Rheumatoid arthritis (RA) occurs across the globe in different ethnic populations. Most RA patients harbor anti-modified protein antibodies (AMPA); however, it is unclear whether differences exist in autoantibody responses at different geographic locations and between different ethnic groups, which could provide new clues regarding factors underlying autoantibody development. We therefore investigated AMPA prevalence and association with HLA DRB1 alleles and smoking in four ethnically diverse populations on four different continents.n = 103), Japanese , First Nations Peoples in Canada , and black South African  RA patients. Ethnicity-matched local healthy controls were used to calculate cut-offs. Risk factors associated with AMPA seropositivity in each cohort were identified using logistic regression.Anti-carbamylated (anti-CarP), anti-malondialdehyde acetaldehyde (anti-MAA), and anti-acetylated protein antibodies (anti-AcVim) IgG were determined in anti-citrullinated protein antibody-positive Dutch ; anti-MAA: 29%, 22%, 29%, and 53% (p < 0.001); and anti-AcVim: 20%, 17%, 38%, and 28% (p < 0.001). Total IgG levels also differed markedly, and when autoantibody levels were normalized to total IgG, differences between cohorts became less pronounced. Although there were some associations with AMPA and HLA risk alleles and smoking, none was consistent across all four cohorts.Median AMPA levels were higher in First Nations Peoples in Canada and especially South African patients, as reflected by percentage seropositivity: NL, JP, FN, and SA: anti-CarP: 47%, 43%, 58%, and 76% (AMPA against various post-translational modifications could consistently be detected on different continents across ethnically diverse RA populations. Differences in AMPA levels corresponded to differences in total serum IgG levels. This suggests that, despite differences in risk factors, a common pathway may be involved in AMPA development across geographic locations and ethnicities.The online version contains supplementary material available at 10.1186/s13075-023-03009-7. Rheumatoid arthritis (RA) is a chronic autoimmune disease of unknown etiology that mainly affects the joints and is associated with circulating autoantibodies. Several RA-associated autoantibodies recognize protein epitopes that have been post-translationally modified, and are therefore known as anti-modified protein antibodies or AMPAs. The best-known post-translational modification (PTM) in RA is the enzymatic conversion of arginine to citrulline, which is recognized by anti-citrullinated protein antibodies or ACPA. More recently, other autoantibody systems have also gained attention, including anti-carbamylated protein antibodies (anti-CarP) recognizing homocitrulline-containing antigens, anti-acetylated peptide antibodies (AAPA) recognizing acetylated lysine, and anti-malondialdehyde-acetaldehyde antibodies (anti-MAA) recognizing proteins that are modified by adducts formed under oxidative stress –3.The discovery of AMPA, and in particular ACPA, has had a great impact on current pathophysiological hypotheses regarding RA, due to ACPA’s striking association with classical RA risk factors. The most important genetic risk factor for RA, the HLA shared epitope (SE) alleles , is now known to be primarily associated with the ACPA-positive subset of disease . This haDespite these insights, the exact etiological pathways leading to autoantibody formation are still unclear. It is conceivable that environmental factors may increase the risk for the development of autoantibodies in a geographic or population-specific manner, as is the case in other autoimmune diseases. For example, research in a specific population of Amerindians in Brazil has led to remarkable insights in fogo selvagem, a blistering autoimmune dermatological disease with resemblance to pemphigus. In this population, a high percentage of healthy individuals have low levels of anti-desmoglein 1 antibodies which has been found to be strongly associated with infestation with black flies. Only in individuals carrying HLA susceptibility alleles does epitope spreading occur, leading to pathogenic antibodies directed against particular subdomains of desmoglein 1 . BecauseThis example illustrates that investigating autoantibody responses in diverse locations and ethnic groups can lead to the elucidation of novel factors playing a role in the development of the autoantibody response and of the resulting disease. RA occurs in many ethnically diverse populations around the world, with different genetic frameworks and environmental exposures. Therefore, we set out to characterize the AMPA response in four ethnically diverse RA populations originating from four different continents, since differences in autoantibody presence could point to novel risk factors and shed more light on the development of AMPA in RA.The study population consisted of four cohorts of patients fulfilling the 1987 revised ACR criteria for RA . It was The Dutch RA patients (NL) were part of the Early Arthritis Cohort (EAC), a prospective cohort initiated in 1993 at the Leiden University Medical Center (LUMC) , 12. PatThe Canadian patients and controls came from an Indigenous North American population in Manitoba: First Nations Peoples in Canada (FN), who have an unusually high prevalence of RA , 14. AllIn Japan (JP), RA patients and healthy controls of Japanese descent were recruited in a cross-sectional manner from 5 hospitals in the Kyoto University area .The South