Background and Objectives: Children with developmental coordination disorder (DCD) have difficulty learning motor skills, which can affect their participation in activities of daily living and psychosocial well-being. Over 50% of children with DCD also have attention deficit hyperactivity disorder (ADHD), which further exacerbates their motor problems and impact on quality of life. A rehabilitation approach known as Cognitive Orientation to Occupational Performance uses problem-solving strategies to help children learn motor skills they wish to achieve. While this cognitive approach has been effective for children with DCD, few studies have examined the effectiveness of this approach for children with co-occurring ADHD. Further, the underlying mechanism and neural basis of this intervention are largely unknown.Methods: In this randomized waitlist-controlled trial, we used MRI to examine white matter microstructure after intervention in 8–12-year-old children with DCD (n = 28) and with DCD and co-occurring ADHD (n = 25). Children in both groups were randomized to either a treatment group or waitlist group at their first MRI. The treatment group began the intervention after their MRI scan and returned for a post-treatment scan at 3 months, and follow-up scan at 6 months; the waitlist group waited 3 months before their second MRI, received the intervention, and then had a post-treatment scan. Each child received intervention once weekly for 10 weeks. Diffusion tensor imaging was used to acquire white matter diffusion parameters and was analyzed using tract-based spatial statistics (TBSS).Results and Conclusion: Children with DCD showed significant improvement in white matter microstructure in the bilateral anterior thalamic radiation, bilateral sensorimotor tract, bilateral cingulum, fornix, splenium and body of corpus callosum, right inferior fronto-occipital fasciculus, and white matter pathways to bilateral inferior gyri, right middle frontal gyrus, frontal medial cortex, and left cuneus. We suggest that these rehabilitation-induced neural changes in children with DCD occurred in regions associated with attention, self-regulation, motor planning, and inter-hemispheric communication, which positively affected brain connectivity and motor function. In contrast, children with DCD and co-occurring ADHD did not show any brain changes following the intervention. Modifications to the treatment protocol might help address the attentional and self-regulatory needs of children with a dual diagnosis.Clinical Trial Registration: ClinicalTrials.gov ID: NCT02597751. Up to 5 to 6% of all school-age children may be affected by developmental coordination disorder (DCD), a neurodevelopmental disorder characterized by difficulty performing and learning motor skills that significantly interferes with daily activities and academic achievement  is one of the recommended treatments for DCD as per international clinical guidelines , we used computer-generated sequential blocks of four to six, prepared by a statistician to randomize children with DCD, with or without ADHD, into treatment and waitlist groups. To ensure a power of 90% to detect a 3% difference in axial diffusivity (AD) with a type-1 error of 0.01, we used our pilot study on DTI in this population . Children aged 8–12 years were eligible to participate in the study if they were diagnosed with DCD as per the Diagnostic and Statistical Manual–5th edition , followed by post-intervention assessment, a second (post-treatment) MRI scan, and a third follow-up MRI scan 3 months later to determine if brain changes were maintained after the intervention was discontinued. In contrast, children in the waitlist group were scanned 3 months after their first MRI, received their pre-assessments and intervention, followed by a third (post-treatment) MRI. A study design schematic  Canadian Occupational Performance Measure  detection and replacement  to extract quality metrices of within-and between-volume average relative motion, absolute relative motion, signal-to-noise ratio (SNR), and contrast-to-noise ratio , the degree of anisotropy/directionality of water diffusion in each voxel; mean diffusivity (MD), average amount of water diffusion independent of directionality in each voxel; axial diffusivity (AD), water diffusivity along the tract; radial diffusivity (RD), water diffusivity perpendicular to the tract  to analyze whole-brain white matter microstructural properties without pre-specification of tracts of interest  with an alpha level of 0.05 was applied to correct for multiple testing errors. We also used PALM to run a generalized linear model and investigate the effect of motor outcomes , low MRI quality , and child disliked MRI . See Eighty children were recruited for this study; two children with DCD + ADHD declined to participate. Of the 78 children enrolled and randomized into treatment and waitlist groups, 37 children were diagnosed with DCD  and 41 children were diagnosed with both DCD and ADHD . Nine children with DCD and 16 children with DCD + ADHD were excluded from the analysis due to false inclusion  and follow-up analyses  were performed with fewer participants. At the time of intervention, three children with DCD and 13 children with DCD + ADHD took ADHD-related medications . Accordingly, we compared pre-and post-intervention scans from 28 children with DCD  and 25 children with DCD + ADHD . Due to the quality of baseline and follow-up scans, maturation effect  and anterior limb of internal capsule  as well as a significant increase in MD and RD (FWE-p < 0.01) of the right anterior thalamic radiation, bilateral corticospinal tract, bilateral inferior longitudinal fasciculus, bilateral superior longitudinal fasciculus, bilateral inferior fronto-occipital fasciculus, bilateral cingulum, corpus callosum, and right anterior corona radiata, posterior limb of internal capsule, and retrolenticular part of internal capsule  in FA of the bilateral anterior thalamic radiation, bilateral sensorimotor tract, bilateral cingulum, fornix, splenium and body of corpus callosum, right inferior fronto-occipital fasciculus, and white matter pathways to the bilateral inferior gyri, right middle frontal gyrus, frontal medial cortex, and left cuneus  and changes in white matter microstructure in children with DCD.p > 0.05) in any of the DTI parameters in the 3-month period before CO-OP intervention (n = 10), immediately after the intervention (n = 25), or in the follow-up scan (n = 13). We did not find any relationship between motor performance and white matter parameters.Children with DCD + ADHD did not show any significant change  and supplementary motor area (SMA) through the corticospinal tract , these results should be interpreted with caution. Second, it could be related to the unique role of brain function and structure in supporting a specific behavior  and reduced statistical power.In addition, we were not able to find any maturational changes in the white matter microstructure of children with DCD + ADHD prior to the intervention, indicating that their brain development does not follow a typical trajectory. This finding should be interpreted with caution as this might be due to a smaller sample size , they did not show any changes in white matter microstructure after the intervention. This is in line with Green et al.’s  study inAdditionally, literature suggests that only hyperactivity symptoms of children with ADHD improve over time, and this improvement is highly correlated with reduced FA in the left corticospinal tract (Francx et al., Taken together, some modifications to the CO-OP protocol to better address the attentional needs of children with ADHD (Gharebaghy et al., A smaller than anticipated sample size for the analysis could have biased our results. This study is the first study to use DTI to investigate training-induced brain changes in children with DCD; however, we only performed a voxel-wise analysis of the white matter microstructure, which has spatial inaccuracy (Edden and Jones, Our results indicate that the CO-OP intervention induces microstructural changes in white matter tracts involved in self-, attention-, and emotion-regulation and white matter structures involved in intra-and inter-hemispheric transfer of motor information. These changes were maintained 3 months after the intervention. However, children with a dual diagnosis of DCD and ADHD did not show any microstructural changes following CO-OP intervention, suggesting their different needs in motor-based interventions. These results are consistent with our functional connectivity results of improved motor performance and associated increases in functional connectivity of DMN with the pACC after CO-OP intervention in children with DCD, but not in children with a dual diagnosis of DCD and ADHD (Izadi-Najafabadi et al., 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 University of British Columbia/BC Children’s and Women’s Research Ethics Board. Written informed consent to participate in this study was provided by the participants’ parent/legal guardian. Child assent was also obtained.SI was responsible for participant screening, data collection, data processing, statistical data analysis, data interpretation, and drafting the manuscript. JZ conceived and designed the study, coordinated and supervised data collection, and critically reviewed the draft manuscript for intellectual content. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study aimed to investigate the risk of Alzheimer’s disease among patients with age-related macular degeneration and its association with confounding comorbidities.This was a population-based, retrospective cohort study. By accessing data from the National Health Insurance Research Database of Taiwan, we identified 10,578 patients aged 50–100 years who were newly diagnosed with age-related macular degeneration between 2000 and 2012 and 10,578 non- age-related macular degeneration individuals. The comorbidities assessed were osteoporosis, diabetes, cirrhosis, cerebrovascular disease, chronic kidney disease, hypertension, hyperlipidemia, coronary artery disease, and chronic obstructive pulmonary disease.Patients with age-related macular degeneration had a 1.23-fold increased risk of their condition advancing to Alzheimer’s disease . The younger patients were diagnosed with age-related macular degeneration, the more likely patients got Alzheimer’s disease . In addition, there were significantly higher risks of Alzheimer’s disease for patients with cirrhosis  in the age-related macular degeneration cohort than in the non-age-related macular degeneration cohort.Patients with age-related macular degeneration may exhibit a higher risk of Alzheimer’s disease than people without age-related macular degeneration. Alzheimer’s disease (AD) is a neurodegenerative disorder characterized by progressive and irreversible cognitive impairment. AD is the most common cause of dementia in the elderly, with an estimated 44 million people having AD worldwide, and the prevalence is predicted to triple by 2050 . The chaThe exact etiology and pathogenesis of AD remain unclear. Over the past two decades, the amyloid cascade hypothesis has been one of the most acceptable theories , 5. Aβ sAge-related macular degeneration (AMD) is another neurodegenerative disease that mainly affects the aging population. The disease results in progressive central vision loss and is the fourth leading cause of blindness worldwide , 11. TheBecause of the similarity in pathologic features between AMD and AD, there has been an increasing interest in investigating the potential link between the two diseases in recent years. However, most studies on the association between AMD and AD have shown paradoxical results. Several publications have documented that AMD was associated with cognitive impairment and dementia –29. On tThe requirement for informed consent was waived by both the National Health Insurance (NHI) Administration and China Medical University Hospital Research Ethics Committee.Taiwan adopted a single-payer NHI program in March 1995. It is mandatory for