However, assembling individual plots in different formats from various sources into one high-resolution figure in the desired layout requires mastery of commercial tools or even programming skills. In addition, it is a time-consuming and sometimes frustrating process even for a computationally savvy scientist who frequently takes a trial-and-error iterative approach to get satisfactory results. To address the challenge, we developed bioInfograph, a web-based tool that allows users to interactively arrange high-resolution images in diversified formats, mainly Scalable Vector Graphics (SVG), to produce one multi-panel publication-quality composite figure in both PDF and HTML formats in a user-friendly manner, requiring no programming skills. It solves stylesheet conflicts of coexisting SVG plots, integrates a rich-text editor, and allows creative design by providing advanced functionalities like image transparency, controlled vertical stacking of plots, versatile image formats, and layout templates. To highlight, the sharable interactive HTML output with zoom-in function is a unique feature not seen in any other similar tools. In the end, we make the online tool publicly available at  Popular computational biology databases such as Reactome , WikiPatComposing multi-panel publication-ready figures, such as the one presented in Materials and Methods section.A previously developed web-based plot designing tool, canvasDesigner , attempthttps://baohongz.github.io/bioInfograph. Written in plain JavaScript language, bioInfograph takes advantage of open-source JavaScript libraries including common ones like jQuery, bootstrap, and lodash. As shown in https://bit.ly/3Gup4Zp for details. Second, gridstack.js is used to layout draggable, resizable, responsive bootstrap-friendly panels in a grid on the designing canvas. Each panel in the grid holds one image that can be panned or zoomed in and out by attached control provided by svg-pan-zoom.js. Modifications are made in gridstack.js to preserve inline styles, including positions, size, and z-index in order to drag a panel to an accurate location instead of pre-defined stops; see https://bit.ly/3CaOg3T for details. Functions of tinymce.js and svg-inject.js libraries are discussed in the following related sections. Third, FileSaver.js is utilized to save image content and associated metadata about size, position, opacity, and zoom scale in an HTML file. When taken together, an intuitive user interface is built and shown in action as illustrated in With simplicity and accessibility in mind, it is implemented as a one-page, client-only, web-based application without the server-side component, available online at https://bit.ly/3wTxoxk. To be aware, the tool is fully tested in the Chrome browser, which provides the best experience.Besides online access, users can install it as a desktop app by downloading the html page or creating a shortcut of the page on the desktop by following the instruction in GitHub repo, https://www.tiny.cloud). Moreover, resizable text boxes can be placed freely on the canvas to input paragraphs of text by following the instructions in test” in the editor.textpattern_patterns: ,Regular characters plus built-in Emoji and symbols from Chrome browser can be typed in the title of a plot, which can be fully formatted in various font families, styles, sizes, shades, and colors by using an integrated text editor, TinyMCE (https://inkscape.org) (https://bit.ly/2NVtj6E) can be utilized to convert these to one of the acceptable formats, preferably SVG.Besides the SVG format, bioInfograph accepts directly additional popular image formats including png, gif, and jpg as input. For other formats like tiff or pdf, free tools such as Inkscape (ape.org)  or pdf2shttps://bit.ly/3Gus3kz for details) to make ids in the document unique by appending original ids with a suffix in the form of “--inject-X”, where X is a running number that is incremented with each added SVG image.Since stylesheet definitions in SVG files are always applied globally to style elements, they share the same parse tree when multiple inline SVGs are embedded in a single document. Therefore, style overwriting and component id collisions can occur and upset the rendering in canvasDesigner as shown in Each image is associated with a vertically stacked control button. Desired vertical stacking order (z-index) is attainable by moving these control buttons up or down by mouse as demonstrated in The white background in the SVG file is optionally removable to make it transparent so that plots can be overlaid onto each other to create appealing art. Opacities of individual images can be adjusted granularly as well to make a comprehensive effect of overlaid images as showcased in visualizing spatial transcriptomics data, which is displayed in https://bit.ly/39ClQnD. An individual plot can be enlarged and further zoomed in to view details in high resolution by clicking on the plot and then the button with a plus sign in the popup window. Unique to this HTML presentation, links to detailed information of proteins in UniProt database (The finished work can be saved as a self-contained HTML file with necessary JavaScript code embedded for easy sharing by email or hosting at GitHub-like services as exemplified at database  are actiWe developed bioInfograph, an interactive web-based tool with a focus on computational biology, which arranges high-resolution images in various formats, mainly SVG, to produce one multi-panel publication-quality composite figure in both PDF and interactive HTML formats in a user-friendly manner, requiring no programming skills.We compared it with several popular tools to illustrate the advanced features of bioInfograph. Among the six tools listed in BioInfograph is an open-source and publicly available web-based tool that can be accessed online or downloaded as a desktop application. It has the most feasible features to improve productivity in the case of creating high-resolution multi-panel figures for scientific publication. Furthermore, the innovative HTML output brings a new way of illustrating high-resolution figures interactively with unlimited zoom-in capability, which could be a nice feature for journals to incorporate in online publishing.


P = 0.023). Our finding is in line with those of other studies and although this issue should be widely known, we feel that it is widely neglected, especially when comparing glucose concentrations across Europe, using large databases without any information on preanalytic sample handling.During a dual-center study on obese and normal weight children and adolescents, focusing on glucose metabolism, we observed a marked difference in glucose results  between the two sites, Salzburg, Austria and Uppsala, Sweden (P < 0.001). After excluding differences in patient characteristics between the two populations as cause of this finding, we investigated other preanalytic influences. Finally, only the tubes used for blood collection at the two sites were left to evaluate. While the Vacuette FC-Mix tube  was used in Uppsala, in Salzburg blood collections were performed with a lithium heparin tube . To prove our hypothesis, we collected two blood samples in either of these tubes from 51 children  and compared the measured glucose results. Indeed, we found the suspected bias and calculated a correction formula, which significantly diminished the differences of glucose results between the two sites ( Beta-cell function in JUvenile Diabetes and Obesity) study  was carried out at Uppsala University Hospital, Sweden and Paracelsus Medical University Hospital in Salzburg, Austria. In the project well-characterized European patient cohorts of children and adolescents aged 6 to 18 years with obesity as well as normal weight control subjects were characterized with particular emphasis on insulin secretion and glucose metabolism.The dual-center cross-sectional Beta-JUDO  samples from eight healthy fasting and non-fasting adult volunteers were collected on ice-water slurry, centrifuged at + 4 °C at 2500xg, aliquoted and frozen at - 70 °C. Always one part of these prepared aliquot pairs was then shipped on dry ice to the University Hospital of Salzburg for laboratory testing and the other was thawed and analysed in the Uppsala laboratory. Thus, preanalytical conditions were identical for all aliquot pairs.After reaching a consensus about the comparability of analytical methods between the two laboratories, the study started and samples from 865 obese and normal-weight children  were collected at several time-points in each individual.Altogether, 16,840 glucose results, some from fasting patients, some collected during an oral glucose tolerance test (OGTT), were acquired during the study . After excluding extreme values within these results (N = 79), identified by application of the 3.0 IQR rule, the Kolmogorov-Smirnov test showed a non-normally distributed data set. Therefore, the Mann-Whitney-U-test was applied to test for differences between the groups. A systematic difference in glucose concentrations between Swedish and Austrian children became evident (P < 0.001), with higher values in Uppsala samples. Several biasing variables, potentially explaining these differences, were statistically analysed by co-variant ANOVA and linear regression models, including age, gender, body mass index, family history of diabetes, and ethnic origin. There were significant differences in Body-Mass-Index Standard Deviation Score (BMI-SDS) between all groups, except between Salzburg controls and Uppsala controls. Mean fasting glucose concentrations in the Uppsala control cohort as well as in the Uppsala patient cohort were higher compared to both the Salzburg patient and control group. When including the fact that mean BMI-SDS was lower in Uppsala controls than in Salzburg patients, the findings led to the hypothesis that differences in mean BMI-SDS could not be cause for the observed shift. Thus, results from the validation round were reassessed, this time using the blood collection tube additives that had been used during the clinical part of the study at the different sites (K2-EDTA and lithium-heparin (LH) Na-F/C).Study population characteristics was showed in Results from the first and second validation rounds are presented in Since the second validation round showed differences between results from different tube additives, the most probable explanation for the differences between the two sites was the type of tube additive used for blood collection. In Uppsala a Na-F/C containing tube from GreinerBio-One was used  while in Salzburg a LH tube from Sarstedt  was used. All other parts of the preanalytical procedures were identical. To confirm this hypothesis, another experiment was conducted at both sites. From routine clinical care patients , blood was collected into the mentioned Vacuette FC-Mix and LH-Monovette at the same time point and transported on slurry ice water to the laboratory, where the samples were centrifuged. Sample pairs were analysed in parallel to avoid any confounding bias on Roche COBAS instruments at both sites . After excluding two outliers, we observed a systematic bias between LH and Na-F/C tubes .We then screened the literature and found several publications in support of our findings  to the rDespite the profound and thorough harmonization of the study design, including a validation round for analytical comparability, the fact that the same tube was used for validating the analytical methods, but different tubes were used for the actual blood collection in the study subjects, was overlooked. This led to a systematic decrease of values in the Salzburg population since glycolysis is inhibited far better by Na-F/C than by LH  mmol/L and 5.0 (± 0.5) mmol/L, respectively  or diabetes might not fit to every setting  Working Group for Preanalytical Phase (WG-PRE), to prevent any kind of preanalytical variable biasing your data (When collecting blood for glucose determination, we recommend using Na-F/C tubes. These additives guarantee short-term and long-term inhibition of glycolysis, thereby securing a less altered glucose result.


