical outcome measures, including two- and six-week pain scores, reoperation rates, ED returns, wound complaints, residual symptoms, and Quick DASH scores, were observed Table .The results of this study demonstrate that the use of an absorbable suture and telemedicine protocol for patients undergoing trigger finger release appears to yield similar outcomes as traditional methods of care. However, the use of absorbable sutures may result in decreased satisfaction with surgical wound healing. In this study of 329 patients, compared to those that received non-absorbable sutures, patients who received absorbable sutures were more likely to have wound complaints, although they had similar rates of postoperative complications. Patients who received absorbable sutures were also more likely to utilize telemedicine visits at two- and six-week follow-ups. Based on these results, we suggest telemedicine and absorbable sutures are viable alternatives to traditional in-clinic follow-ups and the use of traditional sutures in the trigger finger release population, but surgeons should be prepared to address decreased patient satisfaction with postoperative wound healing when using absorbable sutures. This will be accomplished with increased patient education and informed decision-making.Our findings regarding the results of using absorbable sutures are similar to other studies in the literature. In a randomized controlled trial comparing nylon and chromic gut sutures in minor hand surgery, Kortlever et al. found that there were more wound issues among patients receiving the chromic suture, although overall satisfaction and satisfaction with wound appearance were similar among groups . AdditioIn the setting of COVID-19, the use of telemedicine in clinical practice has expanded significantly. Within orthopedics, recent studies have found that when compared to those receiving in-office visits, those who received telemedicine visits had similar rates of satisfaction, decreased travel costs and time, and additionally, most patients preferred telemedicine for their next visit . RegardiWhile multiple studies have demonstrated that telemedicine visits can be effectively performed and result in high levels of patient satisfaction in the orthopedic setting ,14, a coThis study is not without limitations. The study was conducted at a single institution, and therefore, the results may not be applicable to the general population. In addition, as an observational study, the potential for selection bias exists. Patients may have had previous experience with telemedicine, enticing them to choose one type of visit over another. In addition, our comparison of outcomes between patients treated using the telemedicine and absorbable suture protocol is limited by the fact that patients may have deviated from the protocol and scheduled in-office visits if they experienced complications or had significant wound concerns. Finally, it is possible that other unmeasured confounding factors aside from the type of suture used and the type of postoperative follow-up visit influenced our results.Despite these limitations, our results demonstrate the success of utilizing absorbable sutures and the effectiveness of incorporating telemedicine follow-up visits in this patient population. Surgeons should be aware that patients receiving absorbable sutures may be more likely to have wound complaints at follow-up visits and should therefore choose the suture type at their own discretion.The use of an absorbable suture and telemedicine protocol for patients undergoing trigger finger release appears to yield similar outcomes as traditional methods of care. However, the use of absorbable sutures may result in decreased satisfaction with surgical wound healing. Based on these results, we suggest telemedicine and absorbable sutures are viable alternatives to traditional in-clinic follow-ups and the use of traditional sutures in the trigger finger release population, but surgeons should be prepared to address decreased patient satisfaction with postoperative wound healing when using absorbable sutures.