African population (SA) consisted of black RA patients with less than 2 years of disease duration recruited from two tertiary hospitals in South Africa participating in the Gauteng Rheumatoid Evaluation Assessment Trial (GREAT) . South AAll included patients were ACPA-positive, determined by clinical second- and third-generation anti-CCP enzyme-linked immunosorbent assays (ELISAs) , 14–16.For the Dutch cohort, smoking habits were recorded at the time of sera collection (or at baseline if 1-year data was not available) by a trained research nurse or physician. For the Canadian cohort, patients filled in an extended smoking history questionnaire at inclusion. For the South African and Japanese cohorts, smoking history (ever or never) was recorded at inclusion.HLA four-digit genotyping data was available for most patients of each cohort. The SE alleles were defined as described previously . PatientBy ELISA, total IgG and four AMPAs were tested: anti-CarP fetal calf serum (FCS) IgG, anti-malondialdehyde acetaldehyde (MAA) FCS IgG, anti-acetylated-lysine vimentin IgG (anti-AcVim of the AAPA family), and anti-CCP2 IgG.Total IgG levels were determined using Bethyl Laboratories reagents and protocol (Bethyl Labs E80-104). In-house ELISAs were conducted essentially as previously described for anti-CarP FCS IgG . Anti-AcFor all AMPA ELISAs, absorbance values were converted to arbitrary units per milliliter (aU/mL) using a titration curve of pooled, serially diluted Dutch patient sera positive for that AMPA. We established cohort-specific cut-offs using each cohort’s respective healthy controls’ mean aU/mL plus two standard deviations, resulting in four distinct cut-offs .The cohort characteristics of the four geographically and ethnically diverse ACPA-positive RA populations are summarized in Table Cohorts differed significantly for all baseline characteristics except RF status. Notably, patients in the FN and SA cohorts were younger and the NL and SA cohorts had shorter disease durations, while the JP and SA cohorts had few smokers.Figure Remarkable differences were seen between the cohorts with levels generally being higher in FN and SA RA patients. This pattern of higher reactivity against the PTM antigens could also be seen to a lesser extent in the healthy controls of these two cohorts, although in each population, responses of healthy controls were clearly lower than those of RA patients . To avoid finding spurious associations, we limited our analyses to HLA SE and DRB1*03 alleles. Since the levels of AMPA and the cut-offs differed per cohort (as described above), all association analyses were performed based on dichotomous seropositive versus seronegative autoantibody results, rather than autoantibody levels. The results are displayed in Figs. Regarding smoking, there was no association with anti-CarP or anti-MAA. However, there appeared to be a positive association with smoking and anti-AcVim in NL and JP, although this did not achieve statistical significance.For HLA DRB1*03, which was not present in JP and only rarely in FN, there were several positive albeit non-significant associations with the different AMPA. This was found for anti-CarP in NL (which has been reported before in ACPA-negative patients ) and forWith regard to the HLA SE alleles, there was a positive association with anti-CarP in NL. For the other cohorts, there were no associations with anti-CarP, anti-MAA, or anti-AcVim in these ACPA-positive patients.In light of the recent discovery of several different RA-associated autoantibodies directed against post-translational modifications (AMPA), we determined three major novel AMPA in four geographically and ethnically diverse cohorts of ACPA-positive RA patients, to elucidate whether there might be population-specific risk factors involved in their development. We found differences between cohorts in the prevalence and median levels of anti-CarP, anti-MAA, and anti-AcVim. However, this diversity corresponded to a large extent to cohort-specific variation in total IgG. Finally, there were no associations between AMPA and the classic risk factors HLA SE, HLA DRB1*03, or smoking that were consistent across all cohorts.Our results are in line with a limited number of previous publications investigating the prevalence of ACPA and anti-CarP in different ethnic populations and geographic locations. A study from Malaysia investigating RA patients of three different Asian backgrounds  reported similar frequencies of ACPA among these patients and an association with HLA SE alleles . LikewisThe higher AMPA and IgG levels found in black South African RA patients may be due to several independent factors. First, there are multiple publications describing higher IgG levels in people of African descent although the mechanisms underlying this intriguing observation remain unclear , 20. WhiWe found no consistent associations of smoking and SE with AMPA positivity in the investigated cohorts. At the most, there was a positive associative trend for smoking and AAPA in NL and JP, but not in the others. This lack of association could have been due to the limited size of the cohorts, although the effect sizes generally did not indicate that greater power would have resulted in significant findings. The positive association of SE with anti-CarP in NL is surprising considering that this has not been found before in analyses of larger datasets , 29. ThiOverall, our finding that the various AMPA could be detected in substantial amounts