Taiwanese citizens to enroll in the program; the coverage rate of NHI is over 99 percent. We used the Longitudinal Health Insurance Database 2010 (LHID 2010), which contains the claims data of 1,000,000 beneficiaries randomly sampled from the National Health Insurance Research Database (NHIRD). No significant differences in age and sex were found between the LHID 2010 and the enrollees in the mother NHIRD. Patient demographic characteristics included encrypted identification numbers, sex, dates of birth and death, diagnostic data, and procedures. The diagnostic data were coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The accuracy of the diagnosis codes of common conditions in NHIRD has been validated –33. ThisWe included 10,578 individuals aged at 50–100 years who were newly diagnosed with AMD  by certified ophthalmologists between 2000 and 2010 in the AMD group. The date of the first outpatient visits or inpatient visit for AMD was defined as index date. For comparison, each AMD patient was frequency matched with an individual without AMD based on gender, age (in 5-year bands), and index-year. The exclusion criteria was patients with a pre-existing diagnosis of AD (ICD-9-CM 331) in both AMD cohort and control cohort. All study subjects were followed up until the appearance of AD, death, withdrawal from the insurance program or the end of study period .All included patients were followed from the index date until the occurrence of the endpoint, withdrawal from the NHI program, or the end of 2013. The potential comorbidities included osteoporosis (ICD-9-CM code 733), diabetes (ICD-9-CM code 250 and A181), cirrhosis (ICD-9-CM code 571 and A347), cerebrovascular disease , chronic kidney disease , hypertension , hyperlipidemia (ICD-9-CM code 272), coronary artery disease (ICD-9-CM code 410–414), and chronic obstructive pulmonary disease .Descriptive statistics of demographics and comorbidities were summarized by counts, percentages, averages, and standard deviations (SDs) for the AMD and non-case cohort. Chi-square and Wilcoxon rank-sum tests were used to examine the differences in the characteristic distributions between the two cohorts. The cumulative incidence for AD was estimated using Kaplan-Meier methods and significance of the difference between the AMD cohort and the non-case cohort were tested using log-rank test. The incidence rate was calculated as the number of events divided by the person-years during the follow-up. The univariate Cox proportional hazards model was used to compute the hazard ratio (HR) and the 95% confidence interval (CI) for AD in the AMD cohort when compared to the non-case cohort. And the multivariate Cox proportional hazards model with covariates of gender, age, and comorbidities was used to compute the adjusted hazard ratio (aHR) and the 95% CI for AD in the AMD cohort when compared to the non-case cohort. Data analysis in this study was performed using SAS statistical software , with statistical significance set at a p value < 0.05.p = 0.003)). p <0.0001).The Kaplan–Meier plot of the cumulative incidence of Alzheimer’s disease in AMD and comparison cohort is depicted in This large-scale, nationwide, retrospective cohort study showed that patients with AMD exhibited a 1.23-fold higher risk of developing AD  than patients without AMD. Old age, cerebrovascular disease, and chronic obstructive pulmonary disease were also risk factors for AD. AMD patients who were female, younger age and with cirrhosis had a significant higher risk of developing AD.Several publications have documented that AMD is associated with increased risk of AD or cognitive impairment. In 2006, the Blue Mountains Eye Study showed that people with late AMD were associated with lower Mini-Mental State Examination scores than people without AMD . A crossAging is the primary risk factor for both AD and AMD . OxidatiThe strength of this study is the use of NHIRD, a nationwide population-based database, which covers over 99% of medical claims data of citizens in Taiwan, reducing the likelihood of selection and participation bias. However, some limitations should be noted. First, some confounding variables were unavailable in NHIRD. Smoking habit, alcohol consumption, body mass index, physical activity, and family history of AD could not be adjusted in the data analysis. Second, NHIRD lacks imaging findings, neuropsychological assessment results, and laboratory data. Third, AD, AMD, and additional comorbidities cases were identified using ICD-9-CM codes. Same as all claims databases, the accuracy of diagnosis codes is still a concern. However, several studies have validated the positive predictive value of the diagnostic ICD9-CM codes for common diseases, such as ischemic stroke, hypertension, diabetes and all cancers –33. FinaIn conclusion, our study suggests that patients with AMD have a higher risk of AD than people without AMD. The exact pathological factors are still poorly understood, and further studies need to be conducted to explore the underlying mechanism between AD and AMD.S1 Data(DOCX)Click here for additional data file.


To understand the behavior and function of bone-marrow mesenchymal cells (BMMCs), we overviewed the morphological presentation of BMMCs in bone-marrow granules (b-BMMCs), isolated BMMCs (i-BMMCs), and BMMCs (c-BMMCs) cultured in H4434 methylcellulose semisolid and MEM media. All samples were derived from bone-marrow aspirates of 30 patients with hematocytopenia. Light microscopy exhibited b-BMMCs and i-BMMCs characterized by abundant cytoplasm and irregular shape in bone-marrow smears, as well as c-BMMCs in culture conditions. Scanning electron microscopy demonstrated cultured c-BMMCs with a sheet-like feature enveloping hematopoietic cells. Transmission electron microscopy revealed b-BMMCs constructing a honeycomb-like structure by thin bifurcate processes among hematopoietic cells. Furthermore, i-BMMCs had bifurcate parapodiums on the surface and prominent rough endoplasmic reticulum (rER) connected with the plasmalemma of the parapodiums. The detailed images suggested that rER may serve as a membrane resource for plasmalemmal expansion in BMMCs in bone marrow. In the bone-marrow granules, which are regarded as having a good replication of the in vivo state of bone marrow, BMMCs within areas of organized bone-marrow tissue were designated as b-BMMCs, while solitary BMMCs also from bone-marrow granules but not closely associated with any other cells as in a tissue, were designated as i-BMMCs (“isolated” BMMCs). The i-BMMCs appear to have become detached as solitary cells during the aspiration process. BMMCs in culture were designated as c-BMMCs.Bone-marrow mesenchymal cells (BMMCs) construct hematopoietic microenvironments to regulate hematopoietic stem/progenitor cells (HSPCs) in bone marrow. The morphologic relationship between BMMCs and HSPCs has been analyzed from the 1960s to 1990s,. Sometimes, i-BMMCs were found among hematopoietic cells in bone-marrow smears, characterized by a round nucleus, irregular processes with granular cytoplasm and vacuoles .Bone-marrow granules varied in size and contained many hematopoietic cells (erythrocytes and granulocytes) in bone-marrow smears. Most b-BMMCs were difficult to distinguish from hematopoietic cells and macrophages on account of cellular overlapping in large bone-marrow granules, but some b-BMMCs clearly exhibited a round nucleus and irregular shape with cytoplasmic processes around hematopoietic cells in small bone-marrow granules Fig. A, B. Somles Fig. C.In semithin sections of Epon 812 blocks, b-BMMCs showed a main body with a nucleus and scanty cytoplasm, and long thin processes around hematopoietic cells. Proximate processes were usually thick and divaricated into thinner ones between hematopoietic cells. Additionally, there was a circular crevice between hematopoietic cells and processes. The circular crevices and processes constructed a single compartment for each hematopoietic cell . On the other hand, c-BMMCs in MEM media were flat and polygon-like, and positive for CD44 and α-SMA . By SEM, these c-BMMCs looked like a huge thin blanket, enveloping and supporting blood cells , but most b-BMMCs were fully developed, characterized by a smaller main body with an ovoid nucleus and more bifurcated processes among hematopoietic cells. They included plentiful rER, lysosomes and phagosomes in the peripheral cytoplasm and proximate processes . Sometimes, a few b-BMMCs connected together and enclosed hematopoietic cells by processes . The processes usually divaricated hierarchically and became thinner and thinner between hematopoietic cells. Distal processes were from 60 to 80 nm thick and contained few cellular organelles, which constructed a honeycomb-like structure for hematopoietic cell in bone-marrow granules . Most rER cisternae were expanded and divaricated, demarcating cytoplasm into segments like those in megakaryocytes.14 The segments of cytoplasm were of the same size as parapodiums on the cell surface. In higher-power views, rER often appeared to open on to the cell surface and connect with the plasmalemma of i-BMMCs .i-BMMCs were about 60 μm in diameter, including a round nucleus, plentiful lysosomes, rER, and many bifurcate parapodiums on the cell surface  are a heterogeneous group of cells with distinctive morphological features that construct hematopoietic microenvironments by varied physical structures and releasing different hematopoietic factors in bone marrow. Each BMSC is located in a specific region, for example, osteoblasts, osteoclasts and chondrocytes line the endosteal surface, whereas adventitial cells and pericytes are adjacent to the outer wall of sinusoids and perivascular regions.5In the present study, b-BMMCs showed irregular processes with blurred boundaries among hematopoietic cells; however, i-BMMCs exhibited a round nucleus and coarse processes with granular cytoplasm in bone-marrow smears. The above appearances were seldom described because of the difficulty in identifying them in obscure images in bone-marrow smears by light microscopy. In semithin sections of Epon 812 blocks, b-BMMCs exhibited the original morphology of those in vivo, characterized by a main body with an oval nucleus and many bifurcate processes projecting out between hematopoietic cells. In culture conditions, most c-BMMCs were spindle shaped, but some of them were flat. The flat BMMCs often adhered to hematopoietic cells and showed AKP activity in H4434 methylcellulose semisolid medium. All c-BMMCs in MEM media were flat and polygonal, and positive for CD44 and α-SMA. The results were consistent with other observations.On TEM, b-BMMCs stretched out many bifurcate processes among hematopoietic cells, most of them about 60 nm thick, more than 3 times that of the plasmalemma, and constructed a honeycomb-like meshwork for hematopoietic cells in bone-marrow spaces. The question arises: how do b-BMMCs obtain the large amount of membrane to supplement the plasmalemma on these processes in bone marrow?In attempting to answer this question, it should be noted that i-BMMCs had many parapodiums on the surface and plentiful rER in the cytoplasm compared with the processes and cytoplasm of b-BMMCs. The morphologic differences might be associated with external factors: parapodiums on i-BMMCs resulted from the release of hematopoietic cells and process retraction of b-BMMCs during bone-marrow aspiration. In contrast, processes of b-BMMCs resulted from the squeezing and pressing together of hematopoietic cells in bone marrow. Furthermore, detailed TEM images demonstrated that rER were bifurcated in the peripheral cytoplasm and connected with plasmalemma of i-BMMCs. It suggested that the huge plasmalemma of b-BMMCs may be derived from cytoplasmic rER. In other words, rER may contribute the membrane component and, in effect, be the origin of the processes of BMMCs in bone marrow.22 In fact, the conventional view has been that vesicles and phagosomes act predominantly as transporters or carriers of proteins rather than being a membrane resource for the plasmalemma.24Theoretically, plasmalemma is