Patients with atrial fibrillation (AF) undergoing transcatheter aortic valve implantation (TAVI) have been associated with worse short-term outcomes compared with patients in sinus rhythm but data on long-term outcomes are limited. The aim of our study was to evaluate the association between AF and short- and long-term outcomes in patients undergoing TAVI.We retrospectively evaluated patients undergoing TAVI between 2012 and 2022 in four tertiary centres. Two different analyses were conducted: (i) in-hospital and (ii) postdischarge analysis. First, we evaluated the association between preexisting AF and short-term outcomes according to VARC-3 criteria. Second, we analyzed the association between AF at discharge (defined as both preexisting and new-onset AF occurring after TAVI) and long-term outcomes at median follow-up of 3.2 years .A total of 759 patients were initially categorized according to the presence of preexisting AF (241 vs. 518 patients). The preexisting AF group had a higher occurrence of acute kidney injury  and major bleeding . Subsequently, the population was categorized according to the presence of AF at discharge. At the adjusted Cox regression analysis, AF was independently associated with an increased risk of all-cause death and cardiovascular hospitalization , all-cause death and all-cause hospitalization  and all-cause hospitalization .In a real-world cohort of patients undergoing TAVI, the presence of AF (preexisting and new-onset) was independently associated with both short- and long-term adverse outcomes. Agostino Estense Baggiovara, (iii) University Hospital Parma, and (iv) St. Maria Nuova Hospital of Reggio Emilia.9 were included in the present analysis. Both high-gradient aortic stenosis  and low-flow low-gradient aortic stenosis  types were included.2 Prior to the intervention, sociodemographic parameters, echocardiographic data and comorbidities were collected. All the screening and preoperatory assessments included coronary angiography, transthoracic echocardiography, contrast-enhanced multislice computer tomography scan of the chest and abdomen to assess aortic, iliac and femoral vessels with the evaluation of calcium amount.10All patients with severe aortic stenosis, diagnosed by echocardiography following the recommendations of the European and American Societies of Echocardiography,2 Motivations to refuse SAVR were the presence of contra-indications to cardiac surgery, e.g. porcelain aorta, frailty, and previous radiation therapy of the chest. The access site was evaluated based on the measurements of preprocedural multislice computed tomography scan. Valve implantation was performed via either a transfemoral  or a nontransfemoral approach (transaxillary or direct aortic). No transapical approaches were performed in our cohort. The prosthetic valve sizing and model  were selected according to operators’ choice and patients’ characteristics. Clinical, echocardiographic, and procedural data were recorded by individual centres in a single, anonymized database.Eligibility for TAVI was assessed by the local Heart Team involving cardiac surgeons, interventional and clinical cardiologists and echocardiographers. Patients were classified according to the Society of Thoracic Surgeons (STS) score  and evaluated for percutaneous intervention according to current international recommendations.In order to evaluate the impact of AF in patients with TAVI on clinical outcomes, two different analyses were conducted: (i) ‘in-hospital’ and (ii)‘postdischarge’ analysis.12 We evaluated the association between preexisting AF and short-term in-hospital outcomes, defined according to the Valve Academic Research Consortium-3 (VARC-3) consensus document.13 The composite of VARC-3 short-term outcome  was considered as the primary in-hospital end point. The single components of the primary in-hospital composite outcome were considered as secondary in-hospital end points.The in-hospital analysis considered patients categorized into two groups: (i) ‘no history of AF’ and (ii) ‘preexisting AF’ defined as the presence of clinical AF independently of the pattern .14 For this second analysis, the composite of all-cause death and cardiovascular (CV) hospitalization in the long term was the primary postdischarge end point. Secondary postdischarge long-term outcomes were all-cause death, all-cause hospitalization, and major adverse cardiovascular events (MACE), defined as the composite of stroke/TIA, myocardial infarction, and CV death.In the postdischarge analysis, we compared patients without history of AF vs clinical AF at the end of hospitalization, defined as both preexisting and new-onset AF that occurred after TAVI.Continuous variables were expressed as mean ± standard deviation (SD) and compared using analysis of variance (one-way ANOVA). Categorical variables were reported as counts and percentages and compared using Pearson chi-square or Fisher's exact test when appropriate.For the in-hospital analysis, we used unadjusted logistic regression to establish the relationship between preexisting AF and individual VARC-3 outcomes . Furthermore, we built an adjusted logistic regression model to evaluate the association between preexisting AF and the primary in-hospital composite outcome of VARC-3 and the secondary outcomes of AKI and major bleeding. We focused on these two individual end points given their known clinical implications in AF patients undergoing TAVI. Age, sex, arterial hypertension, diabetes mellitus, renal function , previous stroke, previous coronary artery disease and