in RA patients of 4 different ethnicities on different continents implies that population-specific ethnic or geographical risk factors do not seem to play a major role in shaping the AMPA response once ACPA have developed. Contrary to the example of fogo sevalgem in which endemic black flies are a specific factor influencing autoantibody reactivity, this kind of effect does not appear to exist within autoantibody-positive RA. This indicates that the development of a broad AMPA response to different PTMs represents a final common outcome of different pathways leading to the development of ACPA and eventually RA. This hypothesis is in line with murine studies which have shown that immunization with a protein containing one particular PTM can induce cross-reactive AMPA against other PTMs as well . HoweverThe main limitation of this study is the fact that we had access only to ACPA-positive RA patients. This precludes any conclusions about the prevalence of each AMPA in the entire RA population consisting of both seropositive and seronegative patients. However, because non-ACPA AMPA occur largely in ACPA-positive RA, this selection does maximize our ability to identify AMPA-positive patients and compare AMPA levels. In addition, the presence of ACPA in all patients does make the comparison between cohorts more straightforward, since differences in ACPA presence would have been a major confounding factor. However, in light of the strong association between HLA risk factors and ACPA, the results regarding genetic associations should be interpreted with extreme caution. Another limitation is the differences in cohort demographics. We attempted to account for these differences by correcting our smoking analyses for gender, which most closely determined smoking habits. Disease duration also differed, which can be seen as a proxy for treatment effects; however, correction for this made some models statistically nonconvergent and did not change the results of the others. Data on clinical characteristics were limited, making it impossible to correlate observed differences in autoantibodies with disease activity, DMARD exposure, and clinical outcomes. Since information on other  exposures like previous infections, air pollution, or comorbidities was unavailable, we limited our analyses to the communal risk factors which were known for each cohort: smoking and HLA DRB1 alleles. A further limitation is the relatively small sample sizes in each cohort.Strengths of our study include its innovative design in measuring several different AMPA in 4 different ethnic and geographical cohorts. This leads to relevant insights regarding differences not only in the levels of autoantibodies, but also of total IgG; a fact that has thus far attracted little attention in the rheumatology autoantibody literature. Another strength of the study is the fact that all AMPA determinations were performed in the same manner. All cohorts were analyzed in the same center on the same day and were represented on each ELISA plate, and the cut-offs were determined using cohort- and ethnicity-matched healthy controls. All these measures serve to maximize comparability between cohorts, which is not a trivial issue as illustrated by the fact that our data show clear differences in calculated cut-offs, thereby underlining the importance of using locally matched controls in determining cut-offs.In these geographically and ethnically diverse ACPA-positive RA populations, AMPA against other post-translational modifications were consistently present, with higher levels in the South African patients. However, total IgG levels were also higher in South African patients, and after correcting for this, differences were less striking. This suggests that in ACPA-positive patients with different genetic and environmental exposures, the development of a broad AMPA response to different PTMs may represent a final common outcome of autoimmune pathophysiology.Additional file 1:Supplementary Figure 1. AMPA and control peptide reactivity in RA and HCs. Levels in arbitrary units (aU/mL) for four AMPAs in the serum of four ethnically diverse RA populations and their ethnicity-matched healthy controls (HC). Grey dots indicate reactivity to the control peptide that was tested in tandem with the AMPA (which are shown with black dots). Blue violin plots display the median, interquartile range, and distribution of levels.NL: Netherlands, FN: First Nation, JP: Japan, SA: South Africa, RA: RA patients, HC: healthy controls. Supplementary Figure 2. Autoantibody levels in patients seropositive for each AMPAs in ethnically diverse RA populations. Levels in arbitrary units (aU/mL) for four AMPAs in the serum of four ethnically diverse RA populations. Patients clustered at the maximum were above the highest standard of the ELISA. Grey shading indicates the cohort-specific cut-off . Lines indicate median and interquartile range and p-values correspond to Mann-Whitney U tests. Supplementary Figure 3. Autoantibody levels in patients seropositive for each AMPAs in ethnically diverse RA populations. Ratios of levels in arbitrary units (aU/mL) for four AMPAs per grams per liter (g/L) total IgG in the serum of four RA populations. Ratios are only shown in patients that were positive for the AMPA and that were also not above the highest standard. Lines indicate median and interquartile range; p-values correspond to Mann-Whitney U tests. The range of aU/mL per g/L are not directly comparable between AMPAs.


