Seronegative antiphospholipid syndrome (SN-APS) is often defined as the presence of APS criteria manifestations, negative antiphospholipid antibodies (aPL), and coexistence of APS non-criteria manifestations. Nevertheless, the impact of these non-criteria features is still unclear. On a different note, the relevance of one single aPL positive determination in patients with APS manifestations is another domain with limited evidence. We aim to compare the course of SN-APS and single-positive aPL (SP-aPL) patients with that of individuals with APS manifestations without non-criteria features/aPL positivity (controls).Retrospective analysis of patients with thrombosis/obstetric morbidity assessed in two European hospitals between 2005 and 2020. Patients were divided into SN-APS, SP-aPL, and control groups. Clinical characteristics, comorbidities, and therapies were compared.p < 0.001) even when adjusting for the presence of hereditary thrombophilia, systemic lupus erythematosus, or contraceptive hormonal treatment. In SP-aPL, the difference in thrombosis recurrence did not reach statistical significance (p = 0.078). Indefinite anticoagulation  and vitamin K antagonist (VKA) use (p < 0.001 in both cases) were more common in SN-APS/SP-aPL.A total of 82 patients were included in the SN-APS group, 88 in the SP-aPL group, and 185 in the control group. In Cox regression model, SN-APS displayed more thrombosis recurrence than controls (HR 3.8, 95% CI 2.2–6.5, SN-APS displayed more thrombosis recurrence, indefinite anticoagulation, and VKA use than controls without non-criteria manifestations. The presence of such features in patients with thrombosis and negative aPL may negatively impact their clinical course. The classification criteria for definite antiphospholipid syndrome (APS)  are currlivedo reticularis, whose antiphospholipid antibodies (aPL) tests are doggedly negative ; recurrence of events; number of thrombotic events; number of spontaneous abortions; presence and type of “non-criteria” manifestations (in the case of SN-APS); aPL positivity and profile (in the case of the SP-aPL group); associated autoimmune diseases (AID); presence of autoantibodies  and complement consumption; cardiovascular risk factors ; and presence of risk factors for thrombosis . A possible future progression towards systemic lupus erythematosus (SLE), based on clinical manifestations and autoantibodies’ profile, was also noted.In addition, we collected information on the treatments each patient was under, including indefinite therapy with oral anticoagulation [vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC)], antiplatelet agents or hydroxychloroquine, anticoagulation duration, and recurrence under treatment. In the case of obstetric manifestations, treatment of at least one pregnancy with low-dose aspirin (LDA) monotherapy, low molecular weight heparin (LMWH) monotherapy, LDA/LMWH combination, or hydroxychloroquine was noted.Continuous variables were described by means and standard deviations or by medians and interquartile ranges (IQR), while categorical variables were described using absolute and relative frequencies. We built univariable logistic regression models to compare SN-APS patients versus controls and SP-aPL patients versus controls. Tested independent variables included clinical manifestations, recurrence, comorbidities, and treatment options. Multivariable analyses were performed when adjustment for confounders was considered required. Seronegative APS patients and SP-aPL patients were also compared against controls regarding the development of thrombosis recurrence—we built univariable and multivariable Cox regression models , considering the time between the first thrombotic event until the development of a second thrombotic event . In addition, Kaplan-Meier curves were obtained.p < 0.05 were considered statistically significant. Data were analyzed using SPSS Statistics 26.0 .Exponentials of logistic regression coefficients were interpreted as odds ratio (OR) and exponentials of Cox regression coefficients were interpreted as hazard ratios (HR). Exponentials of regression coefficients were calculated along with their respective 95% confidence intervals (CI). Values of p = 0.519) and age of first event (p = 0.241). In univariable regression analyses, a significantly lower frequency of males was observed in the SN-APS group in comparison to the control group , with no difference (p = 0.120) when adjusting for the presence of obstetric patients in each group; on the other hand, no significant differences on gender distribution were found between the SP-aPL and control groups (p = 0.107). Complete results are available in Table Three hundred and fifty-five patients were included in the analysis: 82 in the SN-APS group, 88 in the SP-aPL group, and 185 in the control group (161 without and 24 with hereditary thrombophilia). Patient characteristics and demographic data are summarized in Table p = 0.026) than in the control group, with no significant difference between SP-aPL and control patients (p = 0.322) .Concomitant AID was more common in the SN-APS group  than in the control group, even when adjusting for the presence of associated AID . Complement consumption was more common in the SN-APS group , but this difference was not maintained when adjusting for the presence of associated AID (p = 0.067). No difference was found in the proportion of patients in which a progression towards a diagnosis of SLE was suspected between SN-APS (p = 0.828)/SP-aPL (p = 0.278) and the control group. Complete results are available in Table Positive ANA were more common in the SN-APS/SP-aPL groups . Only one patient in the control group (0.5%) displayed both thrombotic and obstetric manifestations, a feature present in 6.1% and 5.7% of patients in the SN-APS (p = 0.025) and SP-aPL (p = 0.029) groups, respectively.SN-APS and SP-aPL groups were associated with a higher frequency of obstetric manifestations in comparison with the control group . On the other hand, the SP-aPL group displayed significantly less arterial thrombosis than the control group , with no significant difference between SN-APS and control patients (p = 0.711). Concerning specific thrombotic manifestations, SP-aPL patients displayed significantly less frequency of stroke  but more frequent cerebral vein thrombosis  than patients from the control group. No significant differences were found in the remaining clinical manifestations between SN-APS/SP-aPL and the control group. Complete results are available in Table No significant differences were found between SN-APS/SP-aPL and the control groups in the frequency of venous thrombosis (p < 0.001) , associated SLE  or OCP . In the case of SP-aPL group, we observed a non-significant trend for a higher chance of recurrence both in unadjusted analysis  , associated SLE  or OCP . The mean number of thrombotic events was higher in both SN-APS and SP-aPL groups in comparison with the control group . No patient in the control group displayed recurrence under anticoagulation, a feature present in 10.6% and 4.7% of patients in the SN-APS and SP-aPL groups, respectively.Regarding thrombosis recurrence, in a Cox regression model, SN-APS associated with significantly higher chances of recurrence than the control group , brain white matter lesions , migraine , superficial vein thrombosis , and seizures .When assessing SN-APS patients among themselves, no particular non-criteria manifestation was specifically associated with thrombosis recurrence. When selecting SN-APS patients with specific non-criteria features and comparing them with the control group, various manifestations were statistically associated with recurrence, albeit the OR’s displayed wide confidence intervals, hinting a low estimate precision due to small sample size: thrombocytopenia . Additionally, a longer global duration of anticoagulation was observed in SN-APS  and SP-aPL patients  in comparison with the control group. In anticoagulated patients, anticoagulation with a VKA (instead of a DOAC) was more common in the SN-APS/SP-aPL groups than in the control group . In patients with obstetric manifestations, no significant difference was observed in pregnancy treatment between SN-APS/SP-aPL patients and the control group. Complete results are available in Table In patients with thrombosis, indefinite anticoagulation was more common both in SN-APS and SP-aPL groups comparing with the control group  displayed a higher frequency of obstetric morbidity and concurrent obstetric and thrombotic manifestations in comparison with controls. Additionally, ANA positivity was more prevalent even when taking into account the presence of other AID, hinting a possible role as a marker of autoimmunity in these patients. When focusing on patients with thrombosis, although the type of events did not differ from controls, a significantly higher number of events and thrombosis recurrence was observed in patients with non-criteria manifestations, a deed still sustained even after adjusting for various relevant confounders . A previous work described similar prevalence of thrombosis recurrence between patients with SN-APS  and definite APS patients . Our datlivedo reticularis, a previous work reported an increased frequency of this feature in patients with arterial events and decreased frequency in those with venous events [Regarding the impact of specific non-criteria manifestations on thrombosis recurrence, the significance of the observed associations is undermined by the small sample size possibly leading to estimates of low precision and misleading high magnitude. Nevertheless, there is already some evidence in the literature portraying a possible role of these manifestations. In the case of thrombocytopenia, although previous data provided conflicting results, most publications increasingly support a potential impact of this feature in APS prognosis. While two studies found no significant difference in thrombosis recurrence among APS patients with and without thrombocytopenia , 22, a ss events , 26. In s events . Relativs events , 29. It s events , 29, wits events . The evis events .Regarding SP-aPL patients, in a similar fashion to SN-APS, they also displayed a higher frequency of obstetric criteria manifestations and concurrent obstetric and thrombotic manifestations in comparison with controls. Focusing on thrombosis, even though the mean number