left ventricular ejection fraction (LVEF) were used as adjustments. Results were expressed as odds ratio (OR) and 95% confidence interval (CI)For the postdischarge analysis, we explored the relationship between AF at discharge (new onset or history of AF) and long-term outcomes. Plots of Kaplan–Meier curves for the composite primary postdischarge end point of all-cause death and CV hospitalization and secondary postdischarge end points  according to AF at discharge were performed. Survival distributions were compared using the Log-Rank test.Unadjusted and adjusted Cox regression analyses were performed for the postdischarge long-term outcomes. The same adjusted regression model as described above was used. The hazard ratio (HR) and the corresponding 95% CI, were reported.All statistical analyses were performed using IBM SPSS Statistics 26.0 .A total of 759 patients were included, equally distributed by gender  with a mean age of 82.2 ± 5.2 years. Two different analyses were conducted: (i) ‘in-hospital’ and (ii)‘postdischarge’ analysis.In the in-hospital analysis, we considered a total of 759 patients admitted for a TAVI procedure and stratified according to history of AF . Baseline characteristics of the two groups are summarized in Table Table At the adjusted logistic regression analysis, preexisting AF was independently associated with a higher occurrence of AKI  and a trend toward a higher occurrence of major bleeding  . As shown in Table Table Overall, 227 (30.3%) patients experienced all-cause death or hospital readmissions for CV reasons. The occurrence of the composite outcomes of all-cause death/CV hospitalization and all-cause death/all-cause hospitalization was higher in the AF patients (35.6% and 38.2% respectively). These findings were consistent also when considering all-cause death and hospitalization alone , all-cause death and all-cause hospitalization  and hospitalization alone . The adjusted Cox regression analysis showed consistent results: AF at discharge was independently associated with an increased risk of all-cause death and CV hospitalization , all-cause death and all-cause hospitalization  and hospitalization alone . No statistically significant association was observed between AF at discharge and MACE, while there was a nonsignificant trend towards a higher risk of all-cause death  (Table The main findings of our study are as follows: (i) patients with AF undergoing TAVI are more likely to develop AKI and to experience major bleeding; (ii) preexisting AF and new-onset AF both were associated with a higher risk of the composite outcome of all-cause death and CV hospitalization, as well as the composite outcome of all-cause death and all-cause hospitalization and all-cause hospitalization alone in the long term.15Approximately one-third of patients treated with TAVI regularly experience AKI, which is linked to a longer hospital stay and a higher mortality rate.16 In our cohort, the mean amount of contrast used was slightly lower in patients with AF. Despite this, the occurrence of AKI was higher in AF patients, highlighting that this risk is multifactorial, and the amount of contrast used is probably only one of the concomitant factors involved in the complex interplay between AKI and AF. The use of large-lumen aortic TAVI catheters increases the risk of renal cholesterol embolism, which may be also a risk factor for AKI due to the high frequency of concomitant generalized atherosclerosis in these patients.17The TAVI procedure includes the administration of contrast medium (CM) and episodes of pronounced hypotension (‘rapid pacing’) during balloon valvuloplasty and valve implantation, both these factors, added to patient's risk factors, increased the risk of AKI.20AKI is a strong predictor of 30-day all-cause mortality; particularly, AKI superimposed to severe chronic kidney disease (CKD).et al., who examined retrospectively a cohort of 7266 patient who underwent TAVI between 2012 and 2015. AF was recorded in 44% of patients, showing association with AKI  and blood transfusion  but not with inpatient mortality .21 More recently, Nso et al. performed a meta-analysis for a total of 15 studies that enrolled 158 220 patients who underwent TAVI. Primary clinical outcomes were 30-day mortality, stroke, early bleeding, and late bleeding; the secondary outcomes were AKI and length of stay. The authors found that atrial fibrillation was associated with higher risk of all primary and secondary outcomes. Specifically, patients with pre-AF compared with patients with sinus rhythm had a higher risk of AKI . New-onset AF, but not pre-AF, was associated with higher risk of 30-day mortality, stroke, and extended length of stay after TAVI.22Our data were in accordance with those of Patil 13In relation to bleeding complications, we used the VARC-3 definition of complications that ensured a major homogeneity and comparability of data from different research centres.et al. used the VARC definitions too and found that the patients with post-TAVI bleeding had an increased 30-day postoperative mortality compared with controls. Preexisting AF was correlated independently with TAVI-associated bleeding , likely due to AF-related anticoagulation.23Wang et al. evaluated some clinical outcomes shared with VARC-3, in order to predict the length of the discharge after the TAVI procedure. High STS score, general anesthesia, high NYHA class and in-hospital onset of conduction disturbances and new PM implantation were associated with slower discharge.24Also Angelillis et al. and their evaluation included