The high COVID-19 morbidity and mortality are observed among residents in long-term care facilities (LTCF) worldwide. Employees of LTCF, who are facing a critical epidemiological situation endangering the vulnerable residents, are exposed to pandemic’s psychological consequences daily.The main aim of this study was to assess psychological consequences  among LTCF employees exposed to the SARS-CoV-2 pandemic crisis. Moreover, we investigated if factors such as: personal protective equipment (PPE) availability, safety guidelines or access to psychiatric and psychological support at the workplace, correlated with the level of psychological distress experienced by personnel.A cross-sectional study was conducted among personnel of LTCF in Poland. The survey consisted of the sociodemographic section, the authors’ questionnaire with questions related to COVID-19 exposure, working conditions, access to PPE and mental health services, GHQ Questionnaire-28.show that access to PPE (P= .018), to workplace safety guidelines (P= .031), psychological support at workplace (P<0.01), fixed shift schedule (P= .05) and feeling that the right number of staff are employed in the workplace (P= .009), were related to the lower severity of psychopathological symptoms evaluated with the GHQ-28.The study indicates an evidence that LTCF personnel are susceptible to the development of anxiety, depression, insomnia and social dysfunction during the pandemic crisis. However, these can be modified by: access to PPE, safety guidelines and psychological support. Findings from this study lay a basis for effective interventions aiming to support psychological health within this group.


Simultaneous localization and mapping (SLAM) system-based indoor mapping using autonomous mobile robots in unknown environments is crucial for many applications, such as rescue scenarios, utility tunnel monitoring, and indoor 3D modeling. Researchers have proposed various strategies to obtain full coverage while minimizing exploration time; however, mapping quality factors have not been considered. In fact, mapping quality plays a pivotal role in 3D modeling, especially when using low-cost sensors in challenging indoor scenarios. This study proposes a novel exploration algorithm to simultaneously optimize exploration time and mapping quality using a low-cost RGB-D camera. Feature-based RGB-D SLAM is utilized due to its various advantages, such as low computational cost and dense real-time reconstruction ability. Subsequently, our novel exploration strategies consider the mapping quality factors of the RGB-D SLAM system. Exploration time optimization factors are also considered to set a new optimum goal. Furthermore, a Voronoi path planner is adopted for reliable, maximal obstacle clearance and fixed paths. According to the texture level, three exploration strategies are evaluated in three real-world environments. We achieve a significant enhancement in mapping quality and exploration time using our proposed exploration strategies compared to the baseline frontier-based exploration, particularly in a low-texture environment. The evolution of sensors and the robotics industry has attracted many researchers to focus on mobile robots. These robots can be mounted with onboard sensors to conduct indoor autonomous exploration missions. To name a few such missions, autonomous mobile robots can be exploited in rescue scenarios, utility tunnel monitoring, or indoor 3D mapping. Accordingly, all the required modules for autonomous exploration have been extensively studied. Such autonomous exploration modules in unknown environments using autonomous robots should model the scene from various connected locations to merge all local models into one consistent global map. Three main connected modules are needed to achieve autonomous mapping. First, a simultaneous localization and mapping (SLAM) system is required in GPS-denied environments, such as indoor environments. Several SLAM systems have been proposed, such as visual ,6,7,8,9 This study mainly focuses on exploration strategies and path planning to achieve high-quality mapping, especially in a low-texture environment. For the exploration module, the main question is, “Where is the best new goal?” This question should be answered according to the exploration’s main objectives: full coverage, the shortest exploration time, or the best 3D mapping quality. The “next goal” decision affects autonomous robots’ robustness to explore unknown environments safely and efficiently. However, several factors that challenge autonomous robots include the uncertainty in observations from the available sensors, imperfect control of robots, algorithm drawbacks, limited computational capability, limited payload, limited power consumption, and real-world complexity. Therefore, each module must be developed considering these factors, from the SLAM system to the exploration strategy and path planning. Furthermore, the integration of all modules should be considered to help them combine to produce a globally consistent high-quality map. For example, to achieve better mapping quality, the exploration strategy should consider the SLAM mapping quality requirements, such as the alignment