of events was higher in SP-aPL, recurrence was not significantly different from controls. This is in line with the notion that one single aPL positive determination is not associated with increased recurrent thrombosis, as stated in the previous systematic review reporting, in these patients, a similar recurrence rate to the general population .Lastly, the comparison of the characteristics and treatment of obstetric patients between SN-APS/SP-aPL patients and the control revealed no significant differences, but the small sample undermines the extraction of significant and generalizable conclusions.14th International Congress on Antiphospholipid Antibodies Technical Task Force on APS Clinical Features reviewed the literature devoted to some of these non-criteria manifestations, and the sparsity of data regarding their impact was clear. Even in the new criteria under development [This work encompasses significant strengths but also limitations. First, as these patients did not have definite diagnosis, they were managed according to their physician’s judgment and not respecting a predefined protocol, leading to potential disparities in their treatment. The treatment options might also reflect specific management approaches of the studied centers and not be easily comparable with other institutions. Additionally, the retrospective design and the fact that both SN-APS and SP-aPL groups include quite heterogeneous individuals  weaken the extrapolation of obtained results. Nevertheless, considering the rarity of the entity and the difficulties in identifying these patients, a retrospective design is a feasible first approach to gather initial data in a domain with practically no available evidence. This is also valid regarding the different non-criteria manifestations. The report of the elopment , part ofThese results carry clinical implications, suggesting that the presence of non-criteria manifestations negatively affects the prognosis of SN-APS. This could imply a potential need for a more thorough follow-up and aggressive management of these patients, with earlier and prolonged anticoagulation. Conversely, the presence of only one single aPL positive determination does not seem to dictate increased risk of recurrent thrombosis, serving as a reinforcement to the current practice of managing these patients in a similar fashion to the general population. However, confirmation of these results should be obtained in future prospective, ideally multicenter studies (considering the scarcity of these patients), ideally focusing on specific non-criteria manifestations.SN-APS patients displayed more thrombosis recurrence, indefinite anticoagulation, use of VKA (instead of DOAC), and longer anticoagulation duration than controls without non-criteria manifestations. SP-aPL patients did not display significantly higher thrombosis recurrence in comparison with controls. The presence of non-criteria manifestations in patients with thrombosis and negative aPL may negatively impact the clinical course of these patients and confer a poorer prognosis.


Neuroimaging research seeks to identify biomarkers to improve the diagnosis, prognosis, and treatment of attention-deficit/hyperactivity disorder (ADHD), although clinical translation of findings remains distant. Resting-state functional magnetic resonance imaging (R-fMRI) is increasingly being used to characterize functional connectivity in the brain. Despite mixed results to date and multiple methodological challenges, dominant hypotheses implicate hyperconnectivity across brain networks in patients with ADHD, which could be the target of pharmacological treatments. We describe the experience and results of the Clínica Universidad de Navarra (Spain) Metilfenidato (CUNMET) pilot study. CUNMET tested the feasibility of identifying R-fMRI markers of clinical response in children with ADHD undergoing naturalistical pharmacological treatments. We analyzed cross-sectional data from 56 patients with ADHD . Standard preprocessing and statistical analyses with attention to control for head motion and correction for multiple comparisons were performed. The only results that survived correction were noted in contrasts of children who responded clinically to lisdexamfetamine after long-term treatment vs. treatment-naive patients. In these children, we observed stronger negative correlations (anticorrelations) across nodes in six brain networks, which is consistent with higher across-network functional segregation in patients treated with lisdexamfetamine, i.e., less inter-network interference than in treatment-naive patients. We also note the lessons learned, which could help those pursuing clinically relevant multidisciplinary research in ADHD en route to eventual personalized medicine. To advance reproducible open science, our report is accompanied with links providing access to our data and analytic scripts. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting 5–10% of children and adolescents . PharmacNeuroimaging research in mental disorders, including ADHD, aims to elucidate the pathophysiology and neuropsychopharmacology of these conditions and their treatments in a quest for personalized medicine . Yet, deResting-state functional magnetic resonance imaging (R-fMRI) has become a mainstream brain imaging technique. It highlights the statistical properties of spontaneous fluctuations in blood oxygen level dependent (BOLD) signals to infer “functional connectivity” among spatially distant areas which represent putative brain functional networks .R-fMRI research in ADHD has identified widespread brain circuitry differences between patients and typically-developing control individuals (TDCs) and their possible normalization with medications; however, results have been inconsistent across studies , 9. ChalThe “Clínica Universidad de Navarra Metilfenidato” (CUNMET) study was designed as a proof-of-concept study in partial fulfillment of the requirements for a Ph.D. . TheCUNMET's overarching objective was to evaluate the feasibility of conducting a naturalistic neuroimaging study with a clinical sample of children and adolescents with ADHD, with the aim of exploring putative R-fMRI correlates of differential symptomatic response to stimulant medications. Specific objectives were: (1) To obtain phenotypic , neuropsychological, and R-fMRI data from a cross-sectional sample of children and adolescents with ADHD with differential pharmacological responses to stimulants and a longitudinal subsample of treatment-naive patients evaluated pre- and post-treatment; (2) to conduct rigorous and transparent methods to minimize the effects of imaging artifacts, in particular, head motion and false-positive rates, in the exploration of neural correlates of treatment response; (3) to explore reliable R-fMRI differences in whole-brain network correlations across treatment-response groups and treatment-naive patients, as well as the modulation of these correlations after treatment with methylphenidate in treatment-naive patients; (4) to transparently describe the challenges encountered and the limitations of the study; and (5) to contribute to open-science efforts through best practices in reporting and data sharing.Detailed information on methods is available in After consent and assent were obtained along with clinical assessments that confirmed inclusion/exclusion criteria were met, R-fMRI data were acquired with a Siemens MAGNETOM 3.0 Tesla Skyra  with a Siemens 32-channel head coil. Each scan session lasted around 20 min and consisted of a R-fMRI echo planar imaging BOLD sequence , a perfusion-weighted ASL sequence (not further described here) and an anatomical T1-weighted magnetization-prepared rapid gradient-echo sequence .Briefly, preprocessing and quality control of images used the Configurable Pipeline for Analysis of Connectomes   which inAnalyses were conducted at two levels of spatial resolution. Dual regression of the Smith et al. 10-network parcellation   were useStata Statistical Software: Release 12. College Station, TX: StataCorp LP., https://www.stata.com). Group comparisons of neuroimaging graphs were performed using the Network-Based Statistic (NBS) Toolbox (https://sites.google.com/site/bctnet/comparison/nbs)  Stimulant-treated vs. untreated (merged MPH + LDX groups vs. naive).(b) MPH-treated vs. untreated (MPH vs. naive).(c) LDX-treated vs. untreated (LDX vs. naive).(d) MPH-treated vs. LDX-treated (MPH vs. naive).N = 80; 20/group): first, GFC participants were difficult to recruit, due to the relative paucity of non-responders to stimulants in our clinic and their higher likelihood of presenting exclusion criteria; second, we were only able to obtain a post-treatment scan and evaluation in eight naive patients prior to the termination of the study at the end of the principal investigator's residency. Due to insufficient recruitment, the three GFC participants were excluded from analyses. Similarly, the eight post-treatment scans from the subgroup of naive participants who were assessed pre- and post-MPH were also excluded; instead, resources were shifted to slightly increase the samples in the MPH, LDX, and naive groups. Difficulties encountered in the recruitment process, in general, were: (a) logistical, such as scheduling issues for MRI scans due to limited scanner availability and scheduling difficulties for patients and families, many of whom lived far from the hospital; (b) constraints related to the research design, such as exclusion criteria and the challenges of complying with complex procedures on the day of scanning.We recruited a sample of 68 participants, who provided a total of 76 scans . This distribution deviated from the original plan . This led to a final sample of 56 retained participants, relatively evenly distributed across the MPH, LDX, and naive groups.Across-group comparisons of functional connectivity between pairs of the ten brain networks extracted through dual regression based on Smith et al.  yielded Across-group comparisons of functional connectivity between pairs of the 200 brain nodes extracted based on Schaefer et al.  detectedIn this exploratory study primarily designed to assess feasibility, within the constraints of a training program and with limited resources, we confirmed that it is feasible to conduct a complex brain imaging effort within a naturalistic clinical practice setting, albeit with multiple