supplemented by the enveloping membrane of recycling phagosomes and vesicles from Golgi apparatus; membrane of the Golgi apparatus was mainly derived from rER during protein transport in well-developed cells.26 In particular, the morphology of b-BMMCs was influenced by environmental factors, that is, bifurcate processes were associated with a pressing together of hematopoietic cells. However, this specific network demands a large amount of membrane to supplement the plasmalemma of b-BMMCs in bone marrow. In this study, evidence has been provided for the phenomenon of prominent rER connecting with plasmalemma, which suggested that plasmalemmal expansion was closely related to transformation of rER in the cytoplasm of b-BMMCS in the same way as occurs in yeast cells.28Cell morphology and structure was not only determined by cytoskeleton components of actin, tubulin, myosin, dynamin, actinin and supervillin filaments, but also was influenced by other cells in multicellular tissues.30 Some experiments have recently revealed that rER contacted the plasmalemma and participated in macrophage phagocytosis.33 Gagnon and colleagues34 showed that phagosome membranes were derived from rER in addition to plasmalemma during macrophage phagocytosis. The relationship between the plasmalemma and endoplasmic reticulum has also been investigated and identified in various cells in recent decades.37 These studies reinforce the presumption that rER of BMMCs may be transformed into plasmalemma in human bone marrow  was detected by cytochemistry after 14 days. Other mononuclear cells were incubated in MEM media with 10% fetal bovine serum for a week, and c-BMMCs on the bottom surfaces of dishes were also identified by monoclonal antibodies for CD44 and α-smooth muscle actin (α-SMA) immunocytochemically.The c-BMMCs, adhering with hematopoietic cells on the bottom surfaces of dishes with MEM media, were processed for SEM. Mononuclear cells and bone-marrow granules isolated from bone-marrow aspirates were processed according to TEM procedures. Briefly, the samples were fixed in 2.5% glutaraldehyde, postfixed in 1% osmium tetroxide, washed in phosphate-buffered saline, dehydrated in graded alcohols and embedded in Epon 812. Ultrathin sections at 60 nm were stained with uranyl acetate and lead citrate. The b-BMMCs and i-BMMCs were observed by TEM.


Germinal centers (GCs) are essential sites for the production of high-affinity antibody secreting plasma cells (PCs) and memory-B cells (MBCs), which form the framework of vaccination. Affinity maturation and permissive selection in GCs are key for the production of PCs and MBCs, respectively. For these purposes, GCs positively select “fit” cells in the light zone of the GC and instructs them for one of three known B cell fates: PCs, MBCs and persistent GC-B cells as dark zone entrants. In this review, we provide an overview of the positive selection process and discuss its mechanisms and how B cell fates are instructed. This specialized microstructure transiently forms within the B cell follicles of secondary lymphoid organs during the course of T cell-dependent immune responses. The process of increasing antibody affinity is known as affinity maturation , 2 and rdivision –9. GC-B in vivo  -B cells . Alterna-B cells . Thus, rr (BAFF)  which car (BAFF) , 57. Undlsewhere –60]. In lsewhere , may plain vitro microscopic observations that the higher-affinity cells can form more stable contacts with the membrane, better resist the pulling force required to capture Ag without causing cell rupture, transmit stronger BCR signals and acquire a larger amount of Ag to present to T cells compared to low-affinity cells  and contribute to GC responses at a comparable level to DEL-OVA-immunized recipients  on FDCs is essential for GC formation and positive selection  cipients , 67. In election –71, whilelection –74. Noneelection . Since Gelection , 76, it election . Retenti+ GC-B cell compartment is suggested to be heterogeneous due to differential signal activation   is expressed in most cMyc+ LZ-B cells and the transcriptional activator Miz-1 switches to a transcriptional repressor upon cMyc binding   might di binding , 95. The binding . A trans binding , 90 can  binding . Recepti binding , which mThe remaining positively selected LZ-B cells other than cells instructed to PB/PC and MBC fates transit to the DZ for further proliferation as DZ-entrants. BCR signals downregulate FoxO1 and cyclin D3, which are essential for maintenance and proliferation of DZ-B cells, respectively , 98, 99.Clonal breadth achieved by permissive selection is particularly useful for protection from viruses that constantly mutate. Understanding the underlying mechanisms of permissive selection followed by B cell differentiation will guide vaccine design and improve their efficacy in the future.RN and DC wrote the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the Francis Crick Institute, which receives its core funding from Cancer Research UK (FC001057), the UK Medical Research Council (FC001057), and Wellcome Trust (FC001057) to DC and by the UK Medical Research Council (grant reference MR/J008060) to DC.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.


Self-administered outcome measures on burnout, resilience, emotional regulation, self-compassion, death attitudes, and quality of life were collected at baseline, post-intervention/second-baseline at 6weeks, and follow-up/post-intervention at 12weeks. Results from mixed model ANOVAs reveal that treatment group participants experienced significant reduction in mental exhaustion, as well as significant improvements in overall emotional regulation, nonreactivity to intrusive thoughts, approach acceptance of death, and afterlife belief as compared to waitlist-control immediately after MCAT completion. Effect sizes of these impacts ranged from medium to large (η2=0.65 to 0.170). Results from one-way ANOVAs further reveal that the treatment gains of reduced mental exhaustion and increased emotional regulation were maintained among treatment group participants at 12-weeks follow-up compared to baseline, with new benefits identified. These include increased ability to observe and describe one’s experiences, elevated overall self-compassion, greater mindful awareness, enhanced common humanity, and better quality of life. Effect sizes of these impacts were large (η2=0.128 to 0.298). These findings reflect the robust effectiveness and positive residual effects of MCAT for reducing burnout, building resilience, nurturing compassion, fostering collegial support, and promoting mental wellness among healthcare workers. The clinical model and applicability of MCAT in larger and more diverse caregiving contexts, such as family dementia care, are discussed.Protecting the mental health of healthcare workers is an urgent global public health priority. Healthcare workers, especially those immersed in palliative care, are prone to burnout due to the intense emotions associated with end-of-life caregiving. This study examines the efficacy of a novel, multimodal, and group-based Mindful-Compassion Art-based Therapy (MCAT) that integrates reflective self-awareness with creative emotional expression for protecting healthcare workers’ mental health. A dual-arm open-label waitlist randomized controlled trial was conducted. A total of 56 healthcare workers were recruited from the largest homecare hospice in Singapore and randomized to the immediate-treatment condition of a standardized 6-week, 18-hours MCAT intervention (Clinical Trial Registration:ClinicalTrials.gov # NCT03440606, #NCT04548089. Healthcare workers, especially those immersed in palliative care, engage with life and death situations and dilemmas on a day-to-day basis and are exposed to the immense stress of end-of-life caregiving. Amidst these challenges, they are expected to provide unwavering compassionate care to dying patients and their families with immediate responsiveness . HoweverBurnout is a reaction to chronic job-related stress and occurs when individuals become overwhelmed with the mental, emotional, and physical distress associated with their professional work. Defined as “a state of exhaustion in which one is cynical about the value of one’s occupation and doubtful of one’s capacity to perform” , burnoutvia meaning-making to derive a renewed appreciation and purpose of one’s caregiving roles  prior to the commencement of the study.N=56). Sample size was calculated based an 80% power to detect an effect size (Cohen’s d) of 0.8 ; this is followed by a mini psychoeducation module comprising of an interactive lecture support by visual aids that introduces the foundational theory and empirical research that accentuate the selected topic (10min); a mindfulness meditation with a theme-based guided imagery exercise (25min); a facilitated expressive art-making session that center on the selected theme (45min); a short break (10min); a creative and reflective writing activity (35min); small group and large group sharing (40min); and ending with a mindful breathing check-out (5min). The integration of these therapeutic elements aimed to provide participants with the foundational knowledge on various aspect of self-care, deepen cognitive awareness, and understanding of their emotionality, while empowering them to be fully aware and articulate of the immediacy of their experiences, and to appreciate the authenticity of their self-reflections, creative expressions, personal insights, and collective wisdoms generated through individual and group work. A detailed intervention protocol is published elsewhere , and Tabvia Research Randomizer  was generated ndomizer . ThereafOutcomes were assessed with quantitative and qualitative measures. All study participants were assessed by a battery of standardized self-reported psychometric measures on burnout, resilience, emotional regulation, and quality of life at baseline (T1), immediately post-intervention/second-baseline at 6weeks (T2) and follow-up assessment/immediately post-intervention at 12weeks (T3). In addition to the quantitative assessment, large group sharing during from all MCAT sessions were recorded with participants’ consent and transcribed verbatim for analysis.α=0.81). The MBI-GC assesses three domains of burnout, including exhaustion, cynicism, and professional efficacy; scoring for professional efficacy is reversed, with lower scores representing greater burnout. Resilience was assessed by the 11-item Ego-Resilience Revised Scale . The ER-11 assesses three domains of resilience, including active engagement with the world, problem-solving strategies, and integrated performance under stress. The MBI-GS and ER-11 possess internal validity, reliability, and cross-cultural applicability.Demographic information including age, gender, marital status, religion, professional roles, employment status, and years of professional experience in end-of-life care was collected at baseline. Primary outcomes included burnout and resilience. Burnout was assessed by the 16-items Maslach Burnout Inventory – General Survey MBI-GS; , with hie ER-11; , with hiα=0.89). The FFMQ assesses five domains of emotional regulation, including the ability to observe, and describes one’s experience, act with awareness, non-judgment of experience, and nonreactivity to intrusive thoughts. Self-compassion was assessed by the 12-items Self-Compassion Scale (SCS) Short Form (α=0.84). The SCS assesses six domains of self-compassion, including self-kindness, mindfulness, common humanity, self-judgment, isolation, and over-identification; scoring for self-judgment, isolation, and over-identification are reversed, with lower score indicating higher self-compassion. Death attitude was assessed by the 32-items Death Attitude Profile-Revised , death avoidance (Baseline Cronbach α=0.90), approach acceptance (Baseline Cronbach α=0.81), escape acceptance (Baseline Cronbach α=0.91), neutral acceptance (Baseline Cronbach α=0.82), personal acceptance (Baseline Cronbach α=0.62), and afterlife belief . Again, the FFMQ, SCS, DAP-R, and EUROHIS-QoL-8 possess internal validity, reliability, and