accuracy and availability of loop closure, while selecting the next goal. In addition to the exploration strategy, the path-planning module is responsible for generating efficient, obstacle-free paths to reach the goal. However, to assist the SLAM system, these paths should have further characteristics such as smoothness and the same paths chosen between any two poses, back-and-forth. These characteristics help the loop closure detector find more accurate loops that enhance the SLAM drift, to generate a better, more consistent map.A novel exploration strategy was developed using the number of features and their distribution uniformity score in 3D, thereby achieving better mapping quality using feature-based RGB-D SLAM.A generalized Voronoi path planner was modified and implemented to keep the robot on a fixed road map of paths. Moreover, we ensured the same path was taken between any two positions , to increase the probability of accurate loop closure detection. The robot also had the maximum clearance from any obstacle in the investigated, narrow real-world environments.A comprehensive and intensive evaluation of our proposed autonomous exploration system was conducted in three real-world, complex, indoor scenarios, with its performance compared to the FBE approach.Previous exploration strategies have not considered the mapping quality when using low-cost RGB-D sensors in a low-texture environment. To fill that gap, our study considered the mapping quality of such low-cost sensors in challenging scenarios , seeking to improve their mapping quality. We developed a novel exploration system specially designed for feature-based RGB-D SLAM systems. The three main contributions of this study are summarized as follows:This paper is organized as follows: The FBE approach  is the bAlternatively, the NBV  is an exMost state-of-the-art approaches are based on FBE and NBV exploration methods but apply different optimization functions. Over the past few years, various exploration approaches ,20,21,22The feature-based RGB-D SLAM system is attractive due to its various advantages, such as a low computational cost, dense real-time reconstruction ability, and low-cost sensors. Consequently, this SLAM system has become popular for real-time indoor mapping and localization. On the other hand, high-end sensors and robots are utilized in extreme conditions, such as the exploration of the underground environments in the competitions funded by the Defense Advanced Research Projects Agency (DARPA), called the “DARPA Subterranean Challenge”. The last winning team  developeContrary, the RGB-D sensor is cheap, has low power consumption, and can generate a dense map using its pixel-wise color and depth. Therefore, a feature-based RGB-D SLAM system was utilized for our exploration system. The mapping quality using feature-based RGB-D SLAM depends on two main factors. The first factor is the number of extractable features in the desired environment, and the second factor is the level of uniformity of these features. Therefore, the feature-based RGB-D SLAM system works well in texture-rich environments having evenly distributed features, while its performance is degraded in low-texture environments. Our proposed exploration approach accounts for these factors when selecting a new goal.A path planner that maximizes the clearance between the robot and an obstacle should be considered for the following reasons: (1) to ensure obstacle avoidance in narrow and complex indoor environments, and (2) to guarantee the same path is taken back-and-forth between any two positions to increase the probability of detecting more accurate loop closures. Several path-planning algorithms have been proposed to generate efficient paths, such as search-based ,35,36,37Unlike the previous path-planning methods, the generalized Voronoi diagram (GVD) path planner ,46,47 geThe above literature indicated that the mapping quality when using a low-cost sensor such as an RGB-D camera was not considered in most state-of-the-art exploration strategies. These strategies can be efficient in certain mapping conditions, such as in texture-rich environments, for perfect mapping, and to support localization systems. However, in real-world scenarios, such optimum conditions are not available; in that context, we propose exploration strategies to increase the mapping quality for challenging real-world scenarios. The proposed exploration strategies simultaneously achieve a high mapping quality and short exploration time in challenging conditions of real-world complexity, low texture, limited computational capability, SLAM drift, and uncertainty in the low-cost RGB-D observations.This section presents our proposed approach to autonomous exploration—as shown in FBE  introducFrontier detection was implemented using a method proposed in  to detecAfter every iteration of frontier detection, the influencing factors of mapping quality and exploration time were calculated for each detected frontier region. The area borders of every detected frontier were identified based on each frontier’s cell’s maximum and minimum 2D coordinates. According to these borders, all feature points extracted by SLAM were projected. Subsequently, the