limitations. Conducting this study was an explicit learning process. The research team was aware of the main methodological threats of R-fMRI research: small sample sizes, poor data quality due to signal artifacts [in particular, head motion , which iGiven the limitations of this study, all of our results have to be considered preliminary. In particular, we cannot be confident regarding the null results in the comparisons involving the MPH group. The greater similarity in functional connectivity patterns between the MPH group and the NAIVE group than the LDX group is surprising, as the neuropharmacological and clinical effects of MPH and LDX, both stimulants, are similar. We note a lack of R-fMRI research comparing methylphenidate vs. amphetamines  so cannoOur preliminary results showed strengthened negative correlations (anticorrelations) across pairs of brain regions corresponding to different networks in children with ADHD who responded clinically to LDX after long-term treatment, when contrasted to treatment-naive patients. This finding is consistent with higher across-network functional segregation in patients treated with LDX, suggesting that distinct brain networks were operating with less interference from other networks than in treatment-naive patients. Such an increase in across-network functional segregation could be a neural correlate of positive clinical response to LDX in patients with ADHD. Due to the cross-sectional design and the lack of a healthy comparison sample, we cannot ascertain whether these differences between groups reflected pre-post medication changes, were markers of medication intake, mediators between medication intake and clinical response, or rather adaptive changes after clinical response.The overall tentative findings, involving diverse combinations of nodes from six different networks, are compatible with systems neuroscience approaches that highlight the role of functional network segregation in health and disease. In these models, increasing segregation reflects efficient network functioning and excessive integration can be a correlate of brain dysfunction . If exceIn terms of study design, the naturalistic approach, further constrained by difficulties encountered during its execution, has a limited ability to differentiate true pharmacological effects from other potential confounders, and in this sense is inferior to randomized controlled trials . HoweverAnother major limitation was the limited sample size, even if it was in line with that of most previous studies . Small sWe adopted a naturalistic design with relatively broad inclusion criteria reflecting the patients with ADHD seen in our clinic. Thus, we recruited a sample encompassing a wide age range (7–17 years), both sexes, right and left-handed individuals, and allowed certain comorbidities . This approach contrasts with previous studies which had narrower age ranges and/or excluded females . The dowOther study limitations included inconsistencies in demographic and clinical data collected, the specific naturalistic medication scheme , lack of mock-scanning training sessions, lack of real time monitoring of wakefulness and head motion, and flexibility of analytic pipelines  scanning sessions to habituate participants to the experience. Optimize head immobilization tools. Monitor real-time wakefulness and head motion. Record any incidents during the session. Increase the total duration of BOLD sequence data to at least 25 min , and report relevant changes from the initial protocol. Follow the Organization for the Human Brain Mapping - Best Practices in data analysis and sharing in neuroimaging using MRI (OHBM-COBIDAS) (COBIDAS)  to thoroIn conclusion, the CUNMET study constituted a fruitful proof-of-concept of state-of-the-art neuropsychopharmacological research in ADHD. Despite substantial shortcomings, we demonstrated the feasibility of a naturalistic design within the constraints of real-time clinical practice and a training program, and our findings suggest that potential brain correlates of clinical response to lisdexamfetamine in children and adolescents are based in across-network segregation. The lessons learned from CUNMET are offered to inform future research and to encourage prospective investigators to undertake transparent, open-science collaborative efforts. While similar individual small studies will not advance the field on their own, their aggregation may offer frameworks for efficient exploration of designs, methods, and potential biomarkers  in the qhttp://fcon_1000.projects.nitrc.org/indi/retro/CUNMET.html). Our analytic codes are available at GitHub (https://github.com/victorpsanchez/cunmetstudy).The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: The CUNMET Study team supports open science and is sharing de-identified patient data and analytic scripts to allow other researchers to carry out independent analyses, providing they acknowledge the source of the data and its funding in their reports. Deidentified and defaced brain imaging and phenotypic data from the patients for whom we received permission for sharing are available at INDI (https://osf.io/2dfs8) on September 24, 2019, after data collection and pilot preprocessing and before conducting group analysis. The study was ethically reviewed and approved by the Ethics Committee for Medications Research of Navarra (Spain)  on June 21, 2017, with the codes CUNMET-2017-01 EO17/11, which also approved an amended protocol on May 22, 2019. This study was compliant with the research ethics principles of the Declaration of Helsinki , taking into account the specific principles for research with children and adolescents. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.The CUNMET study was registered by the Spanish Agency of Drugs and Medical Products on March 27, 2017, with the registration code CUN-MET-2017-01. The statistical group analysis plan was registered at Open Science Framework . The costs of the gift cards given to the participants were provided by a research-supporting foundation which preferred to remain anonymous. VP-S's training position and the article processing fees for this publication were covered by Fundación Alicia Koplowitz.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Introduction: Optimizing individual outcomes of cognitive-behavioral therapy (CBT) remains a priority.Methods: Youth were randomized to receive intensive CBT at a hospital clinic (n = 14) or within their home (n = 12). Youth completed 3 × 3 h sessions (Phase I) and up to four additional 3-h sessions as desired/needed (Phase II). An independent evaluator assessed youth after Phase I, Phase II (when applicable), and at 1- and 6-months post-treatment. A range of OCD-related  and secondary  outcomes were assessed.Results: Families' satisfaction with the treatment program was high. Of study completers (n = 22), five youth (23%) utilized no Phase II sessions and 9 (41%) utilized all four (Median Phase II sessions: 2.5). Large improvements in OCD-related outcomes and small-to-moderate benefits across secondary domains were observed. Statistically-significant differences in primary outcomes were not observed between settings; however, minor benefits for home-based treatment were observed .Discussion: Intensive CBT is an efficacious treatment for pediatric OCD. Families opted for differing doses based on their needs. Home-based treatment, while not substantially superior to hospital care, may offer some value, particularly when desired/relevant.Clinical Trial Registration:www.ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT03672565, identifier: NCT03672565. Scientific consensus supports cognitive-behavioral therapy (CBT) utilizing exposure and response prevention (ERP) as a first line treatment for pediatric obsessive-compulsive disorder (OCD) given its safety, tolerability, and efficacy in reducing symptom severity and improving global well-being  –5. HowevWhile standardized protocols have been essential in establishing the efficacy of CBT for OCD-affected youth, fixed-dose models inadequately address inter-individual patient needs and desires, reduce efficiency of resource utilization, and thereby hold limited relevance to community care. For example, analysis of data from the NordLOTS trial found that 38% of youth were already considered responders by week 7, 73% were responders by the end of the 14-week protocol, and 50% of non-responders to the 14-week protocol responded after a second 14-week course , 10. OveStepped care models, in which all patients receive a low intensity treatment  and non-responders proceed to higher intensity treatments , have been examined as a means to optimize resource utilization; however, the benefits of this approach are limited by higher OCD-related costs  associated with the delay in optimal care for individuals unlikely to respond to low-intensity interventions . AlternaResearch efforts to better understand the mechanisms through which ERP contributes to positive change in OCD-affected patients have identified the relevance of inhibitory learning  . InhibitIncorporating these goals, the present study sought to implement a patient- and family-driven, flexible-dose model of intensive CBT delivery while randomizing families to receive care in home vs. hospital settings. In particular, the following aims were explored:Specific Aim 1. To evaluate the efficacy of an intensive flexibly-dosed CBT program in reducing OCD-related severity, impairment, and family accommodation. Consistent with past evidence in support of intensive CBT, we hypothesized that the program would be associated with large treatment effects across primary outcomes.Specific Aim 2. To examine the extent to which individuals utilized available treatment sessions across the protocol. Given past evidence of variability in response, we hypothesized that families would utilize differing proportions of available treatment sessions.Specific Aim 3. To compare the efficacy, treatment utilization, and satisfaction between home and clinic settings. Given theoretical models and preliminary evidence, we hypothesized that sessions provided within the home would be associated with greater outcomes compared to sessions provided in a clinic setting.ClinicalTrials.gov . The present study utilized a randomized controlled trial design to compare the utility of home/community vs. outpatient clinic setting delivery of intensive CBT for