cross-cultural applicability.Secondary outcomes included self-reported levels of emotional regulation, self-compassion, death attitude, and quality of life. Emotional regulation was assessed by the 39-items Five Facet Mindfulness Questionnaire FFMQ; , with hiort Form , with hid DAP-R; , which mWeekly group sharing was audio recorded and transcribed verbatim. In addition, all artworks together with creative and reflective writings created by study participants were documented and categorized as supplementary data. To protect the confidentiality of the participants, identifying information was removed and pseudonames were assigned to each participant before analysis.value of p, and the effect size estimates of Eta-Squared (η2) reported. Post-hoc tests using the Bonferroni correction were also conducted to control for error. Moreover, one-way ANOVAs were performed for the immediate-treatment group with an additional time point. All analysis was adjusted for baseline demographic variables . All p-values were based on two-tailed tests of significance and those less than 0.05 were considered statistically significant. Qualitative data were managed by the QSR NVIVO software package. Weekly group sharing was audio recorded, transcribed verbatim, and verified by research team members, as well as all participants’ creative and reflective writings. All qualitative data were analysis using thematic analysis which involved several steps of data reduction and data reconstruction  for categorical variables or mean (SD: standard deviation) for quantitative variables. The immediate-treatment group and waitlist-control group were compared on the primary outcomes and secondary outcomes. To examine the changes in continuous outcome variables between group and over, mixed model ANOVAs were conducted for each outcome with the appropriate means, F ratio, truction . First, truction . This waM=44.40, SD=10.97), predominantly female (75%) and have completed a bachelor’s degree or above (77%). The majority of participants was nurses (48%), followed by physicians (14%), medical social workers (14%), and allied care professionals (14%). The years of end-of-life care experience ranged from l to 30years , with the majority having 1 to 5years of experience (70%). There were no statistically significant differences in demographic measures between treatment group and control group. Please refer to A total of 56 participants were successfully recruited and completed the study with no attrition throughout the entire research period. Participants were aged between 23 to 64years =3.27, p=0.042, η2=0.065] immediately upon MCAT completion as compared to waitlist control. Treatment group participants also experienced significant improvements in overall emotional regulation , nonreactivity to intrusive thoughts , approach acceptance of death , and afterlife belief  immediately after intervention as compared to waitlist control. Effect sizes of these changes were medium to large. These findings reflect MCAT’s robust efficacy for burnout reduction and wellness promotion among healthcare workers. Details of mixed model ANOVAs are provided in Results from mixed model ANOVAs reveal significant interaction effects between immediate-treatment group and waitlist-control group across time. Specially, treatment group participants experienced significant reduction in mental exhaustion  and increased overall emotional regulation  were maintained among treatment group participants at 12-weeks follow-up compared to baseline, with new benefits identified. These include increased ability to observe  and describe  one’s internal and external experiences, elevated overall self-compassion , greater mindful awareness , enhanced common humanity (or interconnectedness to others) , and better quality of life  among treatment group participant at 12-weeks follow-up compared to baseline. Effect sizes of these changes were large. These findings reflect the positive residual effects of MCAT, as well as its ability to generate new treatment benefits beyond intervention completion. Details of one-way ANOVAs are provided in Results from follow-up one-way ANOVAs reveal that the treatment gains of reduced mental exhaustion [16.76 vs. 20.97; The qualitative data from the group sharing among MCAT participants, together with their creative and reflective writing supported by their art works, provided further insights on the intervention’s efficacy and therapeutic mechanisms in reducing burnout, building resilience, nurturing compassion, and fostering collegial support. The following section provides an illustrative summary of the qualitative findings generated through thematic analysis.You are expected to fill up quite a lot of shoes… and that’s why it’s so important to put yourself first you know, and care for yourself first.” Such self-reflection led to a deepened self-understanding and a renewed appreciation for mindful living for calming the emotional burden of end-of-life caregiving. A 47-year-old physician shared “Our work is filled with strong emotions… Sometimes we really have to pause and just breathe, breathe in peace, calmness and awareness, before we can perform our task again.” Upon deep reflection followed by the creation of a Mandala of Self-Care and reflective art observation  I can actually cope with stress better.” This augmentation of reflective self-awareness with creative self-expression rendered through the MCAT integrative model also enabled participants to look at their experience of loss and grief with greater acceptance and psychological flexibility. A 42-year-old nurse wrote about her experience with losing a patient, “When all is drowning and sinking in adversity, we need to be still and persevere, to embrace the trapping moves and see them as a dance of life.” Being able to transform one’s cognitive appraisal of adverse events through creating a Symbol of Stress as represented by an active volcano and thereafter changing it into a lush forest through the transformative art exercises  and functional MRI studies that show the ability of mindfulness meditations in activating brain regions that are involved in self-regulation, focused problem solving, adaptive behavior, and interoception .Third, the study findings reveal that MCAT was moderately effective in fostering positive attitudes toward death among healthcare workers who are faced with mortality on a day-to-day basis, including approach acceptance to death and the belief in the prospect of an afterlife where the deceased can be reunited with loved ones. While these impacts were not maintained at 12-weeks follow-up, possibly due to participants being continuously affected by their patients’ suffering and mortality, MCAT had nonetheless provided an invaluable opportunity for healthcare workers to explore and process their feelings of grief and loss in a supportive team-based environment. Such reflective opportunities are hard to come by in conventional healthcare workplace environments, if at all. In contrast, research has consistently found that palliative care professionals do not receive adequate support in dealing with the trauma and empathy fatigue resulting from deaths of patients . EmpathyFinally, MCAT was found to have the ability to generate new and robust treatment benefits after intervention completion at 12-weeks follow-up among healthcare workers, including the cultivation of self-compassion, a deepened sense of common humanity, and elevated quality of life. While these findings are in accordance with those reported separately in research on mindful self-compassion and art-based therapy , MCAT reDistinctly, the whole of MCAT is greater than the sum of its parts. Healthcare workers are not only invited to reflect on their experiences or express their minds, but also are supported through a scaffolding of intricately curated therapeutic activities that inspire continuous self-discoveries and embodied reflexive practices , those tDespite the many promising findings generated from this RCT, a few caveats must be noted. First, this is a pilot study with a small participant sample recruited from a single healthcare institution. This study scope may have influenced the implementation and outcome of MCAT, and future research could expand the sample size and study sites to include a variety of healthcare institutions, such as acute and community hospitals, in- and out-patient hospices, as well as other residential care facilities. Second, in spite of the numerous significant positive impacts that MCAT was able to generate, results revealed that treatment group participants only experienced marginally significant improvements in the primary outcome of resilience as compared to waitlist control immediately post-intervention. This finding, or lack thereof, may be due to the way in which resilience is constructed within the ER-11 measure, which comprises active engagement with the world, performance under stress, and problem-solving repertoire. This constitution does not appear to align with how resilience is being experienced by MCAT participants, which involved cognitive reappraisal, meaning-making, acceptance, and self-kindness. Future research may consider a more fitting measurement of resilience. Third, the current implementation of MCAT is manpower intensive and requires physical in-person facilitation. With the ongoing and unrelenting global public health crisis that has imposed persistent and restrictive physical distancing measures, the popularization of telemedicine and virtual social services is inevitable and may well stay as part of the new COVID-19 normal. Thus, future renditions of MCAT need to consider a digital adaption to improve accessibility, equity, and inclusion. Finally, this study is conducted in Singapore, a multiracial, and multicultural society with distinctive variants of Asian culture and languages. Hence, future research could expand the program to different socio-cultural settings to examine MCAT’s applicability and effectiveness among more diverse ethnic groups and population cohorts, including other types of caregivers, such as family careers. An ongoing study is being conducted to develop and examine a modified version of MCAT for dementia care . Concisely, a waitlist RCT design has been adopted to assess the efficacy of a 4-weekly, 10-hours, standardized, and group-based intervention for reducing caregiving stress, perceived burden, and psychological distress, while improving resilience, hope, spiritual wellbeing, and quality of life among a sample of 104 dementia family caregivers. MCAT-DC is delivered through a hybrid physical and virtual format using Zoom technology with real time programming. Future research needs to carefully consider the implementation science and target populations for enhancing acceptability and scalability in a post-pandemic world.Protecting the mental health of healthcare workers is an urgent global public health priority as called on by the World Health Organization and major healthcare institutions around the globe . ParticuThe original contributions presented in the study are included in the article/supplementary material, and further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the NTU Institutional Review Board (IRB). The patients/participants provided their written informed consent to participate in this study.AH, GT-H, and JP conceptualized and designed the study. AH obtained the funding, project supervision, and drafted the manuscript. GT-H, TN, GO, PC, and DD was involved in the coordination and implementation of the research study, as well as drafting of the manuscript. AH and GO delivered the MCAT intervention. TN conducted the statistical analysis. All authors contributed to data interpretation, as well as the writing and revision of the manuscript.The MCAT study (grant no. M4081570.100) is funded by the Nanyang Technological University (NTU) Start-Up Grant, and the MCAT-DC study (grant ref. ARISE/2017/23) is funded by the ARISE Strategic Initiatives Fund of the Ageing Research Institute for Society and Education at NTU.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.