number of feature points  between the points of the ground truth 3D models and the points of the output model of each experiment after point cloud registration ,56,57,58Three exploration strategies were investigated, as mentioned in The low-texture surveying scene is shown in We calculated the PTPD between each experimental trial’s aligned output point cloud and the ground truth point cloud, to evaluate the mapping quality.In the moderate-texture environment, there were low-texture walls, as can be seen in The last environment had rich feature points in most observed frames, as shown in As a result of all regions in the texture-rich environment having sufficient features, the mapping quality using feature-based SLAM was high for all exploration strategies. PTPDs are shown in A GVD path planner was modified to keep the robot on a fixed road map to increase the probability of accurate loop closure detection.A novel autonomous exploration strategy was proposed specifically for feature-based RGB-D SLAM. The number of features and their distribution were considered to obtain better mapping quality.In the low-texture environment, we achieved a high mapping quality, which indicates that when using feature-based SLAM, it is valuable to consider the number of features and their distribution to decide the next goal. The enhancement in mapping quality was significant, i.e., more than 40% in PTPD RMSE for both the M and M+D strategies compared to the D strategy. Moreover, the total path length and exploration time were reduced by nearly 30% and 23% for the M and M+D strategies, respectively, compared to the D strategy.In the moderate-texture environment, the enhancement in mapping quality was 15.6% in PTPD RMSE for the M strategy and 13.5% for the M+D strategy. The total exploration path length increased from under 35 to 45 m for the M strategy, but it remained in the same range for the M+D strategy.In the texture-rich environment, our strategy only slightly enhanced the mapping quality, i.e., by less than 3% in PTPD RMSE for the M strategy and 10% for the M+D strategy. However, the total path length and exploration time were enhanced by 26% and 34% for the M and M+D strategies, respectively.The proposed autonomous exploration system was evaluated in three real-world indoor environments (chosen according to the availability of features). Our evaluation concerned how the mapping quality was enhanced compared to the baseline FBE strategy. To that end, we tested the baseline classical frontier-based strategy (D strategy), our proposed mapping quality strategy (M strategy), and a combination of the two (M+D strategy). The results may be summarized as follows:To obtain a better mapping quality using a feature-based RGB-D SLAM system for autonomous exploration in indoor real-world environments, we proposed a novel autonomous exploration system to assist SLAM to build better-quality maps. Our concluding remarks are as follows:The results indicate that our proposed exploration strategy dramatically enhanced the mapping quality and reduced the total exploration time and total path length in the challenging low-texture environment. At the other end of the spectrum, the mapping was high-quality in the texture-rich environment for all strategies, as in such texture-rich environments, feature-based SLAM systems can always detect many features that increase the alignment accuracy and the mapping quality, regardless of the exploration strategy.Future work should consider other SLAM systems and design specific exploration strategies for these. Moreover, an exploration strategy should be proposed for online mapping quality estimation, to ensure the required mapping accuracy has been achieved before the exploration ceases.


We used automated tractography to examine whole-brain and mean FA of the tracts most frequently reported in ADHD; corpus callosum forceps major and forceps minor, left and right superior-longitudinal fasciculus, and left and right corticospinal tract (CST). Associations between FA and hyperactivity severity appeared when in-scanner head motion was not accounted for as mediator. However, causal mediation analysis revealed that these effects are fully mediated through in-scanner head motion for whole-brain FA, the corpus callosum forceps minor, and left superior-longitudinal fasciculus. Direct effect of hyperactivity severity on FA was only found for the left CST. This study illustrates the crucial role of in-scanner head motion in the identification of white matter integrity alterations in ADHD and shows how neglecting irremediable motion artifacts causes spurious findings. When the mediating effect of in-scanner head motion on FA is accounted for, an association between hyperactivity severity and FA is only present for the left CST; this may play a crucial role in the manifestation of hyperactivity and impulsivity symptoms in ADHD.Attention-deficit/hyperactivity disorder (ADHD) is a common and debilitating neurodevelopmental disorder associated with various negative life impacts. The manifestation of ADHD is very heterogeneous, and previous investigations on neuroanatomical alterations in ADHD have yielded inconsistent results. We investigated the