OCD-affected youth. The study was approved by the University of British Columbia Children's and Women's Research Ethics Board and registered in advance with via online advertisements, and to suitable patients who completed an assessment through the Provincial OCD Program (POP), a tertiary level specialty clinic for OCD at BC Children's Hospital. Upon initial contact, study procedures and inclusion/exclusion criteria were discussed with families. Those interested and determined as likely eligible provided parental consent and youth assent to participate. Families referred by the POP provided consent for their clinical assessment data to be utilized for the present study to minimize study burden. External families completed a telephone screen and, if still eligible, progressed to an in-person diagnostic assessment.Study information was disseminated to local clinicians and community organizations, Participants were youth between 7 and 19 years of age with a primary diagnosis of OCD who were seeking treatment and lived within an hour's drive of the study site. In order to be eligible, youth and at least one parent had to be willing to participate in treatment regardless of group assignment. Youth were required to have at least moderate symptom severity as indicated by a total score of 16 or greater on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) . Particin = 12); however, to address emergent feasibility concerns in this pilot trial , sessions were transitioned to occur weekly (n = 14). Following completion of Phase I, participants completed online surveys and were assessed by an independent evaluator (IE) who was blind to participants' group assignment. Participants achieving remission  . This initial dose was selected based on evidence that a portion of youth experience meaningful response after similarly brief interventions , 16. At re < 11)  were traFamilies transitioned to Phase II were eligible to access up to four additional 3-h treatment sessions. Dosing in the second phase was selected in an effort to balance practical considerations  with evidence suggesting a portion of youth require more substantial support to achieve treatment response . Each weIn the month following treatment completion, families were provided with up to three 30-min phone calls focused on reviewing, developing, and problem-solving independent ERP tasks, identifying next steps and long-term goals, supporting access to post-study services, and relapse prevention. This approach was selected based on simplicity, feasibility, and timing to follow-up. One- and six-months following treatment completion, participants completed online surveys and an additional assessment with the IE. Following completion of the one-month assessment, participants were free to access any other treatment resources, including medication changes.Table 2, was provided by the primary caregiver organizing study participation on behalf of the youth. While a variety of response options were provided for demographic variables, Table 2 presents relevant categories based on endorsed responses.Demographic information, as presented in via either: (A) the Anxiety Disorders Interview Schedule for DSM-IV Child Version (ADIS-C) for Parent Report , initial introduction to ERP, and homework planning. Youth and their parent(s) also completed baseline questionnaires online prior to the session.Integrating current conceptualizations of evidence-based CBT for OCD , 37–39, Similarly, given extensive and varied impacts of OCD on family and the relevance of family variables to outcomes  , 40–43, Statistical analyses were conducted using R software version 4.0.2. Following calculation of baseline descriptive statistics for the entire sample and each treatment group separately, treatment effects on repeatedly-measured outcome variables were evaluated using linear mixed-effects models. The intention-to-treat principle was followed such that all randomized participants were analyzed according to their treatment group allocation. The outcome of interest was modeled as a change from baseline at each follow-up time point. Treatment condition, time point, child age at baseline, and baseline value on the outcome variable were included as fixed effects. Additionally, the interaction between treatment condition and time point was included to evaluate differences between groups at each follow-up time point. Each model included a random intercept. These analyses use restricted maximum likelihood estimation, and all randomized participants contribute to estimation of treatment effects regardless of whether they complete follow-up assessments. In the results section, we present the estimated change from baseline within each group, the estimated difference between each group at each follow-up time point, and the 95% confidence intervals for these estimates.> 35% reduction in CY-BOCS score from baseline at each timepoint; (2) the number of youth who demonstrated > 55% reduction in CY-BOCS score from baseline at each timepoint; and (3) the number of youth whose CY-BOCS score < 11 at the timepoint. Prior to calculating these values, missing CY-BOCS scores at each post-baseline follow-up were imputed using predictive mean matching, in which baseline age, treatment group, and prior CY-BOCS score was used to estimate the missing CY-BOCS total. Given that significance testing was already conducted on the continuous CY-BOCS measure, these outcomes are presented in a descriptive manner, with no additional statistical testing completed in regard to these findings.Three binary outcomes, based on established definitions of response and remission , were caSelf- and parent-reported treatment perspectives were assessed only once , and therefore, between-group differences were evaluated using analysis of covariance, with baseline age as a covariate and treatment group as the effect of interest.n = 26) and separately for children randomly allocated to the Hospital setting group  and to the Home/Community setting group . The mean age at baseline was 14.1 years (SD = 2.5) and 52% of the sample identified as male. Generally consistent with local population demographics, the sample was composed of White and/or Asian families. No parents self-identified as having an OCD diagnosis.See This randomized pilot study investigated the benefits of an intensive flexible-length CBT program while comparing outcomes across home and hospital setting delivery. Consistent with prior research, the intensive CBT program was efficacious, with large reductions observed across OCD-specific domains as well as modest benefits in more global domains . Observed differences in treatment session utilization levels across participants suggest that flexibility in treatment dosing is desirable and useful in optimizing levels of care based on individual need. Treatment was rated highly by participants overall. The present study provides further evidence that intensive CBT is a feasible, desirable, and efficacious form of treatment for pediatric OCD.Both groups demonstrated comparable reductions in symptom severity and no between group differences were statistically significant. Youth in the hospital condition utilized a median of one fewer sessions than those in the home condition, which could indicate a faster rate of change, but may also have been influenced by youth's dislike for the hospital setting or reduced utility of remaining in treatment given more limited opportunities for ERP completion within the hospital setting. Although lower median session utilization within the hospital condition may play a role, close inspection of the data suggest some potential benefits associated with the home condition. In particular, reductions in coercive/disruptive-behaviors were significant within the home condition but not the hospital condition; the home condition demonstrated slightly larger improvements in youth- and family-functioning when rated by parents; and rates of response and remission favored the home condition, particularly by the time of 6-month follow-up. Youth and families within this condition may have benefited from additional opportunities to tackle symptoms and impairment within their natural environment and develop alternative systems of management/response, potentially enhancing generalizability and maintenance of learning. In contrast, families among the hospital condition initially demonstrated greater reductions in family accommodation, which may reflect how, when opportunities for specific-ERPs are limited by setting , clinicians instead can support families around reducing accommodations related to those symptoms and achieve positive outcomes. This trend was no longer evident at 6-month follow-up.Despite limited between-group differences, youth in the home condition rated treatment more favorably (significant for easier and more pleasant), and both youth and their parents in the home condition were more likely to report that they believed they benefited more from being in their assigned condition than they would have in the alternative setting. In comparison, parents in the hospital condition appeared to rate treatment more positively (significant for recommending to others and belief that program should be a permanent service). Our clinical observations suggested that home conduct of sessions added particular value for certain participants  while being less relevant to others . Without consideration of inter-individual contextual influences on OCD, the potential to identify benefits associated with home-treatment may be notably diluted. Overall, home-based work may increase participant buy-in and willingness, allow for more naturalistic experiences for patient/family learning, and have particular utility for context-dependent symptoms. Given this, a blended model that incorporates standard clinic-based service provision with occasional in-home/community ERP sessions, especially when relevant, may be optimal for minimizing costs/therapist burden while still capitalizing on potential benefits of home-based sessions.The present study contributes to the growing body of evidence supporting a transition away from fixed-length individual treatment models toward patient-driven treatment and supports intensive CBT as a suitable format to provide tailored care. In particular, the extended session length facilitated in-home treatment provision and increased ERP engagement and practice, allowing for