Purpose: This study aimed to design gentamicin-conjugated poly (amidoamine) (PAMAM) dendrimers to increase the therapeutic efficiency of gentamicin against Pseudomonas aeruginosa. Methods: Gentamicin-presenting dendrimers were synthesized using MAL-PEG3400-NHS as a redox-sensitive linker to attach gentamicin to the surface of G4 PAMAM dendrimers. The gentamicin molecules were thiolated by using Traut reagent. Then, the functionalized gentamicin molecules were attached to PEGylated PAMAM dendrimers through simple and high selectively maleimide (MAL)-thiol reaction. The structure of gentamicin-conjugated PAMAM dendrimers was characterized and confirmed using nuclear magnetic resonance (NMR), dynamic light scattering (DLS), zeta potential analysis, and transmission electron microscopy (TEM) imaging. The antibacterial properties of the synthesized complex were examined on P. aeruginosa and compared to gentamycin alone.Results: NMR, DLS, zeta potential analysis, and TEM imaging revealed the successful conjugation of gentamicin to PAMAM dendrimers. Data showed the appropriate physicochemical properties of the synthesized nanoparticles. We found a 3-fold increase in the antibacterial properties of gentamicin conjugated to the surface of PAMAM dendrimers compared to non-conjugated gentamicin. Based on data, the anti-biofilm effects of PAMAM-Gentamicin dendrimers increased at least 13 times more than the gentamicin in normal conditions.Conclusion: Data confirmed that PAMAM dendrimer harboring gentamicin could be touted as a novel smart drug delivery system in infectious conditions. One of the most important mechanisms used by antibiotic-resistant bacteria such as Pseudomonas aeruginosa, a gram-negative bacterium, is the development of biofilm around infectious agent. Different multidrug-resistance strains of this pathogen are linked with life-threatening diseases like chronic obstructive pulmonary disease, cystic fibrosis, and also P. aeruginosa is the foremost reason of death in patients with extensive burns. Gentamicin belongs to the aminoglycoside class of antibiotics and is used widely to treat several types of bacterial infections. Gentamicin is uptake in three distinct steps by bacterial cells as follows; an initial binding to the bacterial membrane, and chased by two energy-dependent stages . The uptake of gentamicin in EDP-I occurs slowly which surveyed by energy-dependent accumulation of the gentamicin inside bacteria in the next step namely EDP-II. The most accepted concept for the bactericidal function of gentamicin proposes that a small amount of gentamicin enters inside the bacterium in the phase I (EDP-II) and lasts until the second step phase II (EDP-II). Thereafter, this antibiotic could bind to ribosomes, resulted in disrupted multiple proteins by misreading of mRNAs. As a result, membrane integrity is destroyed. This phenomenon contributes to the formation of pores, an increase of osmotic pressure, ion imbalance, and irreversibly saturated ribosomes, resulting in bacterial loss. Drug resistance mechanisms are compensatory mechanisms to resist different antibiotics. Under these circumstances, the expression of genes associated with the construction of multiple proteins including enzymes for drug elimination (β-lactams), drug resistance pumps (efflux pumps), and membrane integrity is increased to prevent bactericidal effects. Unfortunately, numerous studies have shown that P. aeruginosa is resistant to a variety of aminoglycosides, since 1973. Moreover, the high doses of gentamicin predispose patients to nephrotoxicity and ototoxicity.Bacterial infections remain major health challenges worldwide and antimicrobial drug resistance is considered as one of the most unsettled medical problems. The development of stimuli-responsive nano-carriers can be used to combat bacteria upon reaching bacterial microenvironment. Depending on the pathological conditions of infections, stimuli-responsive nanoparticles can respond to the specific pH, enzymes, or chemicals. To date, different modalities have been applied for the conjugation of smart chemical to the target molecules. Maleimide (MAL) derivatives are extensively used for coupling with thiol moieties in the structure of proteins, peptides, and drugs. Unfortunately, nearly all MAL-thiol adducts linkage is recognized unstable under physiological conditions. In the existence of free thiol groups provided by different amino acids such as, cysteine serum albumin, and glutathione, the linkage is reduced via a retro-Michael or thiol exchange reaction. Based on the strength of exogenous thiol nucleophiles (R-SH), the attached drugs are reduced and released from redox responsive drug delivery system. Poly (amidoamine) (PAMAM) dendrimers are hyper-branched, nano-sized globular polymers with tailorable surface functionality which are a great tool for numerous biomedical applications such as drug and gene delivery systems. In this regard, drug molecules can be either encapsulated or covalently attached to the dendrimers by engaging functional groups on the surface. In support of this notion, inhibition of bacterial growth has been shown in some studies by PAMAM dendrimers with different surface functionality.Despite the urgent need to find new drugs to overcome drug resistance, the development of novel classes of antibiotic agents with high antibacterial activity and wide therapeutic window are crucial. In recent years, nano-formulated drug delivery systems have been settled to increase the therapeutic efficiency against bacterial infections, considering new and powerful strategies.in vitro antibacterial capacity of gentamicin against P. aeruginosa after being-conjugated to the G4 PAMAM dendrimer surface. The main goal of this experiment was to improve the therapeutic outcome of gentamicin against drug-resistant bacteria by developing a gentamicin modified PAMAM dendrimer system using MAL-PEG3400-NHS redox-sensitive linker.To the best of our knowledge, we did not find similar reports available on the attachment of specific antibiotics to the dendrimer surface using MAL-thiol linkage to develop a smart nano-drug delivery system against bacterial infections. Here, we evaluated the possible cytotoxicity and  Briefly, this method consists of alkylation with methyl acrylate and subsequent amidation with ethylenediamine. Bifunctional PEG  was purchased from Nanocs Inc. . Gentamicin sulfate was a gift from Zahravi Pharmaceutical Company , Amicon Ultra-15 Centrifugal Filter (15 kDa), and 2-iminothiolane hydrochloride (Traut reagent) were purchased from Sigma-Aldrich.G4 PAMAM dendrimer (MW: 14215 Da) with an ethylenediamine core and methyl acrylate was synthesized by modified Michael-amidation method. To exclude unreacted PEGs, Amicon Ultra Centrifugal Filters with cut off 15 kDa were used.To initiate the reaction of PAMAM primary amine groups to NHS groups of bifunctional PEG, the PAMAM dendrimers were incubated with PEGs in a molar ratio of 1:1  in PBS (pH= 8) for 2 hours at room temperature according to our previously published data.To thiolate gentamicin, gentamicin dissolved in PBS and reacted with 2-iminothiolane hydrochloride (Traut’s reagent) in a 1:2 molar ratio (pH 8.3) for 24 hours.2 of dendrimer: gentamicin, Mol/Mol) in PBS (pH=7.0) at room temperature for 24 hours. Terminal MAL groups of PAMAM–PEG can interact exclusively with thiol groups of gentamicin. The PAMAM-PEG-Gentamicin conjugates were purified by dialysis (MW cut-off 10 kDa).The PAMAM-PEG conjugates were incubated with thiolated gentamicin in a molar ratio of 1:1 (NHnuclear magnetic resonance (NMR), dynamic light scattering (DLS), and transmission electron microscopy (TEM) imaging. To perform the NMR analysis, PAMAM dendrimers, PAMAM–PEG, and PAMAM–PEG–Gentamicin conjugates were initially lyophilized, dissolved in heavy water (D2O), and analyzed by using Bruker 400 MHz Avance II + NMR spectrometer system. Features such as size and zeta potential values were studied using DLS and zeta plus analyzer . The drug loading capacity (DL) was calculated using the following formula:The physicochemical characteristics of gentamicin-conjugated PAMAM dendrimers were evaluated by DL% = Weight of drug in dendrimer/Weight of dendrimer containing drug ×100P. aeruginosa (ATCC® 27853) was used to assess the antimicrobial effect of PAMAM, gentamicin, and PAMAM-PEG-Gentamicin conjugates. The MIC value was calculated using a micro-broth dilution method. For this purpose, the strain was cultured in nutrient broth medium and incubated at 35˚C for 24 hours. Then, suspensions cultures were prepared in sterile normal saline to a density equal to No. 0.5 McFarland turbidity standard according to the CLSI recommendation. The serial dilutions were prepared in 8 test tubes containing nutrient broth medium. The bacterial suspension was diluted 1:100 using sterile Nutrient broth, transferred in each tube, and incubated at 35°C for 24 hours. After incubation at 35°C, inhibition of growth bacterial isolates was determined. The MIC value was defined as the lowest concentration that inhibited detectable growth.In this study, the standard strain of  MIC and 2MIC levels of PAMAM-PEG-Gentamicin nanoparticles were used. Briefly, tubes containing 2 mL of nutrient broth medium with a concentration of MIC and 2MIC were prepared and then were incubated at 35°C for 24 hours. At intervals of 0, 3, 6, 9, and 24 hours, the contents of the tubes were gently mixed and the number of bacteria in each tube was estimated using the pour-plate method. Dilutions of 1: 10, 1: 100, and 1: 1000 were prepared, and the pour-plate procedure was performed. One tube without antibiotics was used as a positive control.The time-kill study of PAMAM-PEG-gentamicin nanoparticles was carried out based on the procedure described by Tsuji et al.P. aeruginosa strain to form biofilm was evaluated after being incubated with PAMAM, gentamicin, and PAMAM-PEG-Gentamicin conjugates. Serial dilutions of both forms of gentamicin were prepared and poured in each well of microtiter plates containing culture media plus 0.5 McFarland of the bacterial suspension. The group with free gentamicin was considered as positive control and data compared with the gentamicin-free group (negative control), respectively. The cut off optical density for biofilm formation was considered as follows; lack of biofilm (-), weak (+), moderate (++), and strong formation (+++). To optimize results and provide reliable analysis of data, three sets of experiments were conducted.The ability of 3400-NHS to PAMAM dendrimers amine groups, in the second step, gentamicin molecules were thiolated by Traut reagent, and finally, the thiolated gentamicin molecules were conjugated with PEGylated PAMAM dendrimers. The main rationality behind our design was the possibility of gentamicin release by the elimination of MAL-thiol adducts linkage in condition exposed to Pseudomonas aeruginosa and intracellular thiol nucleophiles such as glutathione content and/or thioredoxin reductase enzyme.According to our data, G4 PAMAM dendrimer has theoretically 64 numbers of peripheral branches each terminated with a primary amine susceptible to covalent conjugation with a variety of small molecules. The development of gentamicin-modified G4 PAMAM dendrimer occurs via gentamicin and dendrimer amine groups. Gentamicin conjugated G4 PAMAM dendrimers were produced in a three-step chemical reaction . The fir3400-MAL  ester of NHS-PEG3400-MAL . The PEG3400-MAL  and 2B. coupling . The conThe drug loading capacity was about 59% by weight, which is high amount for a polymer-drug conjugate. Also, the conjugated form of gentamicin was soluble in PBS buffer (pH 7.4) compared to the free