Obstructive sleep apnea (OSA) is a sleep-related disorder with breathing difficulties. Previous studies revealed that epicardial fat thickness (EFT) correlates with OSA severity. Interestingly, female patients display a stronger EFT-OSA correlation than males. The purpose of this study is to investigate the relationship between EFT and different clinical characteristics in pre- and post-menopausal women diagnosed with OSA.Patients diagnosed with OSA were divided into pre/early peri-menopausal (Group 1) and post/late peri-menopausal (Group 2) according to the menopause status. EFT was obtained from parasternal long-axis echocardiographic images. We also collected general clinical characteristics of patients involved in this study, and performed spearman correlation analysis to explore the correlations between EFT and the general clinical characteristics. We further applied Multiple stepwise linear regression analysis to explore the predictors for EFT in both groups.2 (oxygen saturation) levels. However, EFT was positively correlated with total cholesterol (TC) only in Group 1 and body mass index (BMI) only in Group2, respectively. Multiple stepwise linear regression analysis showed that AHI was independently associated with EFT in Group 1. However, both AHI and BMI were independent predictors of EFT in Group 2.A total number of 23 and 59 patients were enrolled in Group 1 and Group 2 respectively. EFT in Group 2 was significantly higher than that of Group 1. In both groups, EFT was positively correlated with apnea–hypopnea index (AHI), percentage of total sleep time when blood oxygen saturation was less than 90% (T90), oxygen desaturation index (ODI) and glucose; while EFT was negatively correlated with mean and lowest SaOEFT was notably correlated with menopausal status in women with OSA. AHI was the independent predictor of EFT in women with OSA. BMI was the independent predictor of EFT in post/late peri-menopausal women with OSA. Obstructive sleep apnea (OSA) is a sleep-related disorder with breathing difficulties, which is characterized by repetitive collapse of upper respiratory tract during sleep . These oEpicardial fat is the largest visceral fat storage situated between the epicardium and pericardium . EpicardWomen with suspected OSA were consecutively enrolled in the sleep unit in Shanxi Medical University First Hospital from January 2019 to June 2019. All subjects were enrolled after being informed of the details of this study and signing a written consent form. The study was approved by the Institutional Ethics Committee of the Shanxi Medical University First Hospital. No patients enrolled had previous OSA diagnosis. According to OSA diagnosis guideline , subjectIn this study, we recruited patients diagnosed with OSA, and divided them into pre/early peri-menopausal Group 1) and post/late peri-menopausal (Group 2). We measured EFT and collected general clinical characteristics in both groups. The menopause status of enrolled subjects was classified by the frequency and regularity of menstrual bleeding as previous described . 4 categ and post2   years. The clinical characteristics were presented in Table P < 0.001), T90 , ODI , total cholesterol , and glucose , whereas EFT was negatively correlated with both mean  and lowest SaO2 . However, no significant linear correlation was observed between EFT and age, BMI, waist circumference, triglyceride, LDL, HDL, estradiol, or follicle-stimulating hormone for those patients (Table P = 0.016), AHI , T90 , ODI , and glucose , and a negative correlation was also found for mean SaO2  and lowest SaO2 . Similarly, no significant liner correlation was observed between EFT and age, waist circumference, total cholesterol, triglyceride, low-density lipoprotein, high-density lipoprotein, estradiol, or follicle-stimulating hormone  and post/late peri-menopausal (Group 2) patient. We collected general clinical characteristics of patients involved in this study, and performed Spearman correlation analysis. In pre/early peri-menopausal group, positive correlations were observed between EFT and AHI (r = 0.760, ts Table . In postNext, we performed multiple stepwise liner regression analysis to identify the predictors of EFT in both groups. Our analysis showed that AHI and BMI were independent predictors of EFT for post/late peri-menopausal women. For pre/early peri-menopausal women, AHI was the only independent predictor of EFT Table .Table 4SIn this study, we explored the relationship between EFT and different clinical characteristics in pre- and post-menopausal women with OSA diagnosis. To our knowledge, this is the first research to probe the relationship of different parameters contributing to the EFT in OSA-diagnosed women according to menopause status. In this group of patients, our correlation analysis demonstrated that regardless of the menopause status, EFT was positively correlated with AHI, T90, ODI and glucose level. Our data also indicate that AHI was the universal predictor of EFT in both pre/early peri-menopausal and post/late peri-menopausal women with OSA. However, BMI was the independent predictor of EFT only for post/late peri-menopausal women with OSA. Therefore, our study suggests that total cholesterol level seems to contribute to the EFT only in pre/early peri-menopausal OSA patient; while BMI is a potential manipulative parameter to reduce EFT and the incidence of OSA in post-menopausal women.EFT is considered as a cardiometabolic risk factor of OSA, which is highly correlated with OSA severity and was a statistically-significant independent predictor of AHI in obesity-related OSA patients . ODI is It is worth noting that no previous studies have investigated the correlation between menopausal status and EFT in OSA women. In our study, we found that EFT was significantly higher in post/late peri-menopausal OSA patients in comparison to pre/early peri-menopausal patients. Our findings were consistent with a recent study by Khoudary et al. , 18 in wIn the present study, we further analyzed the correlations between EFT and different clinical parameters in pre- and post-menopausal OSA patients. We showed that AHI was a common independent predictor of EFT in both groups, whereas BMI was an independent predictor of EFT in post/late peri-menopausal women. A previous study demonstrated that AHI is considered as a potential marker for postmenopausal OSA women without hormonal replacement therapy . NotablyWe also recognize several limitations in our study. First, the sample size was small and the study was cross-sectional so that a cause-effect conclusion was not able to be drawn. Second, OSA patients with thicker EFT have more chance to develop metabolic syndrome , it is wOur study shows that EFT was positively correlated with post-menopausal OSA and can be as a risk factor for assessing OSA. Particularly, our finding suggest that BMI is a potential predictor of EFT in post-menopausal women with OSA. A large sample size will be necessary to further validate the contribution of different clinical parameters to EFT and OSA in women with different menopausal status.


Evidence is scarce on caregivers’ perception regarding their participation in exercise interventions targeting individuals with neurocognitive disorder (NCD). This study aims to investigate the views of family caregivers of people with NCD about taking part in a community-based physical exercise intervention with their care-recipients. Twenty caregivers  answered to a semi-structured interview conducted by telephone about their perception on participating or not as class members of a 6-month multicomponent training intervention. Transcribed data from the interview were analyzed through thematic analysis. Main themes regard their perceived key-role in the care recipients’ participation, which included knowing their limitations, making them feel accompanied and motivated, and the possibility of providing comfort and tranquility throughout the intervention. Caregivers also mentioned the possibility of fulfilling own needs for physical activity and being engaged in new experiences. Disturbing the care recipients’ involvement and performance, the opportunity for respite during the sessions’ time, and being enrolled in the program only in specific moments or by telephone were also mentioned. Findings highlight the inclusive perspective of caregivers to take part of exercise programs designed for people with NCD, not only due to their decisive role on care-recipients engagement but also due to the associated (in-/)direct personal benefits. This data may be useful for planning and prescribing future community-based exercise interventions for NCD caregiving dyads. Trial registration: ClinicalTrials.gov - NCT04095962. Supported by FCT: “Body and Brain” (POCI-01-0145-FEDER-031808), CIAFEL (FCT/UIDB/00617/2020), and Ph.D. Grants (SFRH/BD/136635/2018) to FM (2020.05911.BD) to DB.