mediating effect of in-scanner head motion and ADHD hyperactivity severity on motion-corrected fractional anisotropy (FA) using diffusion tensor imaging in the currently largest sample ( Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder diagnosed in approximately 7.2% of school-age children . ADHD afHowever, past research on the white matter underpinnings of ADHD has produced discrepant results , 10, 11.Previous findings are exceptionally mixed for the corpus callosum (CC), the superior longitudinal fasciculus (SLF), and the corticospinal tract (CST) including the corona radiata (CR), internal capsule (IC), and cerebral peduncle (CP) , 12. SomPotential reasons for these discrepancies may be small sample sizes , and disAnother major issue in past research concerns the handling of in-scanner head motion during preprocessing and statistical analysis , 10, 48.Here, we investigate the causal mediation effect of in-scanner head motion and ADHD on whole-brain and tract-wise FA of six tracts previously most commonly reported in relation to ADHD; forceps minor of CC, forceps major of CC, left and right CST, and left and right SLF. Prior to the causal mediation analysis, we compared two approaches to identify which ADHD representation best explains the measured data: using an ADHD rating scale for a full-spectrum dimensional representation of hyperactivity severity  and the Participants were included from the Healthy Brain Network (1st–7th release), an ongoing open data acquisition initiative by the Child Mind Institute . All parn = 65) or an ADHD-HI diagnosis (n = 30) were excluded due to underrepresentation and overall rarity of ADHD-HI in the global population [Participants were included if they received an ADHD diagnosis or had no diagnosis of any mental disorder . Participants underwent acquisition of structural T1-weighted imaging and diffusion tensor imaging (DTI). All participants included were right-handed, defined as an Edinburgh Handedness Inventory (EHI) total score above 40 , 58, andpulation . SpecifiParticipants whose MRI data could not be preprocessed due to severe artifacts or did not pass visual inspection by a rater blind to the demographics and psychological conditions were excluded  pipeline  using FMBriefly, DTI scans were denoised  and corrPreprocessing continued with outlier detection and robust estimation of MRI parameter , tensor We used the deterministic streamline-tracking algorithm Automating fiber-tract quantification  –78 to exFirst, a T1-weighted scan, which was co-registered to the DTI scan, was used to set anatomical regions of interest as seeds for tractography. Second, whole-brain tractography was computed with the default FA threshold of 0.2, an FA mask threshold of 0.3 , and an We obtained FA tract profiles for 100 equidistant segments for each participant and tract of interest. From these profiles, we calculated for each participant (a) whole-brain mean FA based on all profiles of all identifiable tracts and (b) a tract-wise mean FA by averaging the FA tract profile for each of the following six tracts: the CC forceps minor and major, the left and right CST, and the left and right SLF see Fig. . Hence, All statistical analyses were conducted in R version 4.1.1. Formulas are described using the Wilkinson notation.First, we identified the best generalized linear mixed-effects model for explaining the data. We used both a categorical and dimensional representation of ADHD on whole-brain FA to identify the most explanatory model for both approaches. The base model contained whole-brain FA (continuous) as dependent variable, in-scanner motion (continuous) as variable of interest and age (continuous), sex , IQ (continuous), and acquisition site  as confounding factors. The acquisition site was included to account for different scanning sites . ThWe used a causal mediation analysis  to invesModel M0: FA ~ Age + Sex + IQ + Site + SWAN-HY.Model M to assess the effect of SWAN-HY on in-scanner head motion was defined asModel M: Motion ~ Age + Sex + IQ + Site + SWAN-HY.Model Y, which comprises the effect of SWAN-HY and the effect of in-scanner head motion on FA, was defined asModel Y: FA ~ Age + Sex + IQ + Site + Motion + SWAN-HY.Models M and Y were used as input for causal mediation analysis. Figure Nested model comparison using ANOVA . At tract level, a significant ACME was observed for the CC forceps minor , and the left SLF . An average direct effect (ADE) of SWAN-HY on FA was observed for the left CST  (Table p < 0.0102 using the method suggested by Nyholt (2004) [The premise for causal mediation analysis revealed that ADHD symptomatology  is associated with larger in-scanner head motion in all structures analyzed in this study Table . The caut (2004)   considered head motion as a confounding factor in their statistical analysis , and NagIn contrast, a direct effect of SWAN-HY on lower FA was observed for the left CST. This supports previous findings of lower FA , 26–29 iThe CST is a projection fiber tract originating at the corona radiata (CR) and extends into the internal capsule (IC) and further into the cerebral peduncle (CP) . The CSTA clear limitation of this study is the lack of an ADHD-HI subgroup in all analyses; this