form. The conjugation of gentamicin with PAMAM was also confirmed by DLS analysis . The PAMP. aeruginosa was 16 and 4.7 μg/mL, respectively. The MIC of PAMAM was 64 μg/mL  [G4-(NH2)64] and thiol terminated 8-arm polyethylene glycol (PEG) as an amoxicillin control released platform.The rationale behind the development of redox-responsive dendrimers is to use disulfide bonds for conjugation in the structure of the nano-based drug delivery system. In another work, the organometallic dendritic scaffold has been used to the eradication of vancomycin-resistant Enterococcus faecium and methicillin-resistant Staphylococcus aureus by the destruction of the cell wall and the generation of oxidative stress. Because of similar effects on healthy cells, these positively charged nano-structures efficiently destroy the lipid membrane, which limits their routine application. Wang and co-workers created a PAMAM dendrimer/gold nanoparticles with redox-responsive capability for delivering thiolated anticancer agents such as 6-mercaptopurine and captopril, via the foundation of Au–S bond. The results showed that drugs were released from this structure in the “OFF-ON” manner after exposure to the high amount of intracellular GSH similar to our developed nanoparticle. Additionally, Du et al. designed a redox-sensitive Janus dendrimer for the delivery of siRNA. Because of disulfide linkages in the structure of the dendrimers, siRNA was released in response to the cell’s redox system. Compared to these studies, our concept in the design of nanoparticles has some advantages, including simple synthesis protocol without the necessity to use additional disulfide linkers which can affect the nanoparticle integrity and limit their application to the clinical setting.Yan et al designed another smart nanostructure by using dendrimers containing hydrophobic di-sulfide units, which are assembled and de-assembled in the presence of GSH.P. aeruginosa.It seems that the intracellular release of gentamicin occurs chemically and enzymatically by the increase of the kinetics of retro-reaction of MAL-thiol adducts. The efflux of gentamicin could be abolished by a sudden increase of inside gentamicin concentration leading to saturation of MDR. The synthesized nanoparticles can be also used to inhibit antibiotic-resistant mechanisms such as biofilm formation at lower concentrations compared to the free drug. The current strategy seems to be appropriate to treat infections caused by P. aeruginosa.In the present study, we used successfully the MAL-thiol reaction to develop a smart drug delivery system based on gentamicin-PAMAM dendrimers to increase the intracellular delivery of gentamicin in All authors confirmed that this work has not been previously published elsewhere and is not currently being considered for publication elsewhere. Also, the authors confirm that all of the experiments adjusted to the ethical committee of Tabriz University of Medical Sciences.The authors declare that there is no conflict of interest.This work is a part of a MSc. the thesis of Hamed Sheykhloo in Microbial Biotechnology at Rabe Rashidi University, Tabriz, Iran. This study was financially supported by young researchers welcome grant [NO: 58859] from the Faculty of Advanced Medical Science, Tabriz University of Medical Sciences, Tabriz, Iran.


Background: Over the past decade, many studies have reported the association of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) with clinical outcome of intracerebral hemorrhage (ICH). However, a broad consensus has not been reached.Objective: To evaluate the role of BNP/NT-proBNP levels in prognosis and disease severity assessment in patients with ICH.Methods: A systematic literature search was conducted utilizing PubMed, Embase, Web of Science and the Cochrane Library databases up to July 23, 2021. Studies that explored the association between BNP/NT-proBNP level and clinical outcome or disease severity in ICH patients were eligible. Outcome measures were all-cause mortality, poor functional outcome, adverse cardiac events and markers of disease severity.Results: Ten studies, involving 1,373 patients with ICH, met the inclusion criteria. Nine studies focused on clinical outcomes  and seven on disease severity. In terms of prognosis, all five studies showed an association between elevated BNP/NT-proBNP level and increased risk of all-cause mortality in ICH patients. Four of the five studies reported poor functional outcomes in patients with higher BNP/NT-proBNP levels and one study associated higher BNP/NT-proBNP levels with increased risk of adverse cardiac events. Moreover, two studies identified an additional predictive ability of BNP/NT-proBNP level beyond that of pre-existing prognostic variables. In terms of disease severity, five studies (71%) reported that BNP/NT-proBNP level correlated positively with hematoma volume in addition to ICH and GCS scores.Conclusion: Elevated BNP/NT-proBNP level is associated with increased risk of all-cause mortality, poor functional outcome, adverse cardiac events and disease severity in patients with ICH. Thus, BNP/NT-proBNP level is a promising prognostic indicator for ICH and also an effective marker of disease severity. Current evidence remains limited by the small number and high heterogeneity of included studies. Further appropriately designed, large-scale studies are required to confirm the current findings. Intracerebral hemorrhage (ICH) is the second most frequent subtype of stroke and affects ~2 million people worldwide each year . ICH is Brain natriuretic peptide (BNP), a polypeptide neurohormone with natriuretic, diuretic and vasodilator properties, is synthesized and released primarily by ventricular myocytes , 7. CleaThere is growing evidence that the brain interacts with the heart , that isThe present systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement . A literStudies meeting the following criteria were included: (1) population: patients over 18 years old with ICH confirmed by computed tomography (CT); (2) exposure: levels of blood BNP or NT-proBNP; (3) comparison: cases with vs. without elevated BNP or NT-proBNP levels; (4) outcome measures: all-cause mortality, poor functional outcome, adverse cardiac events and markers of disease severity; (5) study design: longitudinal observational studies. Studies were excluded if the following conditions applied: (1) cerebral hemorrhage secondary to trauma, brain tumor or vascular malformation, hemorrhagic transformation of brain infarcts, aneurysm associated ICH; (2) a mixed population of patients were described , unless patients with ICH were reported separately within the publication; (3) conference abstracts, reviews or case reports; (4) repeated studies of the same patient population (only the study with the largest sample size or the most detailed information was included); (5) patients with heart disease were included but adjusted risk estimate was not reported.Two independent authors made a preliminary examination of the titles and abstracts to exclude studies that were obviously irrelevant. The full texts of the remaining studies were then reviewed to determine the included studies according to the aforementioned inclusion and exclusion criteria. Disagreements were resolved by involving the third reviewer.Data extraction was completed independently by two authors using standardized data extraction forms. The following information of each study was collected: the first author's surname, publication year, country of origin, study design, recruiting period, number of participants, mean ages of participants, percentage of male participants, intervals from onset to admission, type of natriuretic peptide, blood collection time, methods of BNP/NT-proBNP detection, levels of BNP/NT-proBNP (mean ± SD), outcome measures, follow-up time, outcomes , cutoff values of BNP/NT-proBNP levels  and the area under the receiver operator characteristic (ROC) curve (AUC), and any further findings relevant to this review. Any disagreements between the two authors were settled through involving the third reviewer. When data provided in an article were insufficient or missing, we attempted to contact the respective authors for further information.The primary objective of the current review was to produce a qualitative analysis of the correlation between BNP/NT-proBNP level and adverse clinical outcomes in ICH patients. The secondary objective was to evaluate the relationship between BNP/NT-proBNP level and disease severity. The primary endpoint was prognosis, including all-cause mortality, poor functional outcome (the primary prognostic indicators) and adverse cardiac events (the secondary prognostic indicator). Functional outcome was assessed using the modified Rankin Scale (mRS) or Glasgow Outcome Scale (GOS), in which an mRS score of >2 or a GOS score of ≤ 3 was defined as a poor functional outcome. Adverse cardiac events included cardiac death, severe arrhythmia  and non-fatal myocardial infarction. The secondary endpoint was disease severity, evaluated by hematoma volume  , GlasgowThe Newcastle-Ottawa Scale (NOS) for the cohort studies  was utilA narrative summary of results was presented . The heterogeneity between the included studies precluded the application of data synthesis.An electronic search retrieved a total of 1,651 articles with no additional articles being identified via a manual search. After eliminating duplications, 1,125 articles were retained, of which 1,097 were excluded due to irrelevant titles and abstracts. The full texts of the remaining 28 articles were reviewed for inclusion, and 10 studies , 25–31 fNine studies involving 1,226 participants reported an association between BNP/NT-proBNP levels and adverse clinical outcomes and seven (893 participants) mentioned a relationship with disease severity. The NOS scores of the included studies ranged from 6 to 8, indicating moderate to high quality .Four studies under scrutiny , 25–27 fP < 0.01). Shibazaki et al. (P < 0.0001).Four studies evaluated BNP/NT-proBNP concentration changes with time. Li et al.  conductei et al.  also fouP < 0.05). Three studies reported multivariate logistic regression analysis to assess risk estimate. Two studies correlated BNP/NT-proBNP levels on admission with the risk of short-term mortality. For in-hospital mortality (P = 0.032) after adjustment for covariates . For 1-month mortality (P = 0.011). Another study (P = 0.007). The series of studies outlined above indicated that higher BNP/NT-proBNP level was associated with increased risk of death after ICH. Thus, BNP/NT-proBNP level may have utility in predicting all-cause mortality for ICH patients.ortality , the OR ortality , the OR er study  followedTwo studies reported ROC curves to evaluate the efficiency of BNP/NT-proBNP levels in discriminating between death and survival outcomes. Goya et al.  demonstrP = 0.04), and two focused on NT-proBNP: Gregorio et al. (P = 0.009) for poor functional outcome after adjustment for age, gender, GCS score, hematoma size and Graeb score; and Li et al. (P = 0.008). By contrast, Eldawoody et al. .Five studies , 29, 31 o et al.  demonstri et al.  gave a OP < 0.001). What's more, James et al. . ROC curves analysis revealed that a cutoff BNP level of 156.6 pg/ml gave a sensitivity of 68% and a specificity of 66% for prediction of adverse cardiac events, with the AUC of 0.749.One study  reportedP < 0.05). Two studies (P < 0.05), regardless of the inconsistent definition of the GCS scores for severe ICH . Moreover, Niu and Teng , but negatively with blood sodium concentration (r = −0.704), which did not occur in mild-moderate patients. Further studies demonstrated associations between