Stroke is considered one of the main causes of adult disability and the second most serious cause of death worldwide. The combination of botulinum toxin type A (BTX) with rehabilitation techniques such as modified constraint-induced movement therapy (mCIMT) has emerged as a highly efficient intervention for stroke patients to start synchronized motor function along with spasticity reduction. The current systematic review and meta-analysis were conducted in order to evaluate the available literature about the safety and efficacy of constraint-induced movement therapy (CIMT) combined with BTX in stroke patients with upper limb spasticity.Searches were conducted on WoS (Web of Science), Ovid, EBSCO-ASC&BSC, and PubMed for identifying relevant literature published from 2000-2020. Randomized Controlled Trials (RCTs) and Quasi-experimental studies were considered for inclusion. Rayyan (systematic review tool) QCRI (Qatar Computing Research Institute) was used for independent screening of the studies by two reviewers. For risk of bias and study quality assessment, Cochrane risk of bias tool (RoB 2) and Physiotherapy Evidence Database (PEDro) scales were used. Cochrane review manager was used to carry out the meta-analyses of the included studies.The search resulted in a total of 13065 references, of which 4967 were duplicates. After the title, abstract and full-text screening, two RCTs were deemed eligible for inclusion. Both the RCTs scored 8 on PEDro and were level evidence. The studies were heterogeneous. The findings of this meta-analysis in all the three joints post-stroke spasticity assessed on modified Ashworth scale (MAS) at four weeks post-injection aren’t statistically significant , however, according to one of the included studies the therapeutic efficacy of the combination of BTX-mCIMT injection assessed at four weeks post-injection in wrist and finger flexors was promising. The effectiveness of BTX-CIMT combination over conventional therapy (CT) for improving post-stroke spasticity still needs to be explored with long-term, multicenter rigorously designed RCTs having a good sample size. However, the BTX-CIMT combination is promising for enhancing motor function recovery and improving activities of daily living (ADLs). Stroke is among the most serious diseases globally. It affects millions of people all over the world. It is associated with a high economic burden every year due to rehabilitation and pain ,2. ConseRehabilitation techniques include but are not limited to mirror therapy, virtual reality, robot-assisted rehabilitation and constraint-induced movement therapy (CIMT) -5. CIMT Spasticity, a common complication of stroke, hinders the rehabilitation process substantially and requires practical and effective management . Its manA highly promising therapeutic approach to post-stroke spasticity was the injection of botulinum toxin type A (BTX), which is associated with minor side effects. Although the effect of BTX injections in combination with CIMT showed a promising impact on arm motor function and reduced spasticity in a chronic stroke patient, this combination has not been fully elucidated thus far .The combination of BTX injections and CIMT (BTX-CIMT) is possibly a promising approach for such an important issue. These injections can counterbalance the arms’ motor recovery along with managing the spasticity . BesidesThis meta-analysis aimed to evaluate the available literature about the safety and efficacy of CIMT combined with BTX in stroke patients with upper limb spasticity. This will keep researchers, decision-makers, and healthcare practitioners up-to-date with the current evidence on the topic.MethodsSearch StrategyThe databases/platforms Web of Science (WoS), Ovid, EBSCO-Academic Source Complete(ASC) and Business Source Complete (BSC), and PubMed, were used for literature search and study identification. These databases were searched to identify relevant literature at the end of January 2021. The Ovid of Huazhong University of Science and Technology library is a platform for searching databases, like EMBASE, MEDLINE, LWW Medical Full-text Journal Database, and LWW medical eBooks (Updated: 2019-3-29). Medical Subject Heading (MeSH) terms and keywords identified on these databases for this study are used as following: PubMed : Ovid : EMBASE . These MeSH terms and keywords were used during basic and advanced searches on the databases. A search was also performed without using the above PubMed MeSH terms because using those MeSH terms may restrict the search to a subset of PubMed citations only. Boolean phrases, truncation, and wild cards were used wherever necessary. The search filters applied were publication years (2001-2020), species (humans), and article type . Other sources for study identification were screening the reference lists of the included studies.Inclusion and Exclusion CriteriaThe study inclusion criteria were as follows: 1) Randomized Controlled Trials (RCTs) and quasi-experimental studies that studied the combined effects of constraint-induced movement therapy and botulinum toxin A; 2) Enrollment of adolescents and adults with post-stroke spasticity [modified Ashworth scale (MAS) 1-⩾3]; 3) Quantitative measurement of post-stroke spasticity before and after BTX-CIMT therapy.Studies with lower limb spasticity, pediatric stroke, or traumatic brain injury were excluded. Moreover, single-arm studies, animal studies, ex vivo/in vitro studies, review studies, retrospective studies, case series, and case reports were also excluded.Studies Selectionrayyan.qcri.org) for citation screening .Study Quality Assessment and Risk of Bias AssessmentData extracted for external validity and reporting quality included study ID [author(s) name(s) with the year and reference], study design characteristics , participants details , intervention , control , primary and secondary outcome measures, results and information regarding dropouts were collected.The Physiotherapy Evidence Database (PEDro) scale was used for study quality assessment . Two indStudy risk of bias was assessed by two independent reviewers  by Cochrane risk of bias tool (RoB 2) . Every sData ExtractionTwo independent reviewers  performed data extraction; any conflicts/disagreements were resolved on discussion with the corresponding author and comparing the recorded data. The Microsoft data extraction form consisted of details of the included studies, design, population, target variables, interventional procedure, and results. Authors  pre-piloted the data extraction form on some studies. Data were extracted from the texts, tables, and figures of the included studies.Data SynthesisWe performed both qualitative and quantitative analyses. The data extracted were summarized in table form to present the characteristics and results of the included studies effectively. A meta-analysis was performed for the study primary variable using a random-effect model. We planned to do subgroup analysis and sensitivity analysis, but due to a lack of studies, we could not proceed with these analyses.Meta-Analysis Methodology2 index (I2) and Chi-square tests (Chi) were used for evaluating heterogeneity among the studies. We considered an I2 value of 25% as low, 50% moderate, and 75% as depicting high heterogeneity .,17.15,17Discussion Meta-Analysis SummaryThis review included two RCTs to evaluate and compare the effectiveness of the combined application of BTX-CIMT or BTXA plus CT on the patients with post-stroke upper limb spasticity, providing an updated evidence base for policy-makers, physicians, and researchers. The findings of this meta-analysis in all the three joints post-stroke spasticity assessed on modified Ashworth scale (MAS) at 4 weeks post-injection are not statistically significant; however, according to one of the included studies, the therapeutic efficacy of BTX-CIMT combination therapy assessed at four weeks post-injection in wrist and finger flexors was promising as compared to BTX-CT combination .Both the level 1 RCT studies included in this review provided within-group effectiveness of BTX-CIMT combination therapy, and all participants improved in their spasticity compared to their baseline results. The RCT study by Nasb et al.  reportedBoth the RCTs started rehabilitation regimes one day after BTX therapy; however, there were still some interventional and sample size differences that could affect the study results. Nasb et al.  inclusioThere were slight differences in the treatments to control and treated groups in the 2 studies. One of them treated the randomized experimental groups with a massed practice consisting of placing, reaching lifting, and grasping activities of the affected arm while unaffected are restrained . The othThe significant improvement in motor functions and recovery reported in the qualitative analysis is consistent with other studies. One of the included studies reported significant improvements in the elbow, wrist, and finger flexors spasticity after six months, after combined BTX-CIMT as compared to combined BTX A injection and CT .Levy et al.  reportedA case study with a one-year long-term follow-up reported that CIMT after BTX A injection resulted in improvement of outcome measures MAS, FA, ARAT significantly before and after one year of treatment .Although many case studies and non-randomized studies had reported the superiority of BTX A and mCIMT or CIMT combination therapy, due to heterogeneity in the included studies as shown in this meta-analysis and the low number of studies included, we could not provide some guidance regarding the efficacy of BTX-CIMT combination as compared to conventional rehabilitation for managing post-stroke spasticity. However, the BTX-CIMT combination has proved to be highly effective for improving and enhancing functional performances and ADLs. The scores of the different scales such as FMA, MAL, BI, BBT, WFMT, and ARAT were found to be significantly improved with the BTX-CIMT combination as compared to conventional rehabilitation.Study LimitationsThis study has some limitations. The first limitation is the follow-up duration of the included studies; one study has a follow-up period of four weeks , while tThe effectiveness of the BTX-CIMT combination over conventional therapy for improving post-stroke spasticity still needs to be explored with long-term, multicenter rigorously designed RCTs having a good sample size. However, the BTX-CIMT combination is promising for improving motor function recovery and ADLs. Moreover, merging BTX-CIMT with other traditional modalities, such as functional electrical stimulation, can lead to a substantial effect on the improvement of chronic upper limb spasticity. Most BTX-CIMT trials have not addressed treatment protocols or therapy dosage.