substantial within-session progress and rapid improvements within a short period of time. However, clinical observations and informal participant feedback indicate that greater flexibility (even beyond that offered in the current pilot study) is warranted. First, for families with limited scheduling flexibility, lower levels of impairment/immediate need, and/or higher levels of ambivalence, the 3-h format may be a barrier to accessing and/or continuing with treatment. As a result, the traditional 1-h session length may be optimal for many families. Second, we observed emergent challenges around treatment decisions when families had largely improved but still desired supports around specific symptoms that could not be effectively targeted in session . This challenge could likely be addressed by tapering down from 3- to 1-h sessions as symptoms improve. Third, while the total therapeutic dose in the present study was limited to a maximum of 22.5-h (7 × 3 h + 3 × 0.5 h), many families requested, and would likely have benefited from continued treatment or higher levels of care, as has been demonstrated previously , 17.The following are limitations of the present study. First, eligibility assessments differed slightly depending on recruitment source which may have impacted determination of eligibility and identification of comorbid conditions. Second, given the use of a flexible treatment protocol, lack of a control condition, and limits to participant choices , the present study did not aim to assess superiority relative to standard weekly sessions, or to establish an optimal approach to dosing. Third, as a pilot trial, the study focused primarily on establishing the overall feasibility and efficacy of the treatment program (regardless of delivery method) and lacked power to detect smaller between group differences. Given some indications toward the potential benefit of home-delivered treatment , further study of this domain is warranted. Fourth, responding to feasibility concerns, Phase I session frequency was changed mid-study, potentially introducing an additional confound; however, the impacts of this confound should be equivalent across groups. Fifth, facilities used for treatment delivery within the hospital condition were limited and generally less comfortable or inviting than may be typical of community-based offices . This may have contributed to less favorable perceptions within this condition, such as in regards to “pleasantness.” Finally, the extent to which findings may generalize to other groups may be limited by the characteristics of the sample .In summary, the results of the study support the conclusions that: (1) intensive CBT is an efficacious treatment for pediatric OCD that produces improvements in a wide variety of domains and is acceptable to patients and their families; (2) adjusting the amount of treatment provided based on patient need/preference is feasible and allows for flexible allocation of resources; and (3) although treatment setting was not found to have a major impact on outcomes, treating patients within their home environment may offer some additional benefits in generalizability and maintenance of gains as well as youth satisfaction. Continued efforts to develop and evaluate individualized approaches to the treatment of pediatric OCD are warranted.estewart@bcchr.ca.The datasets presented in this article are not readily available because sharing of data is dependent on participant consent that data may be shared . Requests to access the datasets should be directed to S. Evelyn Stewart, The studies involving human participants were reviewed and approved by University of British Columbia Children's and Women's Research Ethics Board. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.RS, LF, and SES contributed to conception and design of the study. ZN managed study recruitment, implementation, and data collection. RS, DF-Y, SQ, JF, XD, and DH completed initial assessments and delivered study treatment. CO, LB, and JN completed blinded study assessments. RS, JN, and SES provided supervision and study oversight. JB performed the statistical analysis. RS, ZN, and JB, wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Importantly, novel DLAs targeting Gram-negatives, including the lysin CF-370 and the amurin peptides, are active in biological matrices (blood/serum) and, as such, offer promise for therapeutic use as systemically administered agents for the treatment of life-threatening invasive infections. In this review, DLAs are discussed as potential new classes of antimicrobial biologics that can be used to treat serious systemic infections.Direct lytic agents (DLAs) are novel antimicrobial compounds with unique mechanisms of action based on rapid cell wall destabilization and bacteriolysis. DLAs include two classes of purified polypeptides—lysins (peptidoglycan hydrolase enzymes) and amurins (outer membrane targeting peptides). Their intended use is to kill bacteria in a manner that is complimentary to and synergistic with traditional antibiotics without selection for DLA resistance. Lysins were originally described as having activity against Gram-positive pathogens and of those, exebacase, is the first to have advanced into Phase 3 of clinical development. Recently, both engineered and native DLAs have now been described with potent bactericidal activity against a range of Gram-negative pathogens, including multidrug-resistant (MDR) and extensively drug-resistant (XDR)  Since the introduction of penicillin, new antibiotics have been primarily identified from natural sources, often bacteria and fungi, or as derivatives of pre-existing compounds . There hWhile continued advances in genomics, bioinformatics, and structural biology still offer the promise of finding new small molecule antibiotics, altogether new chemotypes with innovative antimicrobial strategies are providing advanced leads that may eventually become the next generation of compounds in clinical use. Of particular note is a novel family of antimicrobials, recently referred to as “Direct Lytic Agents (DLAs)” by ContraFect Corporation ,b. The Din vitro, ex vivo, or in vivo activity against Gram-negative pathogens. The identification of DLAs that can target Gram-negative bacteria which are amenable to systemic administration represents a major advance in the field, addressing unmet clinical needs by offering potential treatments against antibiotic-resistant pathogens that cause life-threatening infections for which there are no or limited therapeutic options.Herein we review DLAs that are active in blood matrices and can be administered systemically, focusing primarily on the antistaphylococcal lysin exebacase, which is in Phase 3 clinical development, and then on recently described engineered lysins and amurin peptides that have demonstrated via binding to either peptidoglycan or secondary cell wall components  examining the safety, pharmacokinetics, and pharmacodynamics of single dose of LSVT-1701  in 32 healthy male subjects at a single center in South Korea .Lysins with terature . A limitterature . A seconterature . Roivantth Korea . LSVT-17CF-301), which is currently under development by ContraFect Corporation . Exebacase has been granted Breakthrough Therapy designation by the FDA and is the first and only lysin to advance into Phase 3 of clinical development as a systemically administered treatment to improve clinical outcomes for Staphylococcus aureus bacteremia, including right-sided endocarditis . Based on its position as a first-in-class and first-in-field compound, the discovery and development of exebacase is next described, with a focus on its hallmark in vitro microbiologic attributes, efficacy in animal models of infection, and results from a superiority-design, proof-of-concept Phase 2 clinical trial in the United States.Standing out as a potential therapeutic is the lysin exebacase  collected from 2015 to 2017 in the United States, Europe, and South America. The clinical isolates were inhibited at ≤1 μg/ml of exebacase with 50% and 90% of organisms  inhibited at 0.5 and 1 μg/ml, respectively  in all target organs when compared to reductions observed with either antibiotic alone . A singl10 CFU/gram of bone  in a rat model of MRSA osteomyelitis  versus SoCA treatment.As a first-in-class antimicrobial agent with the potential to improve clinical outcomes of al trial . This rap = 0.3137). Importantly, in the pre-specified MRSA subgroup, the clinical responder rate at Day 14 was 42.8 percentage points higher in the exebacase-treated group compared with the SoCA alone group . Furthermore, a 21-percentage point lower 30-day all-cause mortality rate was observed among patients carrying MRSA that received exebacase with SoCA compared with those that received SoCA alone . Among MRSA patients in the United States, the median length of stay was 6 days for patients treated with exebacase and SoCA, compared to 10 days for patients treated with antibiotics alone; a trend toward lower 30-day all-cause readmission rates (48% lower) was also observed in the exebacase-treated group compared with antibiotics alone. Exebacase was, furthermore, generally safe and well-tolerated, with adverse events consistent with those expected in critically ill, hospitalized patients with potentially life-threatening S. aureus bloodstream infection, including endocarditis and/or underlying comorbid conditions.Overall, 70.4% of patients in the exebacase and SoCA group and 60.0% of patients who received SoCA alone, were clinical responders at Day 14  to reach their target peptidoglycan . The OM in vivo to topical use.The long-held belief that the OM barrier precludes use of purified lysins against Gram-negative bacteria was first dispelled by the description of several lysins with “intrinsic” OM penetrating activity. Carboxy-terminal amphipathic α-helices within these lysins mediated translocation across the OM to reach the subjacent peptidoglycan with subsequent hydrolysis and cell killing . The int90 values of 0.5–4 μg/ml against strain sets that include MDR and XDR P. aeruginosa, K. pneumoniae, Escherichia coli, A. baumannii, Enterobacter cloacae, and Stenotrophomonas maltophilia  in addition to meropenem  achieved a 3-log10-CFU reduction per gram of lung compared to a 1-log10 reduction with either meropenem or CF-370 alone  as a treatment for serious and life-threating infections with MDR and XDR