BNP/NT-proBNP levels and intraventricular hemorrhage . Our analysis indicates the utility of BNP/NT-proBNP levels as a potential biomarker for disease severity assessment and prognostic evaluation of ICH patients.ICH accounts for half of the disability-adjusted life years lost due to stroke worldwide . AlthougOur literature survey has revealed a consistent relationship between BNP/NT-proBNP levels and mortality, poor functional outcome and adverse cardiac events after ICH. Moreover, the predictive value was independent of previously recognized prognostic factors such as age, hematoma volume, and baseline neurological impairment. However, in terms of functional outcome, one  of the fMechanisms underlying the association between elevated BNP/NT-proBNP levels and adverse prognosis after ICH remain unclear. The triggering factors for BNP/NT-proBNP release are the changes in ventricular load and wall tension. The activation of the neuroendocrine system and the change of hemodynamic factors following ICH directly cause an increase in ventricular wall tension , and theThere are a few limitations to the current systematic review. First and most important, we can't pool data across studies and conduct a meta-analysis. Quantitative analysis of the included studies was not performed due to the limited sample size, methodological heterogeneity , and limited summary outcomes . Second, publication bias may influence our conclusions, since we only reviewed published articles, which may exclude studies with negative outcomes. Of relevance to this point is that five studies retrieved were published only as conference abstracts, of which one reported negative finding . Third, In conclusion, this systematic review presents evidence that the elevated levels of BNP/NT-proBNP are associated with higher all-cause mortality, increased risk of poor functional outcome and increased incidence of adverse cardiac events in patients with ICH. BNP/NT-proBNP level is thus an independent prognostic indicator for ICH patients and is also an effective marker of disease severity. However, the current findings are limited by the small number and high heterogeneity of included studies, and the clinical utility remains to be further confirmed. There is a need for further well-designed and large-scale cohort studies to replicate, expand and refine the current findings. Such studies will allow clarification of the predictive value of BNP/NT-proBNP levels for the prognosis of ICH.The original contributions presented in the study are included in the article/PZ and ZT conceived and designed the study. JiaW, JinW, and PZ completed the publication screening, data extraction, and quality assessment of the eligible publications. JiaW drafted the manuscript. PZ reviewed and revised the manuscript. All authors have read and approved the final manuscript.This work was supported by the National Natural Science Foundation of China (Grant No. 82071330).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.


The present study aimed to evaluate the effects of virtual reality (VR) simulations combined with bedside assignments on nurses’ self-efficacy in providing pre-treatment educational services. Between March 2019 and November 2020, we conducted a study of VR educational materials that were developed to cover information about the treatment of oral cancers. The effects of the VR simulation, the thinking-path tracking map method, and bedside assignments on the nurses’ treatment decision-related knowledge were evaluated in a ward for oral cancer patients at Taipei Veterans General Hospital, Taipei, Taiwan. The blended training model significantly increased nurses’ familiarity (P<0.01) and confidence (P<0.03) regarding their knowledge of treatments and treatment decision-related knowledge. This model also significantly increased their confidence in their skills in bedside pre-treatment education for admitted oral cancer patients (P<0.002). Oral cancer-specific VR materials enhanced the effectiveness of skills training among nurses in the oral cancer ward. During hospitalization for cancer, primary nurses are the hospital staff who interact most frequently with anxious patients waiting for surgery, chemotherapy, or radiotherapy. Therefore, nurses are in a prime position to provide pre-treatment patient education, decrease patients’ anxiety, and increase patients’ satisfaction and adherence to treatment. Patients with early-stage oral cancer can be treated with oncologic surgery alone or in combination with an elective tracheostomy. In the advanced stage, patients can be treated with radiation therapy, chemotherapy, and immunotherapy, as well as combinations of those modalities with other treatments as necessary . ComparePatients’ degree of understanding and recall of detailed medical information provided by the treating physicians and primary care nurses affects their adherence to forthcoming treatments. Unfortunately, patients with limited medical background knowledge remember as little as one-fifth of the information discussed and immediately forget 40%–80% of the content of their medical encounters. In particular, anxious patients recall very little of the medical information provided by healthcare providers and may be unsatisfied with the medical information that they receive . TherefoVirtual reality (VR) technology can create ideal educational aids that provide consistent, vivid, and real-time interactions and immersive experiences. VR-based training materials are considered to be an effective tool to supplement in-person education and to cover a variety of topics . In partThis study aimed to evaluate the effects of VR-based training including the thinking-path tracking map method, VR simulations, and bedside assignments on the familiarity, confidence, and anxiety regarding treatment decisions and treatment-related knowledge and service skills of nurses in an oral cancer ward in Taiwan.Ethical approval was granted by the ethics committee of Taipei Veterans General Hospital . All of the nurses who were invited to participate were informed about the value of the educational intervention and written consent was obtained. Nurses were informed that their regular training would not interfere with their participation in the study.This was a pre- and post-intervention comparison study.This study was conducted from March 2019 to November 2020 at Taipei Veterans General Hospital in Taiwan, which provides a high quality of medical care for oral cancers.This study was conducted among 26 primary nurses in the oral cancer care unit of Taipei Veterans General Hospital.Using the questionnaire in In the development phase, specific all-in-one educational materials with detailed information about treatments for oral cancer were created. In the implementation phase, nurses in oral cancer units were trained to provide bedside pre-treatment education with VR materials. Information on surgery included surgical preparation, postoperative care, and home care for tracheostomy. For radiotherapy, patients experienced simulations of the processes of localizing the area for radiotherapy, making the treatment schedule of radiotherapy, taking peri-treatment precautions, receiving post-radiotherapy outpatient follow-up, and carrying out oral care. A detailed introduction to chemotherapy , molecular-targeted therapy, and immunotherapy were also included .To increase nurses’ engagement, acceptable or unacceptable behaviors during radiotherapy and chemotherapy were taught by asking nurses to interact with the VR game. Specifically, the VR app responded to nurses regarding whether their choices were correct. The training program emphasized improving nurses’ treatment decision-related knowledge and skills in presenting educational materials. In the introductory session, every part of the VR educational material was introduced to nurses through the VR headset. After an introduction to the goals of the training project , the nurThe Cronbach α reliability test, as a measure of the internal consistency of the questions in http://statulator.com/SampleSize/ss2PM.html. With an expected mean±standard deviation of the paired differences of 10±15, type I error (significance) of 0.05 and type II error (1-power) of 0.2, the estimated sample size was 24. This pilot study enrolled a total of 26 primary nurses from the unit for oral cancer patients.The sample size for this before-after study using the paired t-test was calculated using Statistical comparisons of baseline and post-training (or post-education) data were made using the paired Student t-test. All statistical analyses were performed using IBM SPSS ver. 21.0  and P-values <0.05 were considered to indicate statistical significance.As shown in According to the needs of each patient with oral cancer for their forthcoming treatment, the most common topics that nurses chose for their bedside assignment were preparation for surgery (8), chemotherapy (7), oral care for radiotherapy (5), process of radiotherapy (3), immunotherapy (1), molecular-targeted therapy, (1) and home care of tracheostomy (1) . At baseIn this study, every nurse completed 2–3 assignments of bedside patient pre-treatment education. This study revealed a baseline lack of appropriate materials, a deficiency in nurses’ treatment decision-related knowledge, and inadequate skills in bedside pre-treatment educational services for patients with oral cancer. These deficiencies may be related to inadequate training during their undergraduate years as well as a lack of ongoing post-graduation workplace training and practice sessions. After VR training, increased treatment-decision knowledge scores were observed, which were associated with their positive responses to the newly developed all-in-one educational materials.In the limited time of pre-admission medical encounters, without supplemental audiovisual materials, healthcare providers often fail to provide patients with sufficient medical information about treatments . PrimaryThis VR service model combined medical knowledge and modern technology and transformed complex and abstract medical knowledge into an acceptable VR format that helped nurses convey the information easily and precisely. The results of this study may reduce patients’ degree of anxiety and frustration. In the future, this service could be expanded to other medical subspecialties and other hospitals.It has been reported that patients’ satisfaction and information recall were higher after receiving services provided by a more clinically competent medical team . TherefoThis study has the limitation of a small sample, the potential impact of the timing of the intervention, and the assessment. The findings of this study suggest that reviewing medical records, holding discussions with physicians, participating in VR-based programs to strengthen treatment-decision knowledge, and engaging in bedside practice are feasible strategies to prepare healthcare professionals in the general ward setting to offer comprehensive pre-treatment services for oral cancers or other diseases by using web-based VR or written educational aids, thereby improving the quality of care.In this study, nurses in the oral cancer ward offered positive responses to the training and newly-developed written and VR materials for oral cancer treatment. The results of the current study highlight the importance of VR-based training, including nurses’ thinking-path tracking map method, VR simulation, and bedside assignments, on the knowledge and skills of primary nurses in an oral cancer ward. The initial results of our study encourage further application of VR materials in workplace training sessions for primary nurses caring for oral cancer patients.