The primary role of muscles is to move, and control joints. It is therefore important to understand how degenerative joint disease changes this role with the resulting effect on mechanical joint loading. Muscular control strategies can vary depending on strength and coordination which in turn influences joint control and loading. The purpose of this study was to investigate the variation in neuromuscular control mechanisms and joint biomechanics for three subject groups including those with: uni-compartmental knee osteoarthritis (OA), listed for high tibial osteotomy surgery ; multi-compartmental knee OA listed for total knee replacement , and non-pathological knees . Lower limb kinematics and electromyography (EMG) data for subjects walking at self-selected speed, were input to an EMG-driven musculoskeletal knee model which was scaled and calibrated to each individual to estimate muscle forces. Compared to NP, the peak gastrocnemius muscle force reduced by 30% and 18% for pre-HTO and pre-TKR respectively, and the peak force estimated for hamstring muscle increased by 25% for pre-HTO. Higher quadriceps and hamstring forces suggest that co-contraction with the gastrocnemius could lead to higher joint contact forces. Combined with the excessive loading due to a high external knee adduction moment this may exacerbate joint destruction. An increased lateral muscle co-contraction reflects the progression from NP to uni-compartmental OA (pre-HTO). Pre-TKR patients adopt a different gait pattern to pre-HTO patients. Increased medial muscle co-activation could potentially differentiate between uni- or multi-compartmental OA. Mechanical factors play an important role in the development and progression of Osteoarthritis (OA) . The kneMost gait studies have focussed their investigations on knee kinematics and kinetics –10, muscExternal knee adduction moment (EKAM), suggested as a surrogate measure of knee OA severity , 22, hasMuscle activation features also play an important role in understanding the effects of longitudinal progression or interventions for knee OA. Hubley-Kozey et al.  showed tMeasuring the forces applied to a joint and estimating how these forces are partitioned with respect to surrounding muscles, ligaments, and articular surfaces is fundamental to understanding joint function, injury, and disease. Muscle forces have been proposed as the primary determinants of joint contact forces , 31, witAdvances in musculoskeletal knee modelling and computation power have enabled researchers to generate gait simulations in efforts to estimate joint moments, muscle forces e.g., , 33) and and33]) Although biomechanical evaluations of people with OA are frequently performed to identify gait impairments; little attention has been paid to the provision of quantitative information regarding the function of individual muscles. Adouni and Shirazi-Adl  developeThis paper contributes to our current understanding of the underlying neuromuscular mechanisms during gait for patients with knee OA prior to HTO and TKR surgery. A question has been posed: Do muscle coordination strategies, adopted by subjects with knee OA, and associated changes in knee function reflect the level of involvement of compartmental knee OA?Kinematic and kinetic data were collected in the Motion Analysis Laboratory (Cardiff School of Engineering) from thirty subjects, each gave their informed written consent prior to data collection, divided into three groups: eleven subjects with no knee pathology (NP), ten subjects with medial uni-compartmental knee OA and correctable varus deformity listed for high tibial osteotomy (pre-HTO) , and ninMotion analysis was performed using nine 120Hz infra-red motion capture units . Qualisys Track Manager  was used to capture full body motion using reflective markers placed on the trunk, pelvis, and both the upper and lower limbs (modified Cleveland clinic marker set) , 43. FouMuscle electromyographic (EMG) data were collected bilaterally, using a Trigno™ Wireless EMG System , for seven muscles: rectus femoris, vastus lateralis, vastus medialis, biceps femoris, semitendinosus, gastrocnemius lateralis, and gastrocnemius medialis. The electrodes were placed longitudinally over the muscle bellies after standard preparation of the skin, according to SENIAM recommendations , involviParticipants were asked to perform activities of daily living whilst muscle EMG, ground reaction force and three-dimensional movements were collected using the synchronized movement analysis system. Six trials of level gait at self-selected walking speeds, six trials of ascending/descending a four-step staircase , and twoRecorded raw EMG data, through stance phase, were analysed in Matlab . The raw EMG signals were band-pass filtered, to remove the movement artefacts, by a Butterworth 4th order filter at 10_450) Hz, rectified and finally low-pass-filtered with a 4th order Butterworth filter at 6 Hz to create a linear envelope for each muscle. Then linear envelopes for each muscle were normalized to peak values obtained through activities of daily living, as recommended by . Finally Hz, rectSim v3.3 . CEINMS Sim v3.3 , 52, so Sim v3.3 . After cMuscle forces and joint moments  were normalized to each stance phase of the gait cycle. Values at heel strike, peak weight acceptance and peak push off, along with co-contraction indices were averaged across six representative stance phases for each subject, and then averaged across subjects to obtain group means. Heel strike was defined as the value at 0% of the stance phase. Peak weight acceptance was defined as the first 15% of the stance phase. Peak push off was defined as the mean value between 5% on either side of the peak knee extension moment.Patient-reported outcome measures (PROMs) including Oxford Knee Score , Knee OuP > 0.05) and the equality of variances, respectively. One way analysis of variance (ANOVA) model was tested for significant group differences for demographics, walking speed, and patient reported outcome measures (PROMS), where data was normally distributed and homogenous. All significant findings were post hoc tested using Tukey adjusted alpha level to determine pair-wise significant differences.The Kolmogorov–Smirnov and Levene tests were used to assess the normality of distribution .Demographics and PROMS differed across the three subject groups; summarized in Tables No significant differences, between pre-HTO and pre-TKR groups, were observed in PROMS suggested that these outcome measures were not the most sensitive methods to differentiate between uni- and multi-compartmental knee OA.Group ensemble-averaged waveforms for quadriceps, hamstring and gastrocnemii muscle forces illustrate that peaks and patterns changed between NP, pre-HTO and pre-TKR groups . The seqA reduced range of sagittal plane knee joint angle was observed for OA cohorts (pre-HTO and pre-TKR patients) as compared to NP, Hip, knee and ankle group ensemble-averaged moment curves ) for NP, pre-HTO and pre-TKR patients are shown in A summary of the individual muscle forces and joint moment is reported in Tables This study has shown that neuromuscular control and biomechanics differ between non-pathological knees and those with OA. These differences are magnified as the level of compartmental involvement increases. The results have demonstrated that, in line with previous research findings , knee OAKnee OA is associated with a reduction in gastrocnemius muscle force, whereas quadriceps and hamstring muscles play a significant role in controlling the knee joint. Subjects with knee OA had reduced gastrocnemius muscle forces compared to NP subjects by 30% and 18% for pre-HTO and pre-TKR, respectively. This could happen due to a reduction in knee extension moment  for thesOur finding of increased quadriceps and hamstrings muscle forces in the knee OA groups is supported by an earlier study , where tinitial heel contact (HS) when the line of action of the ground reaction force (GRF) passes posterior to the ankle centre, producing a plantar-flexion moment at the ankle. This moment is countered by the activation of ankle dorsiflexor muscles; this was the case for all groups. Considering the importance of leg stability during this phase, compensations aimed at extending the knee include premature activity of the gastrocnemius [In the NP stance phase, there are at least three crucial sub-phases. First is the ocnemius , avoidinweight acceptance (WA) phase where the ankle dorsi-flexors eccentrically contract towards foot flat. The knee extensors contract, to correct the position of the knee before it accepts further loading into single leg stance. Peak quadriceps action occurs during loading response, when the GRF vector is behind the joint axis. As the vector moves forward of the knee axis, an extension moment is created at the knee, and this muscle group relaxes. The gastrocnemius muscle group contracts to control knee extension at this stage, due to the plantar flexor–knee extension couple. Higher muscle forces occur during WA when the EKAM is high and the knee extends in single limb support. In this study the knee OA subjects (pre-HTO and pre-TKR), used substantially higher lateral hamstring and vastus lateralis muscle forces during WA phase compared to NP  phase, where the leg is accelerated forward by the gastrocnemius creating a rapid ankle plantar flexion to push off and with associated activity at the hip flexor (rectus femoris). During this phase, generally for NP gait, there is a maximal knee extension moment, a second peak knee adduction moment, and a peak dorsiflexion moment. In this study both knee OA groups had reduced the terminal knee extension moments (P<0.05) and ankle dorsiflexion moment (P<0.05) and pre-HTO subjects, and in the pre-HTO subjects compared to the NP subjects (P<0.05).Third, is the n moment , comparen moment , impliesIn the frontal plane, the hip adduction moment is generally found to be high in knee OA patients compared to NP. However, the pre-TKR cohort exhibited a different adduction pattern compared to the NP and pre-HTO cohorts. In both the NP and pre-HTO subjects, frontal plane moments had two distinct peaks. The first peak was higher for the pre-HTO compared to the NP group. This is attributed to altered alignment of the tibiofemoral joint (knee varus), which would create a valgus alignment at the hip.P<0.05) was observed for the pre-HTO subject group  %BW*H compared to the NP  %BW*H at weight acceptance and push-off, respectively. A remarkable increase in the first peak of EKAM for NP, in comparison to the second peak, was mainly due to the increase in the quadriceps force resisting the external knee flexion moment during this time interval. In contrast, the moderate increase of the second peak in the pre-HTO cohort, in comparison to the first peak, was due to the increase in both quadriceps and hamstring muscle forces during this time interval as compared to NP. The double peak could not be identified in pre-TKR patients.The same trend was seen in the EKAM, where a significant increase (P<0.05), during weight acceptance and push off.In the transverse plane, the hip is significantly more internally rotated for the pre-HTO subjects group compared to the NP subject group  higher CCI compared to NP subjects. Interestingly, this study shows that gastrocnemii indices are doubled in the pre-HTO group as compared to NP subjects. For the pre-TKR group, in addition to the gastrocnemii role that is associated with a two-fold increase in the CCI, the hamstring muscles also have the potential to control the knee joint. The hamstring indices increased by almost four-fold on the lateral side and three-fold on the medial side, as compared to NP individuals. There was also a significant increase in VLLH for the pre- TKR group, which may contribute to a reduction in the medial contact force. The lateral indices indicated an almost two-fold increase (P<0.05), for the pre-HTO group compared to NP subjects. Therefore, increased lateral muscle co-contraction reflects the non -pathological knee’s progression to uni-compartmental OA with varus deformity. No significant differences were found between pre-HTO and pre-TKR lateral indices.Pre-TKR patients , have siP<0.05) was identified for the medial side index, VMMH, between the two OA groups, Significant difference . Whereas, the increase of medial muscle co-activation could potentially differentiate between uni-compartmental or multi-compartmental OA.