Gram-negative pathogens.The Enterobacterales (CRE), P. aeruginosa (CRP), and A. baumannii  peptides, with bactericidal activity against a broad range of Gram-negative ESKAPE bacteria including carbapenem-resistant nii CRA; . Derivednii CRA; .90 values of ≤1 μg/ml were reported against strain sets of P. aeruginosa, A. baumannii, K. pneumoniae, E. cloacae, and E. coli. The amurins are furthermore active in human serum and blood and exhibit many of the hallmark microbiological attributes associated with the lysins including in vitro and ex vivo antibiofilm activity , synergy with up to 11 different conventional antibiotics tested and a low propensity for resistance development (As synthesized peptides, amurins demonstrate a mechanism of action based on rapid OM-permeabilization, distinct from the cell wall hydrolytic activity of lysin enzymes . For selelopment .The discovery of an entirely new class of DLAs with potent activity against MDR and XDR Gram-negative pathogens and with a mechanism of action distinct from lysins brings the promise for further expanding the armamentarium of differentiated antimicrobial agents for treating invasive life-threatening infections.S. aureus bacteremia including right-sided endocarditis. CF-370 is the first DLA that can be administered systemically to treat infections caused by antibiotic-resistant Gram-negative bacteria. This enzyme was developed through protein engineering to allow new lysin specificities permeate through the OM barrier. Finally, the amurin peptides have been shown to be unique DLAs that provide differentiated mechanisms of antimicrobial action. Moving forward, still other lysins, amurin peptides, and perhaps altogether new DLAs are envisioned to reinvigorate the pipeline for new antimicrobial agents to satisfy the unmet medical need of treating infections caused by multidrug-resistant bacteria.In this era of diminished antibiotic susceptibility, DLAs provide new and highly differentiated antimicrobial modalities. The promise for DLAs lies in their diverse mechanisms of action and range of potent activity against both Gram-positive and Gram-negative bacteria. Key microbiological attributes shared among the DLAs are rapid bactericidal activity, antibiofilm activity, synergy with antibiotics, and a low propensity for resistance. Exebacase has provided proof-of-concept data in humans for the DLA platform, as it proceeds through clinical trials to treat life-threatening RS, CC, and XV-F conceptualized and wrote the manuscript. All authors contributed to the article and approved the submitted version.ContraFect receives funding from CARB-X, which is sponsored by the Cooperative Agreement Number IDSEP160030 from ASPR/BARDA and by an award from Wellcome Trust.RS, CC, and XV-F are employees of ContraFect Corporation.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The confounding effects of antipsychotics that led to the inconsistencies of neuroimaging findings have long been the barriers to understanding the pathophysiology of schizophrenia (SZ). Although it is widely accepted that antipsychotics can alleviate psychotic symptoms during the early most acute phase, the longer-term effects of antipsychotics on the brain have been unclear. This study aims to look at the susceptibility of different imaging measures to longer-term medicated status through real-world observation.We compared gray matter volume (GMV) with amplitude of low-frequency fluctuations (ALFFs) in 89 medicated-schizophrenia (med-SZ), 81 unmedicated-schizophrenia (unmed-SZ), and 235 healthy controls (HC), and the differences were explored for relationships between imaging modalities and clinical variables. We also analyzed age-related effects on GMV and ALFF values in the two patient groups (med-SZ and unmed-SZ).p < 0.05, family-wise error corrected). Additionally, GMV loss correlated with psychiatric symptom relief in all SZ. However, medicated status did not influence ALFF values: all SZ showed increased ALFF in the anterior cerebrum and decreased ALFF in posterior visual cortices compared with HC . Age-related GMV effects were seen in all regions, which showed group-level differences except fusiform gyrus. No significant correlation was found between ALFF values and psychiatric symptoms.Med-SZ demonstrated less GMV in the prefrontal cortex, temporal lobe, cingulate gyri, and left insula than unmed-SZ and HC (GMV loss appeared to be pronounced to longer-term antipsychotics, whereby imbalanced alterations in regional low-frequency fluctuations persisted unaffected by antipsychotic treatment. Our findings may help to understand the disease course of SZ and potentially identify a reliable neuroimaging feature for diagnosis. Psychotropic medications have long confounded findings from neuroimaging studies. Their effects result in inconsistent findings and hamper efforts to understand further the pathophysiology of neuropsychiatric disorders such as schizophrenia (SZ). Mounting neuroimaging studies have indicated SZ that features structural deficits spanning the multiple brain regions such as frontal, temporal, and parietal lobes , accompaScholars have emphasized more extensive brain network dysfunction. However, the specific pathological mechanism is not clear, and the high heterogeneity between the studies has also led to more controversy and discussion. For SZ with antipsychotics, there are few studies of structural imaging combined with functional imaging. One of the commonly used functional MRI techniques, such as amplitude of low-frequency fluctuations (ALFF), has been developed, which measures the intensity of spontaneous fluctuation in a particular voxel within the BOLD signal . The intHowever, studies of ALFF in SZ also have given inconsistent results. A recent meta-analysis in SZ indicated the decreased ALFF primarily in the somatosensory cortex, posterior parietal cortex, and occipital cortex and increased ALFF mainly in the bilateral medial temporal cortex and medial prefrontal cortex . Howeverversus treatment response.What the role antipsychotic treatment played on the pathophysiologic process of brain deficits in SZ remains unclear. Antipsychotics have been associated with GMV deficits in the frontotemporal cortex and the whole brain in SZ  but haveFurthermore, although experts agree on the efficacy of antipsychotics in alleviating psychotic symptoms during the early most acute phase (0–2 months), the longer-term effects of antipsychotics on the brain have long been controversial . Given tTherefore, in this study, we examined GMV and ALFF using voxel-based morphometry and resting-state functional magnetic resonance imaging (fMRI) techniques in SZ based on medication status: unmedicated (medication naïve or not taking medications for at least 4 weeks before scan) and medicated . We aimed for a preliminary real-world observation with no study-related and longer-term treatment changes to capture the typical conditions of neuroimaging studies to provide some basis for the identification of objective image indicators in patients with SZ. Thresholds for medication status were determined based on prior findings of antipsychotic effects on the brain as early as 1 month after treatment initiation in SZ and standards for unmedicated status by other studies in the literature . We alson = 31, 38.27%) or not taking antipsychotics for at least 4 weeks at the time of scan  and 235 HCs aged 15–55 years. We reviewed information on the type and dosage of medication recorded at the time of the MRI scan. Med-SZ was treated with antipsychotics including clozapine, risperidone, olanzapine, aripiprazole and quetiapine, aripiprazole, and ziprasidone. The doses of antipsychotics were converted to olanzapine equivalents based on defined daily doses  and 81 individuals with SZ (unmed-SZ) who were either antipsychotics naïve  at the Image Institute of The First Affiliated Hospital of China Medical University, Shenyang, China. The three-dimensional fast spoiled gradient-echo sequence was used to obtain sagittal T1-weighted structural images of the whole brain. Scanning parameters were as follows: repetition time = 7.1 ms, echo time = 3.2 ms, field of view = 24 cm × 24 cm, voxel size = 1 mm × 1 mm × 1 mm, slice thickness = 1.0 mm without a gap, 176 slices in total, and the scan time = 8 min 6 s. Functional images were collected using a gradient echo-planar imaging sequence: repetition time = 2,000 ms, echo time = 30 ms, field of view = 240 cm × 240 cm, flip angle = 90°, matrix = 64 × 64, and slices = 35. Participants were instructed to rest with their eyes closed but remain awake during scanning.1 under the MATLAB R2010b platform . Briefly, the segmentation function was used to divide the regions into GM, white matter, and cerebrospinal fluid using the “new segment” tool implemented in SPM8. During spatial normalization, inter-subject registration was achieved using separate registration based on group assignment. A modulation step was used to ensure that the overall amount of tissue in a class was unaltered. The segmented images were normalized to the Montreal Neurological Institute template and were smoothed with an 8-mm full width at a half-maximum Gaussian filter. The voxel size of data acquisition was 1 mm3, and the voxel size of normalized data was 1.5 mm3.Processing was performed using the DARTEL algorithm Statistical Parametric Mapping software (SPM8)2. Data Processing Assistant for Resting-State fMRI 3 was based on SPM8. For each participant, the first 10 volumes of scanned data were discarded to allow for steady-state magnetization. Further data preprocessing included slice timing correction and head motion correction. Each participant’s motion was assessed by means of translation/rotation and an exclusion criterion . Then, spatial normalization was performed using the standard echo-planar imaging template from the Montreal Neurological Institute Spatial smoothing, which was done with a 6-mm full width at a half-maximum Gaussian filter, and linear detrending was performed to remove linear trends r trends . The filp < 0.05. To compare GMV with ALFF values among the med-SZ, unmed-SZ, and HC groups, whole brain GMV and ALFF values comparisons among three groups were performed using a full-factorial design, with age and sex as covariates, using SPM8 . The GMV and ALFF value differences were considered significant at a height threshold of p < 0.05, family-wise error (FWE) corrected