VARC outcomes, although they focused on postoperatory SIRS which resulted as a predictor of 24-month mortality.25A slightly different analysis was made by Monosilio P = 0.03).22Patients with pre-AF had a higher probability of an early bleeding after TAVI than patients in sinus rhythm  compared with those without AF (13.9%); . This was observed irrespective of the type of AF . Mortality gradually increased with higher CHA2DS2–VASC scores . The risks of stroke and life-threatening bleeding were similar among patients with and without AF.27 According to different studies, not only preexisting AF was linked to a higher rate of late mortality,14 but also that new-onset AF is correlated with an increased risk of mortality.27 Furthermore, a new recent study showed an increase in early and late mortality in patients with preexisting and new-onset AF treated with TAVI.12Studies on mortality in patients with preexisting and new-onset AF after TAVI showed counteracting results.et al. in a meta-analysis of 179 studies showed that new-onset atrial fibrillation was associated with a near doubling of 30-day or in-hospital mortality after TAVI .28 The relationship between increased mortality and AF is not clear but surely multifactorial, and includes hemodynamic and functional impairment, thrombo-embolic and bleeding events, and higher rates of renal failure.29Ryan et al. considered 11 studies (11 033 patients) in their meta-analysis. Compared with sinus rhythm, long-term mortality was significantly higher in new-onset AF  and preexisting AF groups . Compared with sinus rhythm, preexisting AF increased the risk of late stroke , but not the risk of late bleeding.30In 2017, Mojoli et al. They proposed a score which included, in addition to biohumoral and functional parameters, AF as the only clinical characteristic, remarking on its prognostic value.31The interest in the study of the link between mortality and AF in the follow-up of TAVI patients could be seen also in more recent evaluation such as the one conducted by Baz Our data showed an increased risk of long-term mortality (until 5 years) in patients with AF and the present study represents a unique experience with long-term follow-up.32 Despite all these observations, the AF status is not included in the available TAVI-specific risk scores yet.35 An additional factor which may contribute to high rates of hospital readmission and mortality in TAVI patients with AF is coexistent mitral regurgitation (MR). The interplay between MR, AF and mortality is complex and not fully understood in the TAVI setting. Preoperative MR (moderate or severe) is significantly more frequent in those with both preexisting and new-onset AF.12 On the other hand, the prevalence of AF increases together with increasing severity of MR. Multiple studies including two meta-analyses have shown that MR is associated with increased mortality after TAVI.38 Despite these inconsistencies, increasing evidence suggests that both MR and AF may have an independent influence on mortality in TAVI patients. Conversely, MR has not proved to be the only determinant of the high post-TAVI mortality rates in those with AF.12 Our findings show that AF at discharge influenced readmission, not only when assessed individually, but also when considered in the primary composite outcome  and the secondary composite outcome .Regarding the hospitalization rate, our results indicated that patients with AF had a higher risk of hospitalization than SR patients, as demonstrated in the SOURCE-XT registry and in the FRANCE-2 study that evidenced an increased re-hospitalization rate due to heart failure.Our study is a real-world analysis of a multicentre, unselected population undergoing TAVI thus providing a unique and updated picture of these patients. One of the strengths of this analysis is the follow-up time which is longer than those of most previous studies. Additionally, most of the patients analysed had a low or intermediate STS score thus providing new insights into this population.However, some limitations should be acknowledged. Our analysis has the intrinsic limitation typical of all observational and retrospective studies, linked to possible selection bias and the eventual presence of confounding factors. Our study did not include a comparison between preexisting and new-onset AF due to the low number of patients with new-onset AF in our database. The analysis also did not consider patients who may have developed AF throughout the entire follow-up and the types of AF during the follow-up are lacking. Another limitation is the absence of a more comprehensive evaluation of the clinical complexity of the patients and the evaluation of frailty. Finally, all patients were enrolled in tertiary centres of a single Italian region thus partly limiting the external validity of our results. For these reasons, our findings should be considered hypothesis-generating and further studies are warranted.Atrial fibrillation in patients treated with TAVI is associated with an increased risk of AKI, all-cause death, and hospitalization. It is uncertain if AF is a cause or a marker of sicker patients, but in any case, it is a factor that should be carefully evaluated for the patient's risk stratification. More studies are required to determine the best monitoring time range for this population.Funding: No funding was received for this work.G.B. received small speaker's fees from Boston, Boehringer, Bayer, Daiichi-Sankyo, Janssen and Sanofi, outside of the submitted work. The other authors declare no conflict of interest.