The impact of frailty on the efficacy and safety of vaccines and therapeutic interventions is increasingly recognized, yet assessment of frailty in clinical trials is often considered logistically challenging. We developed the retrospective Clinical Trial Frailty Index (CT-FI), using baseline medical history and patient reported outcomes collected via standard instruments  in two clinical trials of the adjuvanted recombinant zoster vaccine . This post-hoc analysis aimed to show that CT-FI is a robust measure that may be used in any analysis where sufficient patient data has been collected in a clinical trial.Items included in the CT-FI were scored from 0 to 1, summed for each participant and divided by the total number of potential deficits. CT-FI was validated using descriptive methods verifying distribution and age- and sex-associations in relation to established FI characteristics, Cox regressions in relation to fatal outcomes hypothetically related to frailty, and re-sampling methods (Jackknife and Bootstrap procedures) within the FI to demonstrate robustness to inclusion/exclusion of specific individual variables.The CT-FI distribution followed a gamma distribution with a range of 0 to 0.695; the distribution shifted to the right with age. The age-related slope of mean deficit accumulation per year increased with chronological age and was higher for women than men. The rate of mean deficit accumulation was 0.0025 for women vs 0.0016 for men < 70 years of age, and this increased to 0.0058 for women vs 0.0047 for men ≥70 years of age. In univariate and multivariate Cox regression survival analyses, FI, chronological age and sex were significant predictor factors for mortality. The Jackknife and Bootstrap re-sampling methods showed that the performance of CT-FI was not sensitive to inclusion/exclusion of specific individual or groups of variables, demonstrating the robustness of this methodology. The current analysis validates that CT-FI, an easy-to-implement FI, is a robust method which allows retrospective/prospective evaluation of clinical outcomes by frailty status in clinical trials.Melissa K. Andrew, MD, PhD, GSK (Grant/Research Support)Pfizer Sanofi Seqirus (Advisor or Review Panel member) Sean Matthews, MSc, GSK (Independent Contractor) Joon Hyung Kim, MD, GSK group of companies  Megan Riley, PhD, GSK group of companies  Desmond Curran, PhD, The GSK group of companies


The incredible spread rate of coronavirus disease 2019 (COVID-19) outbreak has shocked the world. More than ever before, this dramatic scenario proved the significance of diagnostics as a cornerstone to make life-saving decisions. In this context, novel diagnostics that generates smart data leading to superior strategies for treatment, control, surveillance, prediction, prevention, and management of pandemic diseases is vital. Herein, we discuss the characteristics that should be met by COVID-19 diagnostics to become smart diagnostics enabled by industry 4.0 especially Internet of Things (IoT). The challenges ahead and our recommendations for moving faster from pure diagnostics toward smart diagnostics of COVID-19 and other possible epidemic/pandemic diseases are also outlined. An IoT-Fog-Cloud model based on smartphones as IoT gateways for smart diagnostics with unified strategies for data collection/transmission/interpretation is also proposed to integrate new digital technologies into a single platform for smarter decisions. Last but not least, we believe that “smart diagnostics” is a perspective that should be realized sooner before we encounter a pandemic far worse than the present one. Since the first reports of the coronavirus disease 2019 (COVID-19) outbreak on 31st December 2019 in Wuhan, China, when many of us believed that the overall wellbeing had been improved by current scientific, technological and industrial achievements, the rapid and unbelievable spread rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has shocked the whole world. COVID-19 severely affected the health, economy, and social activities of more than seven billion people worldwide . Since tIt was recently estimated that COVID-19 pandemic economic impact could reach between $5.8–$8.8 trillion globally which is equal to 6.4–9.7% of global gross domestic product (GDP) . Apart fAccurate, precise, timely, and widespread diagnosis of potentially pandemic outbreaks can be considered as the first effective measure to make life-saving smart decisions in order to start a timely process of treatment, trace and track infected people to isolate each possible suspect, thereby, controlling and breaking its transmission chain . A well-Smart diagnostics can be defined as a diagnosis based on smart data resulted/analyzed from diagnostic tests/devices’ big data. This concept spans diagnostics interconnected with powerful resources facilitated by Industry 4.0 in the form of new digital technologies such as Internet of things (IoT), smartphone, big data analytics (BDA), machine learning (ML), deep learning (DL), blockchain analysis (BA), artificial intelligence (AI), augmented reality (AR), cybersecurity, system integration, cloud, and fog computing . These sIn this perspective, we aim to highlight the necessity of smart diagnostics in a pandemic scenario. We underscore the vital role of smart diagnostics in aid to overcome the present pandemic globally and predict and subsequently prevent the next possible epidemics/pandemics. We also consider an overview of COVID-19 diagnostics to discuss the criteria that should be met by the developed diagnostic tests/devices, as well as new digital technologies related to smart diagnostics. Eventually, future challenges/strategies and our recommendations for future diagnostic tests/devices to fulfill the smart diagnostics of infectious disease outbreaks are offered.COVID-19 displays an incubation period ranging from 2 to 14 days, with symptoms appearing from 8 to 16 days after infection exposure . IndividGiven the crucial role of testing in the treatment and isolation of COVID-19 infected people, several COVID-19 diagnostic methods have been developed all over the world throughout 2020 . Furthervia SHERLOCK (specific high-sensitivity enzymatic reporter unlocking) and thoracic imaging using computed tomography (CT) scans  SARS-CoV-2 genetic material and (ii) immunoglobulins, produced after COVID-19 infection. Generally, acute infection of the novel coronavirus can be detected through its genetic material in nasopharyngeal swab samples using conventional methods such as reverse transcription-polymerase chain reaction (RT-PCR) or employing novel methods, including reverse transcription- loop mediated isothermal amplification (RT-LAMP) and clustered regularly interspaced short palindromic repeats (CRISPR)-based technology . COVID-1T) scans . MoreoveT) scans . SARS-CoT) scans . The resvia POC devices incorporating nucleic acid or immunoglobulins testing. In fact, equipment enabling on-site isothermal amplification of the novel coronavirus genetic material and lateral flow (LF) strips (pregnancy-like tests) targeting immunoglobulins resulting from COVID-19 infection are prominent examples of POC devices employed in SARS-CoV-2 diagnostics , testing strategy, disease severity, test duration, required equipment, operator skill in sampling/specimen collection, running the tests and reading/interpreting the results, and required transport and storage conditions .On the one hand, the developed COVID-19 diagnostic tests/devices are available in the economically developed world– either as centralized services or as POC approaches; on the other hand, most of them are rarely available or affordable in resource-limited settings, such as the developing world and especially resource-limited setting due to their high cost, which is mainly related to the high costs of fabrication, materials, (bio)chemicals, human resources, and equipment used for their development, and other possible costs associated with their transportation/storage/refrigeration, and delivery to end-users . In thisGiven the extreme importance of early diagnosis in proper prevention and treatment of emerging infectious diseases and saving many lives, especially in developing regions, a set of criteria was published in 2003 by WHO for ideal diagnostic devices/assays . AccordiIn a pandemic scenario, real-time connectivity competence is crucial to read and transmit the test results and receive feedback. The use of COVID-19 diagnostic devices with this capability will lead to faster and timelier testing and provide feedback from decision-makers, remote monitoring of the patients’ condition and clinical progress of the treatment process, and subsequently faster and better control of this disease. Besides, this ability will facilitate a significant decrease in turnaround time, energy consumption, carbon-footprint, society/health services cost, and more importantly referring people with suspected COVID-19 (infected or non-infected) to diagnostic centers to perform or obtain test results, which will effectively tackle the transmission chain of this disease, thereby contributing to the control of the spread of the disease. Furthermore, the data obtained from the decentralized real-time connected COVID-19 diagnostic devices will efficiently help to control this disease timely by taking advantage of centralized and real-time decision-making. Importantly, smart prediction can also be supported by these resources to prevent new pandemic waves in the future.One of the main limitations of most of the developed COVID-19 diagnostic tests/devices is their reliance on the use of invasive specimens and/or difficult and complex specimen collection , as well as processing methods that limit their applications at the POC and remote sites away from centralized laboratory facilities. Owing to such difficulties, most of the existing COVID-19 diagnostic tests can only be performed in centralized/sophisticated laboratories with trained operators to run the diagnostic tests and interpret their results, and for this reason, many of them, such as PCR and ELISA, are still far from being used as self/home diagnostic tests.Apart from the obvious and great importance of ASSURED criteria in the design of ideal COVID-19 diagnostic tests/devices see  Land et, anotherAs shown in COVID-19 pandemic demonstrated more than ever the importance of smart diagnostics and consequently the necessity of moving faster the diagnostic tests/devices toward becoming smart. via interoperability  is presently using smartphones which equals 6.8 billion subscribers connected to the Internet while the number of subscribers is rising . It meanrability  to reachrability  and Interability  and becovia numerous IoT devices such as smart thermometers/patches/biosensors  based on Industry 4.0/Healthcare 4.0 principles, into a single platform. Besides, smart diagnostics’ big data should be transcoded and purified to generate smart data for future smart services and use in the war against pandemics form see .•via smartphones, is needed.Lack of ethical guidelines, interoperability, standardization , and security protocols for establishing smart diagnostics-related data is tangible; therefore, a multi-technology, multi-interface, multi-standard, and communication platform, which can integrate different communication and security standards in a unified platform •The generation of smart pandemic data directly from home/self-users (without interruptions) is extremely needed to realize the smart diagnostics.•via especial drills (similar to earthquake or fire drills).Smart and alert citizens are also needed in such a war against pandemics. How to perform self-sampling, self-testing, data sharing/receiving, and safe disposal of the REASSURED-based diagnostic tests (after use) along with other pandemics-related essential educations should be trained to a large number of populations in advance •Multi-disciplinary and multi-cultural groups from different countries with sufficient funds in different disciplines such as medicine, engineering, (bio)chemistry, business, and information technology (IT) should be formed to tackle such problems from different angles. Such diversity and outside the box philosophy will lead to innovative and smarter solutions.The original contributions presented in the study are included in the article/All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