for multiple comparisons, and an extended threshold of 20 voxels  using SPSS. Duration of illness was included as a covariate of non-interest in the patient subgroup comparison. To determine age-related effects on GMV and ALFF values in the two patient groups (medicated and unmedicated), we used the mean values of GMV and ALFF in regions showing the group-level difference and ran a general linear model in SPSS. The GMV and ALFF values were considered as dependent variables. Fixed factors included age and group (med-SZ and unmed-SZ). Analyses were also performed with false discovery rate (FDR) corrected for multiple comparisons to further confirm the findings of age-related effects.Analyses of demographic and clinical characteristics were performed using analysis of variance and chi-square tests. Results were considered significant at 0 voxels . GMV andp < 0.005 was considered significant in correlation analysis.We used exploratory Pearson’s correlation analyses to examine the relationship between GMV/ALFF values and BPRS scores and medication time in each patient group. Analyses were also performed with FDR corrected for multiple comparisons to further confirm the findings of correlation after FDR correction; p = 0.066) or sex (p = 0.248), and handedness (p = 0.640). The unmed-SZ group had significantly shorter illness duration, lower first-episode rate, and higher BPRS scores compared with the med-SZ group   . Comparerrected) .df = 2, p < 0.05, FWE corrected). These clusters are situated in the bilateral occipital lobe, bilateral striatum, and left parahippocampal gyrus   . No signrrected) . Besidesrrected) , 3.In the current study, we compared the susceptibility of different imaging measures with antipsychotics. We found significant GMV decreases in the prefrontal cortex, temporal lobe, cingulate gyri, and left insula in med-SZ compared with unmed-SZ and HC. Among these regions, unmed-SZ demonstrated lower GMV in the left superior temporal cortex and left fusiform than HC additionally. We also found a significant correlation between GMV loss and decline of BPRS scores. No significant differences in ALFF were found based on medication status, and no significant correlations between ALFF and BPRS scores were observed. Both med- and unmed-SZ had significantly increased ALFF in the anterior cerebrum, including bilateral striatum and left parahippocampal, and decreased ALFF in posterior visual cortices, including the calcarine and lingual gyrus, compared with HC. Our findings indicate that GMV may be susceptible to medication effects, whereas ALFF is not in SZ.It is widely accepted that SZ is characterized by extensive GMV abnormalities ; howeverGray matter volume changes in SZ do not appear entirely due to medication effects. We found significant GMV loss in the left superior temporal cortex and left fusiform in unmed-SZ, compared with HC. Previous studies have shown GMV reduction in left posterior superior temporal gyrus and left fusiform in first-episode SZ , 2015. Oversus trait) and treatment response.Gray matter volumes in prefrontal, temporal, cingulate, and insula were positively correlated with BPRS scores, consistent with previous findings . We founWe found age-related differences in GMV between med- and unmed-SZ. More specifically, in patients with med-SZ, imaging studies found accelerated age-related GMV decline than unmed-SZ in all regions showing group-level differences except the fusiform gyrus. To our best knowledge, this is the first cross-sectional study that explores the relation between GMV and age with or without longer medication use. This finding is also consistent with previous studies suggesting that progressive brain GMV changes during the life-long course of SZ appeared in part to be related to antipsychotics . MoreoveHere, we provided evidence focused on the longer-term antipsychotic treatment showing that we may underestimate the risks of longer-term antipsychotic treatment. The temporal relief of symptoms may be a compensation for GMV loss; the coverage of the worrying issue of the longer-term effects of antipsychotics on brain structure loss must not be overlooked. Recently, Our findings with ALFF suggest that ALFF is less influenced by medication and disease state. We found increased ALFF in the anterior cerebrum, including the bilateral striatum, and decreased ALFF in the posterior visual cortex, consistent with previous studies in both unmed- and med-SZ . A meta-Bilateral lingual and calcarine gyrus, which function as the primary visual cortex, have been related to visual hallucinations in most studies , suggestNo significant correlation was found between ALFF and BPRS, indicating that amplitude cannot be used as a quantitative marker for the assessment of symptoms of SZ, although it can be used in a qualitative way to help locate aberrant functional areas. Previous studies have shown that striatal ALFF was not associated with psychotic symptom severity in the first episode and medication naïve SZ . Anna etThere are several limitations to this study. As this represented a real-world observational study, data regarding medication dose, compliance, and duration were not available or included in our analyses. Besides, the ratio of antipsychotic-naïve in the unmed-SZ was 38.3%, which may be a potential confounding effect of medication exposure in the unmed-SZ group. Furthermore, the study was cross-sectional and not longitudinal, in which the same individual was observed in medicated and unmedicated state, although the demographic data among the three groups have been matched to reduce the influence of confounding factors to a certain extent. Thus, further research is needed to confirm the generalizability of our findings.versus remitted). Our study underscores the need for careful selection of neuroimaging measures based on study purpose and the focus on longer-term antipsychotics .Through real-world observation, our study suggests that GMV is a sensitive spatiotemporal marker of longer-term pharmacologic intervention in the brain, whereas ALFF is a relatively static measure reflecting more core disease traits that are less influenced by medication status and disease state (e.g., active The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Medical Science Research Ethics Committee of The First Affiliated Hospital of China Medical University. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.FW and YT designed the experiments. YC, MC, RF, JD, ZY, YW, SW, and XJ acquired the data. YC, RF, and XZ analyzed the data. YC and FW wrote the manuscript. FYW and FW reviewed or edited the manuscript. All authors discussed the results, reviewed the manuscript, and meet the criteria for authorship to be named as authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Imaging sonar systems are widely used for monitoring fish behavior in turbid or low ambient light waters. For analyzing fish behavior in sonar images, fish segmentation is often required. In this paper, Mask R-CNN is adopted for segmenting fish in sonar images. Sonar images acquired from different shallow waters can be quite different in the contrast between fish and the background. That difference can make Mask R-CNN trained on examples collected from one fish farm ineffective to fish segmentation for the other fish farms. In this paper, a preprocessing convolutional neural network (PreCNN) is proposed to provide “standardized” feature maps for Mask R-CNN and to ease applying Mask R-CNN trained for one fish farm to the others. PreCNN aims at decoupling learning of fish instances from learning of fish-cultured environments. PreCNN is a semantic segmentation network and integrated with conditional random fields. PreCNN can utilize successive sonar images and can be trained by semi-supervised learning to make use of unlabeled information. Experimental results have shown that Mask R-CNN on the output of PreCNN is more accurate than Mask R-CNN directly on sonar images. Applying Mask R-CNN plus PreCNN trained for one fish farm to new fish farms is also more effective. In modern aquaculture, fish states are constantly monitored to ensure the health of the cultured fish. Because computer vision can provide noninvasive means of monitoring, computer vision-based systems have been developed for a variety of applications in aquaculture ,2.The visual quality of underwater images can be poor because light can be heavily attenuated and scattered in water. Underwater image enhancement is usually required for analysis of the image of underwater objects ,4. On thFish segmentation is often required for computer vision-based monitoring of fish growth and behavior. Deep convolutional neural networks (CNNs) for instance segmentation, such as SGN , FCIS 1, Mask R-As Decoupling learning of fish instances from learning of fish-cultured environments: PreCNN learns a mapping from sonar images to a semantic feature map. Mask R-CNN is fine-tuned on the semantic feature map. Thus, learning of fish instances and learning of fish-cultured environments can be separated.Utilizing temporal information in successive sonar-image frames: In noisy sonar images, fish identification is usually more accurate by multiple frames than by a single frame;Semi-supervised learning: To reduce annotation costs, ambiguous pixels and pixels similar to annotated background pixels are not required to annotate. Images with partial or no pixel-level annotations can be used to train PreCNN in a semi-supervised learning manner.Mask R-CNN+PreCNN has the advantages:Experimental results have shown that PreCNN can improve the accuracy of Mask R-CNN for fish segmentation, especially across different fish-cultured environments.This paper is organized as follows. Related works are presented in To monitor the states of fish in underwater areas with low optical visibility, imaging sonar systems are often without alternative. Applications of imaging sonar systems in aquaculture are broad, such as fish counting ,17,18,19Object detection and image segmentation algorithms have been developed to detect objects in sonar images. In ,27,28, uMask R-CNN is widely used for instance segmentation in optical images, such as fish detection  and shipMany CNNs for semantic segmentation ,34,35,36In , it turnThe attention mechanism has been applied to semantic segmentation. In , an atteDue to the high cost of pixel-level annotations, weakly- and semi-supervised learning