Protein aggregation is associated with a growing list of human diseases. A substantial fraction of proteins in eukaryotic proteomes constitutes a proteostasis network—a collection of proteins that work together to maintain properly folded proteins. One of the overarching functions of the proteostasis network is the prevention or reversal of protein aggregation. How proteins aggregate in spite of the anti-aggregation activity of the proteostasis machinery is incompletely understood. Exposed hydrophobic patches can trigger degradation by the ubiquitin-proteasome system, a key branch of the proteostasis network. However, in a recent study, we found that model glycine (G)-rich or glutamine/asparagine (Q/N)-rich prion-like domains differ in their susceptibility to detection and degradation by this system. Here, we expand upon this work by examining whether the features controlling the degradation of our model prion-like domains generalize broadly to G-rich and Q/N-rich domains. Experimentally, native yeast G-rich domains in isolation are sensitive to the degradation-promoting effects of hydrophobic residues, whereas native Q/N-rich domains completely resist these effects and tend to aggregate instead. Bioinformatic analyses indicate that native G-rich domains from yeast and humans tend to avoid degradation-promoting features, suggesting that the proteostasis network may act as a form of selection at the molecular level that constrains the sequence space accessible to G-rich domains. However, the sensitivity or resistance of G-rich and Q/N-rich domains, respectively, was not always preserved in their native protein contexts, highlighting that proteins can evolve other sequence features to overcome the intrinsic sensitivity of some LCDs to degradation. Protein homeostasis, or “proteostasis”, encompasses the set of processes involved in the proper production and maintenance of cellular proteins. Proteostasis in eukaryotic cells is achieved through the coordinated action of three main branches—protein chaperones, the ubiquitin-proteasome system, and autophagy—which work together to achieve and maintain native protein folds, prevent protein aggregation, and degrade damaged or misfolded proteins .Under native conditions, most proteins must remain soluble to carry out their normal function(s) in cells. While proteostasis systems are generally quite effective at producing and maintaining thousands or tens of thousands of proteins with diverse sequences and folds, misfolding and aggregation are frequently observed in a variety of organisms. Failure of the proteostasis machinery can be broadly attributed to four main causes : (1) thAlthough cells devote an enormous amount of energy and resources to maintaining proteostasis, failures of the proteostasis machinery are not uncommon. Protein misfolding and aggregation are associated with a variety of pathologies, including diabetes, neurodegeneration, myopathy, and some cancers . Since pPrion proteins constitute a unique class of aggregation-prone proteins, defined by the ability to form infectious, self-propagating aggregates . The domIn a recent study, we utilized model G-rich PrLDs from hnRNPA1 and hnRNPA2, as well as a classical PrD from the yeast prion protein, Sup35, to delineate sequence features that control the proteostatic fates of aggregation-prone LCDs . SpecifiWhile our model G-rich and Q/N-rich LCDs facilitated an in-depth exploration of the molecular features governing their aggregation or proteostatic regulation, it is unclear whether these heuristics only apply to the model PrLDs. Here, we leverage a combination of bioinformatic and experimental techniques to explore whether the molecular rules governing the aggregation or degradation of our model PrLDs generalize to other polar LCDs. Our analyses of the yeast and human proteomes suggest that constraints imposed via the proteostasis machinery may help to determine compositional biases among different classes of LCDs. Additionally, we find that native G-rich LCDs are broadly susceptible to the degradation-promoting effect of hydrophobic residues, whereas native Q/N-rich LCDs consistently mask this effect. However, the proteostatic regulation of these G-rich and Q/N-rich LCDs did not always confer similar degradation susceptibility or resistance in the context of their native proteins, indicating that additional features may modulate this behavior. Finally, we also observe differential sensitivity to hydrophobic degrons for S-rich and T-rich LCDs. These results illuminate the interplay between compositional features and proteostatic fates for polar LCDs in eukaryotes.Despite the sensitivity of our model G-rich LCDs to degradation, a recent analysis of LCD-containing proteins showed that native yeast proteins with G-rich LCDs actually tend to have longer half-lives compared to non-G-rich proteins . Additiop-values corresponding to the degradation propensity scores tended to decrease for amino acids having the greatest effect on degradation, suggesting improved confidence for these residues. Additionally, the correlation (R2) between the hnRNPA1 and hnRNPA2 library scores is markedly higher than observed previously  and appear red on media with limited adenine. Compromised Sup35 function, whether by prion aggregation or enhanced protein turnover, increases read-through of the premature stop codon in the ade2-1 transcript, resulting in cells that are able to grow on media lacking adenine (ADE+ phenotype) and appear white on media with limited adenine. Importantly, the prion domain of Sup35 is spatially and functionally distinct from the domain responsible for chain release during translation termination , is cured upon overexpression of Hsp104, suggesting that an increase in Hsp104 activity can be sufficient for complete dissolution (rather than simply fragmentation) of prion aggregates .595 of 0.75 and grown for 1hr prior to adding CHX . After the treatment period, optical density was used to approximate cell concentrations and normalize the total amount of cells harvested within each strain to the least-dense culture. Cells were harvested and lysed as described in 38], respt-test. However, values for protein half-lives and for predicted degradation scores within native G-rich and Q/N-rich LCDs were often non-normally distributed. Therefore, for consistency and to facilitate direct comparisons, all other statistical comparisons employed the non-parametric two-tailed Mann–Whitney U test. Statistics and plotting were performed using the SciPy and Matplotlib/Seaborn packages, respectively, implemented in custom Python scripts.Degradation scores for the amino acid clustering analyses C,D were In vivo, protein aggregation occurs in the context of extensive proteostasis machinery. In this study, we further defined features of polar LCDs that lead to sensitivity or resistance to proteasome-mediated degradation and differential propensity for prion aggregation. Specifically, G-rich, T-rich, and S-rich LCDs are susceptible to hydrophobic degrons to varying degrees, whereas Q-rich and N-rich LCDs display resistance to hydrophobic degrons and instead often form prion aggregates. However, these regulatory principles can, in some cases, be modulated by other regions in their native proteins. Finally, post hoc bioinformatic analyses suggest that the proteostasis machinery may impose a selective constraint on allowable sequence space for certain types of LCDs.


Stenotrophomonas maltophilia is a multidrug resistant organism with limited antibiotic treatment options. Sulfamethoxazole-trimethoprim (TMP-SMZ) is considered first line agent based on in vitro studies and clinical evidence. Minocycline has been showed to be active on in vitro studies and also has been explored in small retrospective studies However, doxycycline in the same class has variable in susceptibility in in vitro studies and has not been evaluated for efficacy in treatment of S. maltophilia infections The purpose of this research is to compare minocycline and doxycycline to TMP-SMZ for treatment of S. maltophilia pneumonia.S. maltophilia pneumonia with minocycline, doxycycline, or TMP-SMZ for clinical success, microbiologic success, and recurrence or reinfection within 30 days that required treatment. The inclusion criteria were patients ≥18 years old with S. maltophilia confirmed on respiratory culture from January 2013 to November 2020. Patients were classified as treatment with tetracyclines (minocycline or doxycycline) or TMP-SMZ based on definitive agent used for ≥50% of the treatment course and a minimum of four days. Patients with S. maltophilia resistant or intermediate to definitive therapy, and patients with combination therapy for treatment for S. maltophilia pneumonia were excluded. This retrospective, multi-center study evaluated hospitalized patients treated for P = 0.994) or microbiologic success  between tetracyclines and TMP-SMZ, respectively. Recurrence or reinfection requiring treatment (n=24) was higher in the tetracyclines group but not statistically significant compared to TMP-SMZ . A subgroup analysis showed no difference between doxycycline, minocycline, and TMP-SMZ for these three aims. A total of 21 patients were included in tetracyclines group and 59 patients included in TMP-SMZ group. There was no difference in clinical success