A 33-year-old female patient presented with abdominal distention and lower extremities edema. Abdominal wall varicosis and shifting dullness were positive on physical examination. Her liver function was classified as Child-Pugh B and a solid tumor at retro-hepatic vena cava extending to right atrium with thrombi in three hepatic veins were confirmed. The diagnosis of leiomyosarcoma with Budd-Chiari syndrome was highly suspected with preoperative ultrasound, echocardiogram, CT scan, and three-dimensional reconstruction. A zone II-III leiomyosarcoma of IVC origin was confirmed at surgery and ex vivo liver resection and autotransplantation, and hepatic vein thrombectomy with atrial reconstruction were performed under cardiopulmonary bypass (CPB). Operative time, anhepatic time, and CPB time were 12 h, 128 min, and 84 min, respectively. The patients experienced post-operative liver dysfunction and was cured with conservative therapy. Hepatic recurrence two years after surgery was managed with radiofrequency. The patient was alive with liver metastasis three years after surgery. Despite being regarded as an extremely aggressive procedure, ELRA could be considered in the treatment of advanced leiomyosarcoma with Budd-Chiari syndrome and hepatic vein thrombi.We report the first documented case of leiomyosarcoma at zone II-III of inferior  Ultrasonography showed ascites, hepatic congestion, and a solid tumor in retro-hepatic olvement Figure 1A multi-disciplinary team consisting of members from Liver Transplantation, Surgical Oncology, Cardiothoracic surgery, Cardiothoracic Anesthesiology, and Hepatology reviewed patients’ general information and reports. Despite the compromised hepatic function of the patient, surgery was considered as the only curative option for solving the extending tumor and secondary Budd-Chiari syndrome. ELRA with bench thrombectomy was planned considering tumor involvement to three hepatic veins and right atrium as well as thrombi. Gore-Tex graft replacement of the IVC was considered if IVC-sparing tumor extraction was not possible.vena cava circumferentially, freeing the IVC from the retroperitoneum as well as diaphragm. Major vasculatures were carefully dissected, and hepatic artery, portal vein, common bile duct, and intrahepatic vena cava were totally freed and suspended. No significant bleeding occurred during the mobilization of the liver. CPB was then initiated after systemic heparinization via cannulation of ascending aorta, right atrium, and femoral vein. Clamps were placed on the infra-hepatic IVC below the margin of the lesion but above the bilateral renal vein levels, as well as hepatic artery and portal vein. Then, right atrium was incised above the tumor margin, and a vent was placed in coronary sinus. The hepatic inflow and outflow were disconnected for explanting the whole liver with the tumor  solution  thrombi Video 1.Primary leiomyosarcomas of IVC originate from the smooth muscle of vascular wall and present as a rare clinical entity . They usen bloc resection with complicated vascular reconstruction are required. Although postoperative recurrence is common, a pooled data analysis of 377 surgically resected leiomyosarcomas of IVC claimed that radical resection is the best treatment modality and, in many circumstances, can present a complex procedure requiring a multi-disciplinary team to manage appropriately  of only 6%. However, long-term survival was possible after radical resection, with 5-year overall survival (OS) of 55% . In liteLong-term survival is possible after ELRA for IVC leiomyosarcoma. Hepatic veins thrombi and Budd-Chiari syndrome secondary to leiomyosarcoma does not necessarily preclude the option for ELRA. Recurrence of this rare tumor is common, and resection should be considered in light of the tumor biology and the general condition of the individual patient.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Ethical committee of First Affiliated Hospital of Xinjiang Medical University. The patients/participants provided their written informed consent to participate in this study.TT and TL drafted the manuscript. SA, Y-BH, LB, and S-SG performed literature search. Z-PW, TT, and TL analyzed the data. TT, TL, QH, JW, and J-MZ performed the surgery. J-MZ, TL and TT critically revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by grants from Xinjiang Uyghur Autonomous Region Key Laboratory Open Research Program (2018D04002); Tian Shan Youth Program (2017Q094); Shu-Lan Excellent Project-Support Program for Overseas Study of Young Talents in Organ Transplantation, 2017; and Xinjiang Natural Science Funding (2021D01C299).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.


Background: To evaluate the performance of a machine-learning (ML) algorithm to detect and classify choroidal neovascularization (CNV), secondary to age-related macular degeneration (AMD) on spectral-domain optical coherence tomography (SD-OCT) images. Methods: Baseline fluorescein angiography (FA) and SD-OCT images from 1037 treatment-naive study eyes and 531 fellow eyes, without advanced AMD from the phase 3 HARBOR trial (NCT00891735), were used to develop, train, and cross-validate an ML pipeline combining deep-learning–based segmentation of SD-OCT B-scans and CNV classification, based on features derived from the segmentations, in a five-fold setting. FA classification of the CNV phenotypes from HARBOR was used for generating the ground truth for model development. SD-OCT scans from the phase 2 AVENUE trial (NCT02484690) were used to externally validate the ML model. Results: The ML algorithm discriminated CNV absence from CNV presence, with a very high accuracy (area under the receiver operating characteristic [AUROC] = 0.99), and classified occult versus predominantly classic CNV types, per FA assessment, with a high accuracy (AUROC = 0.91) on HARBOR SD-OCT images. Minimally classic CNV was discriminated with significantly lower performance. Occult and predominantly classic CNV types could be discriminated with AUROC = 0.88 on baseline SD-OCT images of 165 study eyes, with CNV from AVENUE. Conclusions: Our ML model was able to detect CNV presence and CNV subtypes on SD-OCT images with high accuracy in patients with neovascular AMD. Early detection of active choroidal neovascularization (CNV) is crucial for the timely treatment of neovascular age-related macular degeneration (nAMD), in order to achieve a good outcome . CliniciIn OCT, CNV is graded based on its relationship to the retinal pigment epithelial layer ,13, wherMachine learning has the potential to unravel high-dimensional patterns from image data (complex interactions related to a given phenotype), as opposed to features that are correlated only individually to the outcome, providing enhanced capabilities for knowledge extraction. It also provides options for automated screening and diagnosis, enhancing the speed and reproducibility of these processes.In this study, using the phenotypic CNV definitions derived from FA as the reference standard, we developed a machine learning (ML) model capable of identifying these CNV subtypes, using OCT alone. We present the data on performance of this model for the detection and classification of CNV (as per FA) using the SD-OCT images. In addition, using a sub-symbolic approach, we identified key features on OCT that relate to particular CNV subtypes on FA. To the best of our knowledge, no previous study has leveraged this combination of ML approaches or reported findings similar to those presented in the current study.This study was a retrospective analysis of prospectively collected baseline FA and SD-OCT images of the study eyes and fellow eyes of patients with nAMD, in the phase 3 HARBOR (NCT00891735) and phase 2 AVENUE (NCT02484690) trials. 3, covering a volume of 6 × 6 × 2 mm3. In AVENUE, SD-OCT was performed using the Heidelberg Spectralis instrument . Study design and main outcomes of HARBOR ); see ML is always impacted by variability and biases in the training data because the annotation of images is performed manually. Although two graders annotated the OCT dataset, each image was only annotated by one of them, potentially leading to a bias. Additionally, FA assessment (the previous ‘reference standard’ for CNV assessment), is subject to reader interpretation, however, here two graders assessed each FA image, with adjudication as needed. Additionally, the scope of the current work is limited to classification of CNV on FA as predominantly classic, minimally classic, and occult phenotypes. As information about other CNV subtypes, such as retinal angiomatous proliferation and PCV, was not available in HARBOR, these phenotypes could not be evaluated. Furthermore, novel SD-OCT classification and terminology suggested by the Consensus on Neovascular Age-Related Macular Degeneration Nomenclature (CONAN) group  were notOur study shows that using ML on SD-OCT images is sufficiently accurate to detect and classify nAMD. This work highlights the reduced need of FA and provides an automated alternative to manual reading of images at baseline. This in turn limits the variety of imaging data sources from which reads are drawn, reduces the need for multiple human graders, and minimizes the risk of inconsistencies in the diagnoses. Finally, automating the read will also help with a major milestone of algorithmic models, which is to streamline and standardize diagnostic processes.