algorithms of semantic segmentation, such as ,45,46, hIn summary, sonar images can be noisy in shallow waters. CRFs can be integrated into PreCNN to get spatial consistent label maps. Since it is not easy to empirically set parameters for CRFs on sonar images, freeform pairwise potentials for CRFs with all parameters trainable are required. Besides, to get rid of laboriously annotating every pixel of a sonar image, end-to-end training for PreCNN in a semi-supervised learning manner is also preferable.Let i. The probability of Let ution as ,39P and the head of Mask R-CNN were fine-tuned by the mini-batch stochastic gradient descent algorithm with at most 200 epochs.The proposed algorithm was implemented in the Python programming language with software libraries OpenCV, Keras, and TensorFlow. The experiments were performed on a desktop with an Intel Core i7-7700 3.6-GHz CPU, 64-G RAM, and one NVIDIA TITAN RTX GPU card.In this experiment, the ground truth for a test image does not include ambiguous fish due to annotation difficulty. The average precision (AP) was estimated by five-fold cross-validation. Thus, a high AP indicates that most of the annotated fish are detected and have a high rank in the list of the detected fish. A low AP reveals that many annotated fish are not detected or there are many ambiguous fish, which are not ground-truthed, have a high rank in the list of the detected fish.The APThe APThe APThe APThe overall APWhen the training and test examples are of different environments, Mask R-CNN+ PreCNN is more accurate than Mask R-CNN. Besides, even though Mask R-CNN is fine-tuned on the examples of the three test environments, Mask R-CNN+PreCNN learned on the training example of one single test environment is at least as accurate as Mask R-CNN. That experimental result shows that Mask R-CNN based on the semantic feature map outputted by PreCNN is less dependent on the environment and supports the feasibility of the proposed approach.Because the APAs This experiment compared Mask R-CNN incorporated with contrast stretching and bilateral filtering to Mask R-CNN+PreCNN. The test for Mask R-CNN with contrast stretching evaluates if contrast stretching can transfer the training sonar image collected from one test environment into the training sonar image for the others. The test for Mask R-CNN with bilateral filtering evaluates if Mask R-CNN on the sonar image preprocessed with bilateral filtering is more accurate. Mask R-CNN+PreCNN is more accurate than Mask R-CNN incorporated with contrast stretching and bilateral filtering because PreCNN is a nonlinear mapping from successive sonar-image frames to a semantic feature map.PreCNN only based on the CNN for YOLOv4  is a welIn this experiment, sixteen sonar images from environment E-A were selected for testing Mask R-CNN+PreCNNIn this paper, a preprocessing CNN has been proposed to provide “standardized” feature maps for Mask R-CNN for fish segmentation in sonar images. The proposed preprocessing CNN is a semantic segmentation network and integrated with conditional random fields. The preprocessing CNN is aimed at decoupling learning fish instances from learning fish-cultured environments. As a result, the proposed approach can improve Mask R-CNN for segmenting fish in sonar images and can also ease applying Mask R-CNN across fish-cultured environments. In the future, the efficiency of the proposed framework will be improved by developing a lightweight fish-instance segmentation network on the proposed preprocessing CNN.


Background: Shock index  is a simple scale with prognostic value in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). The present study introduces an updated version of SI that includes renal function.Methods: A total of 1,851 consecutive patients with STEMI undergoing PCI were retrospectively included at Cardiac Care Unit in Guangdong Provincial People's Hospital and divided into two groups according to their admission time: derivation database  and validation database . Shock Index-C (SIC) was calculated as (SI × 100)–estimated CCr. Calibration was evaluated using the Hosmer-Lemeshow statistic. The predictive power of SIC was evaluated using receiver operating characteristic (ROC) curve analysis.Results: The predictive value and calibration of SIC for in-hospital death was excellent in derivation  and validation cohort . SIC exhibited better predictive power for in-hospital events than SI . Cumulative 1-year mortality was significantly higher in the upper SIC tertile .Conclusion: SIC was an effective predictor of poor prognosis and may have potential as a novel and simple risk stratification tool for patients with STEMI undergoing PCI. Despite advanced evidence-based medical treatments and the widespread use of percutaneous coronary intervention (PCI), ST-segment elevation myocardial infarction (STEMI) is a leading cause of mortality worldwide . The in-Shock index (SI), defined as the ratio of heart rate to systolic blood pressure, is a simple risk-stratification tool used to evaluate patients with STEMI . HoweverWe retrospectively enrolled 1,907 consecutive patients with acute STEMI undergoing PCI at the Cardiac Care Unit in Guangdong Provincial People's Hospital between January 2010 and April 2016. STEMI was diagnosed according to the American College of Cardiology Foundation/American Heart Association guidelines . This stClinical data were collected from the electronic case report form by one researcher and randomly confirmed by another researcher. Data collected included patient demographics, previous medical history, laboratory results, PCI procedural details, adverse events, and medical treatment. Vital signs including blood pressure and heart rate were obtained from data recorded at admission. SI was calculated using the following formula: heart rate (bpm)/systolic blood pressure (mmHg). Estimated creatinine clearance rate (CCr) was calculated with the published equations for Cockcroft-Gault: man: (140–age)/ Scr, woman:(140–age) /Scr × 0.85 . SIC wasAll surviving in-hospital patients were followed-up through telephone interviews. We reviewed hospital readmission records and outpatient clinic interviews for possible events. The primary endpoints were in-hospital and 1-year mortality. In-hospital major adverse clinical events (MACEs) such as stroke, dialysis, acute heart failure, and target vessel revascularization (TVR) during hospitalization were used as a composite end point. In addition, CI-AKI and bleeding were recorded. Contrast-induced acute kidney injury was defined as elevation of Scr by 50%, or 0.3 mg/dL from baseline, within 48 h, according to the Kidney Disease: Improving Global Outcomes criteria .t and non-parametric tests, respectively. Categorical variables are displayed as numbers and percentages, were compared using chi-square tests. The Hosmer-Lemeshow goodness-of-fit test was used to assess the goodness of fit of the final regression model. Receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal cut-off levels of SIC for prediction of adverse events. Decision curve analysis was used to compare the predicting performance for in-hospital mortality by quantifying the net benefits. Area under the curve values were compared using the nonparametric approach described by DeLong et al. .Normally distributed continuous data are presented as the mean ± standard deviation, and non-normally distributed continuous data are presented as the median and interquartile range, which were compared using independent sample g et al. . In addin = 1,145) and validation database . Higher SI, lower CCr and left ventricular ejection fraction (LVEF), less stents implantation and usage of Angiotensin-Converting Enzyme Inhibitors (ACEIs) /Angiotensin Receptor Blockers (ARBs) and β-blocker were found in validation database  died, 118 (6.4%) suffered acute heart failure, 70 (3.8%) received hemodialysis treatment, 12 (0.6%) received TVR, and 23 (1.2%) had strokes. The rate of CI-AKI and any bleeding were 10.0% and 10.4%, respectively. There was no statistical difference for in-hospital events between derivation and validation database, except for dialysis . In addition, the predictive power was higher than SI , −30 to −5 (n = 567), and ≥-5 (n = 700). The incidences of in-hospital mortality  and ≤ 10 . The incidences of in-hospital mortality  based on the ROC curve for in-hospital death: >10 , SIC can be used to assess and stratify the risk for multiple events rapidly and precisely, at no additional cost or effort.Our study suffered from several limitations. First, this study was retrospective, of moderate-scale, and from a single center, and this score should be externally validated in a large-scale multicenter study. Second, blood pressure was not invasively measured in catheterization room, which is more reliable than sphygmomanometer. However, it could represent the contemporary and real-world clinical practice. Third, the predictive value of SIC was only validated in patients with STEMI undergoing PCI, and caution should be used when using this scale to evaluate patients not undergoing PCI. Fourth, the proportion of female in this study was relatively small, the predictive ability should be validated in another female cohort of STEMI, despite the good discrimination power in the subgroup analysis.In conclusion, we showed that SI was a good prognostic indicator in patients with STEMI undergoing PCI, but its discriminatory ability was insufficient. Addition of renal function to SI resulted in better predictive power and good calibration. SIC had similar predictive value for in-hospital death as GRACE score, and better discrimination power than TIMI risk scales. In addition, SIC showed modest predictive value for CI-AKI and bleeding. Higher SIC was an independent predictor for 1-year mortality. This indicator might provide prognostic information for early and rapid risk assessment of patients with STEMI undergoing PCI.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of Guangdong Provincial People's Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.J-yC, D-qY, and GL contributed to the conception or design of the study. PR, X-bW, Y-wL, J-lH, X-yH, and J-qY contributed to the acquisition, analysis, or interpretation of data. PR, X-bW, and Y-wL drafted the manuscript. J-yC and D-qY critically revised the manuscript. All the authors gave final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.