It is also understood that exposure of bacteria to toxic heavy metals like silver can induce the emergence of antibiotic resistance through the process of co-selection. Acinetobacter baumannii is a Gram-negative coccobacillus and opportunistic nosocomial bacterial pathogen. It was recently listed as the “number one” critical level priority pathogen because of the significant rise of antibiotic resistance in this species. NAg has proven bactericidal activity towards A. baumannii, even against strains that display multi-drug resistance. However, despite ample evidence of heavy metal  resistance in this bacterium, combined with reports of heavy metal-driven co-selection of antibiotic resistance, little research has been dedicated to assessing the potential for NAg resistance development in A. baumannii. This is worrisome, as the increasingly indiscriminate use of NAg could promote the development of silver resistance in this species, like what has occurred with antibiotics.The misuse of antibiotics combined with a lack of newly developed ones is the main contributors to the current antibiotic resistance crisis. There is a dire need for new and alternative antibacterial options and nanotechnology could be a solution. Metal-based nanoparticles, particularly silver nanoparticles (NAg), have garnered widespread popularity due to their unique physicochemical properties and broad-spectrum antibacterial activity. Consequently, NAg has seen extensive incorporation in many types of products across the healthcare and consumer market. Despite clear evidence of the strong antibacterial efficacy of NAg, studies have raised concerns over the development of silver-resistant bacteria. Resistance to cationic silver (Ag Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp. The ESKAPE organisms represent the model archetype of virulent and adaptive bacterial organisms, as they frequently cause severe and chronic disease and ‘escape’ the activity of antibiotics  and global clone 2  acquisition of resistance genes , which most often encode drug-inactivating enzymes, such as OXA-type β-lactamases  which hydrolyses carbapenems; (2) insertion sequence (IS)-mediated activation of resistance genes, e.g., insertion of ISAba1 upstream of the intrinsic A. baumannii gene ampC provides it with a strong promoter and results in resistance to 3rd generation cephalosporins; and (3) genetic mutation, e.g., gyrA and parC mutations alter DNA gyrase and topoisomerase IV active sites and blocks the action of quinolones  due to its complex antibacterial mechanisms . Over sebacteria .A. baumannii and other bacteria. We also outline current knowledge on the adaptive ability of A. baumannii, and other significant bacterial species, to NAg and other silver agents. It is important that we understand the applicability, as well as the equally important long-term risks of the nanoparticle as a crucial alternative antimicrobial. This review also describes the emerging phenomenon of the metal-driven co-selection of antibiotic resistance, including silver, to further stress the issue of overexposing bacteria to toxic heavy metals.In this paper, we highlight the antibacterial actions of NAg with its multi-targeting toxicity on Silver nanoparticle has a number of physicochemical characteristics that affect its microbiological activity and overall stability . The nanEscherichia coli when compared to spherical and rod-shaped particles. The triangular shape was thought to improve reactivity of the nanoparticle due to the presence of unique active facets, which are associated with a greater concentration of silver atoms. It was also speculated that this shape enhanced particle adherence onto the bacterial surface, resulting in more extensive membrane damage and subsequent cell killing  ratios, each particle contains approximately 10,000–15,000 silver atoms, rendering them highly reactive . Studies killing .The size and shape of NAg determine, at least in part, the particle concentration required for effective toxicity. For example, higher concentrations of rod-shaped NAg particles at 10–100 nm (lower SAV ratio) are needed to display comparable antibacterial activity with those of truncated triangles at 1–10 nm  due to electrostatic attractions  and influence the nanoparticle net surface charge . Measureractions .The antibacterial activity of NAg has been studied quite extensively . Four ma2), which leads to oxidative dissolution. This causes leaching of silver ions (Ag+) from the nanoparticle, which are crucial to the overall antibacterial activity of NAg  have been associated with a greater rate of ion leaching compared to larger particles  groups that are present in the amino acids cysteine and methionine, as well as amine (NHx) groups in histidine (−NH+), arginine (−NH2+), and lysine , including superoxide (O2•−), in bacteria  can target iron-sulphur (containing thiol groups) clusters in proteins, releasing Fenton-active free Fe2+ ions which can react with cellular hydrogen peroxide (H2O2) and consequently generate highly reactive hydroxyl radicals  in Gram-negative bacteria ” section, Ag enzymes . In addizymes  in DNA, intercalating between the base pairs and binding to the nucleoside structural unit  in proteins can be dephosphorylated by both forms of silver, which consequently changes protein conformity and disrupts cell function , ampicillin-resistant E. coli, MDR P. aeruginosa, ampicillin-resistant K. pneumoniae, and Salmonella typhi  shown comparable efficacy of the nanoparticle against wild-type and resistant strains  = 0.78 μg/ml] to NAg than the wild-type strains (MIC = 0.39 μg/ml). Although a minor difference in efficacy was observed, the team hypothesised that there was caused by ‘partial’ NAg cross-resistance in the MDR strains due to the presence of in-built antibiotic resistance mechanisms, e.g., efflux pumps  aumannii  and otheaumannii . Many rela typhi . Each st strains . In contux pumps . Cavassi strains . Further strains . Both tyA. baumannii in vitro when combined with polymyxin-B (PMB), a last-resort membrane permeabilising antibiotic. The study also demonstrated the nanoparticle-antibiotic synergistic effect in vivo using A. baumannii infected mouse models, increasing mice survival from 0% when treated with PMB (250 μg/kg) alone to 100% when treated with NAg-PMB (2 mg/kg + 50 μg/kg) after a 24 h infection period  bacterial systems, many studies have indicated that smaller-sized nanoparticles are more effective at biofilm killing when compared to larger particles, most likely due to the greater SAV and better EPS penetration of the former  at low NAg doses (0.09 μg/ml or 0.5x the reported MIC), which prevented the attachment and subsequent biofilm formation of (media-suspended) A. baumannii on the surface of human lung epithelia (cell line A549). Indeed, the team observed negligible toxicity of the nanoparticle towards to the lung cells (50% cytotoxicity concentration [CC50] = 5.72 μg/ml) which is important when considering the medical application of NAg (A. baumannii biofilms with NAg [minimum biofilm eradication concentration (MBEC) = 2 mg/ml] when compared to tetracycline, erythromycin, and doxycycline, citing extensive EPS destruction and reduction in viable cells following nanoparticle treatment. The work also recognised a synergistic effect between erythromycin and NAg against the biofilms, with the antibiotic’s efficacy increasing 32-fold in the presence of the nanoparticle . This again emphasises the potential value of NAg-antibiotic combinations  and DNA condensation on planktonic A. baumannii and other bacterial species, leading to subsequent cell death. +, gold (Au+), copper (Cu+), platinum (Pt2+), and palladium (Pl2+) ions on planktonic and biofilm-forming A. baumannii (as well as on E. faecium and K. pneumonia planktonic and biofilm cells). Ag+ and Ag+-Cu+ were found to be most effective individual and synergistic antibacterial ions against A. baumannii biofilms, respectively  in a model plumbing system, providing insights into feasible bacterial biofilm control measures in water distribution systems.Similar to planktonic cells ” section), studies have also specified greater Ag overall . A paperectively . SimilarA. baumannii biofilms by NAg; however, each use different concentration ranges and methodologies  using a 96-well plate  experimental setup, while There are a number of other studies that demonstrate effective inhibition and/or eradication of dologies . For exaIn summary, NAg has promising potential for prophylactic use and treatment of infections caused by MDR bacteria and their biofilms. The nanoparticle is considered highly effective in inhibiting the colonisation of many antibiotic-resistant bacteria, while also showing strong synergism with conventional antibiotics . However+, has been described quite extensively, while evidence of NAg-specific resistance is still emerging. Up to this stage, studies have described the presence of both exogenous and endogenous genetic determinants of Ag+ resistance, which is thought to be relevant to NAg also  and various antibiotics.Bacterial resistance to silver, specifically to AgNAg also . The eare AgNO3; . Two str+ resistance coding region (sil operon) present in a 180 kb plasmid called pMG101. This plasmid was extracted from the silver-resistant S. typhimurium strain previously isolated by + (+ resistance derived from the Sil/Cus systems (and other mechanisms) have been detected in various bacterial species, including A. baumannii  led to the mutational development of Ag+ resistance in the bacteria. The mutant Ag+-resistant strains displayed a loss of the major porins OmpF or both OmpF and OmpC, along with the expression of a natural copper binding/efflux (Cus) system which conferred cross-resistance to Ag+ (cusCFBA operon is a gene cluster which encodes an active efflux system designed to export copper ions (Cu+), and Ag+ , which sense (CusS) and respond (CusR) to increased levels of Ag+/Cu+ , where CusS/R then prompts increased expression of cusCFBA for active Ag+/Cu+ binding and efflux  and phosphorylates the transcription unit of OmpR, which then activates the expression of OmpF/C  in three genes; cusS, as well as purL, which encodes the protein phosphoribylsylforml-glycineamide synthetase involved in purine nucleotide biosynthesis, and rpoB, which codes for an RNA polymerase beta subunit. As previously discussed, CusS is part of the dual-component sensor/responder regulator for the CusCFBA Ag+/Cu+ efflux system , while the NAg-resistant strains could grow at a lower 1.4–4.7-fold increase in dose. It was unclear as to what exact mechanisms conferred the observed resistance to NAg in E. coli. As the leaching of Ag+ from NAg is an integral part of the nanoparticles antibacterial activity, it is thought that the CusCFBA Ag+ efflux system played some role in the NAg resistance effect  were observed, which could perhaps explain their susceptibility to Ag+, suggesting that the Cus system alone is not sufficient for a bacterium to confer resistance to silver , and silver resistance in these bacteria has been associated with sil genes and mutations of physiological genes , and silP, and encode their proteins in three transcriptional units  and responder (SilR) transcriptional regulators for SilCFBAGP, and are direct homologs of CusRS (+ efflux system (+-binding chaperone (similar to SilE), and binds with Ag+ that have passed through the outer membrane from outside the cell , which is known to be involved in heavy metal binding  to E. coli with, once again, subsequent expression of the silver resistance phenotype (A. baumannii strain (BL54), which is unrelated to the Sil system, and was thought to involve in the intracellular accumulation of Ag+ and binding of the ions to metalloproteins to form inert silver complexes. No follow-up inquiries have been made on either of these non-sil derived silver resistance determinants, and, therefore, it is difficult to assess the significance of these resistance mechanisms.The e pMG101 , and duee pMG101 . Since t. aureus . Hosny eacterium . Deshpanhenotype . A studyvia plasmids; see “Chromosomal (Endogenous) Silver Resistance” and “Plasmid-mediated (Exogenous) Silver Resistance” sections). However, there is evidence that an increase in expression of native bacterial processes can also contribute to silver resistance. For example, a study by Muller et al. outlined that the redox-active metabolite pyocyanin, produced by P. aeruginosa, could reduce extracellular Ag+ to non-toxic Ag0 and, in turn, confer resistance to the ions , which appeared to confer transient resistance upon exposure to Ag+ through ion binding; however, the exposure eventually resulted in cell death  in S. aureus (ATCC 25923) through prolonged exposure, with no known presence of the sil genes in its genomes. The bacterium developed physiological genetic mutations, the first reported case of NAg-induced single nucleotide polymorphisms in a Gram-positive bacterium  Silver Resistance” section, evidence of silver resistance in Gram-positive bacteria have been reported, although less frequent in comparison to Gram-negative bacteria. ll death . In anotacterium . More sp and Ag+ .+) is itself a troubling issue, there has been emerging evidence to show that silver and other heavy metals  can co-select for antibiotic resistance  transcriptional regulator protein] in E. coli was found to activate multiple mechanisms which gave rise to resistance phenotypes to silver, mercury, and cadmium, as well as various antibiotics and organic solvents  in the polluted Yamuna River in India. From the collected bacterial isolates, 121 were found to be ESBL producers, including various Acinetobacter, Enterobacteriaceae, and Bacillus species, with the most prevalent ESBL gene being blaCTX-M . Out of the 73 isolates containing blaCTX-M genes, 53 were found to have at least one sil gene , and worryingly, the most common ‘dual’ presence of ESBL/sil genes in these isolates were blaCTX-M + blaTEM  + silE + silP + silS. All ESBLs and sil genes were present in plasmids, and this work found these resistance genes could be horizontally transferred to a plasmid-free E. coli, rendering the bacterium resistant to β-lactams  and Ag+, confirming the co-resistance effect  were associated with lower levels β-lactamase gene expression, while those that were resistant to the metals were associated with higher expression levels of the ARGs. This correlation was particularly evident in A. baumannii  which contains several ARGs, including ESBLs , and MRGs for mercury, cadmium, and zinc, and could perhaps alternatively explain the observations made by A. baumannii throughout the Iraqi-Afghan conflict is one of the most important examples regarding heavy metal-driven antibiotic resistance co-selection in this species  using lab-scale sequencing batch reactors (SBRs), resulted in an increased shift in various ARGs among isolated Burkholderia spp., Streptomyces spp., and Gemmatimonas spp. More specifically, metagenomics data associated the detection of HAE1 family protein (multi-drug efflux protein), strA gene , and acrB gene (encodes multidrug efflux pump subunit AcrB) with the increased presence of NAg, while increased abundance of undecaprenol kinase and undecaprenyl-disphosphatase (resistance to bacitracin) and ermF gene  was associated with Ag+ presence (sil genes) were highest in the SBRs treated with NAg, suggesting that the nanoparticle has the most potential for ARG co-selection compared to Ag+  exposure previously, for example, but not to silver  despite the effective biofilm inhibiting and eradicating activity of the silver agents compared to many conventional antibiotics  Ag+ efflux Sil system, and, as found in some cases, other undefined/non-Sil related mechanisms  to NAg exposure. Our team is currently studying the nanoparticles toxicity on A. baumannii in both its planktonic and dominant biofilm form of growth, and in turn, the adaptation characteristic(s) of the bacterium which could develop in response to prolonged exposure. While it is possible that the Sil system plays a role in resistance to NAg, given that the nanoparticle exerts its toxicity differently from Ag+, it is likely that resistance to NAg involves additional mechanisms that are still largely unexplored.To the best of our knowledge, only the planktonic form of chanisms . No preschanisms . To date+ have been found to facilitate the co-selection of various ARGs, most frequently seen at this stage in polluted water systems (Acinetobacter spp. (including A. baumannii) can display cross-resistance to Ag+  and several antibiotics, but there is yet to be any evidence of NAg-induced co-selection of ARGs in this bacterial genus.In addition, evidence has emerged showcasing the potential for heavy metals to co-select for antibiotic resistance genes (ARGs), facilitated by ‘dual’ metal/antibiotic resistance mechanisms which are related to cross-resistance , co-resistance , or co-regulation  to fine tune its antibacterial activity and, therefore, limit bacterial adaptation. Identification of the molecular basis of NAg resistance will allow us to target the biological signalling molecules and metabolites that trigger adaptation responses, including quorum sensing molecules and/or epigenetic and genetic regulators. The generated knowledge will also help inform strategies for a better risk vs. benefits assessment regarding the application of NAg-containing consumer products, limiting its misuse and inadequate disposal. With no discovery of new effective antibiotics over the last 30 years, we need to protect the efficacy of this valuable alternative antimicrobial agent so that we may continue to use it in the fight against untreatable infections.OM, MH, and CG: conceptualisation. OM: writing . OM, RM, MH, and CG: writing (review and editing). MH and CG: supervision. All authors have read and agreed to the published version of the manuscript.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.