presentation was excluded due to the small sample size. Furthermore, the SWAN-HY score is not a clinical diagnostic measure. High SWAN-HY scores need not imply an underlying ADHD-C or ADHD-HI diagnosis yet are highly correlated with clinical presentations .Another limitation concerns the interpretability of FA and its reflection of white matter integrity. Lower FA is commonly interpreted as resulting from deficient myelination or poorer fiber health, which is often summarized as poorer white matter integrity , 100. Hop < 0.0102 using the method suggested by Nyholt (2004) [Furthermore, the reported effects would not have survived correction for multiple comparisons when considering a corrected significance level of t (2004) . Thus, fIn light of the disagreement on categorical vs. dimensional representations of ADHD manifestations, we compared these two approaches. We identified the SWAN-HY score as more suitable in comparison to the SWAN-IN score and the clinical DSM-5 diagnosis, and used it in line with the RDoC to identify neuroanatomical underpinnings of ADHD with causal mediation analysis. When disregarding the role of in-scanner head motion, we observed an effect of the SWAN-HY score on FA in several tracts. However, the causal mediation analysis revealed most of these associations to be mediated by in-scanner head motion. Therefore, future investigations should focus on the distorting effect of irremediable motion artifacts in DWI. When accounting for a mediating effect of in-scanner head motion, we identified the left CP of the CST tract as the only structure to be directly influenced by hyperactivity. This finding and the role of the CP in the fronto-striatal-cerebellar neurocircuitry supports its interpretation as a biological substrate of ADHD.Supplemental Material


Borderline Personality Disorder (BPD) is an impairing disorder with distinct features such as instability in self-image, relationships and affect. Considering the developmental nature of BPD, borderline features are not rarely exhibited in adolescence. These features tend to be associated with depression and suicide ideation, as well as with a negative self-to-self relationship. Self-compassion has been consistently identified as a positive attitude with oneself when experiencing suffering.The aim of the current study was to explore the role of self-compassion in the relationship between borderline features and suicide ideation, when controlled depressive symptoms.Sample was composed by 665 adolescents , with a mean of 15.54 years of age (SD = 1.52), who completed self-report questionnaires. Data was analyzed using SPSS (version 23) and PROCESS Macro.showed that girls presented higher borderline features and suicide ideation and lower self-compassion compared to boys. The moderation model explained 66% of suicide ideation, with gender and depression as covariates. The interaction of borderline features and self-compassion had a unique and significant effect on suicide ideation, when controlled depression and gender. Adolescents with higher levels of borderline features and lower self-compassion presented significantly higher suicide ideation, compared to those with higher self-compassion.These findings suggest that developing self-compassion in adolescents with evident borderline features might attenuate their tendency to think about committing suicide.


Women in antimicrobials, resistance, and chemotherapy: 2022” Research Topic, a dedicated Frontiers Research Topic totally handled by women as editors aimed at celebrating the achievements of women in this field. The contribution of many women to the history of STEM  is undeniable, with a few remarkable examples throughout time including Ada Lovelace (arguably) considered the first computer programmer in the middle 1880's, Rosalind Franklin discovering the structure of DNA in the 1950's, Barbara McClintock for the discovery of jumping genes in 1983 or Jennifer Doudna together with Emmanuelle Charpentier for their 2012 discovery that a bacterial immune system called CRISPR can be repurposed to edit DNA  obtained from New Hampshire, USA during 2017–2020. Different operons related to heavy metal resistance  and genes associated with resistance to quaternary ammonium compounds  were differentially distributed across multiple STs and serotypes, with the gold operon (gesABC-golTSB) being predominantly present in 99.2% of the genomes. A strong negative or purifying selection able to remove deleterious mutations was demonstrated for these genes, with some frequently co-occurring with AMR genes within common plasmid types. Given the wide distribution and routine use of different heavy metals and biocides in household and industrial products, this study reinforces the need for continued surveillance of strains that frequently carry such adaptive traits able to act as agents of co-selection of AMR genes.Collis et al. reported the prevalence and distribution of extended-spectrum β-lactamase (ESBL)- and AmpC-producing Escherichia coli from farm environmental samples collected over a 15-month period in two New Zealand dairy farms that differed in size, number of cows and effluent management strategies during the study period. Overall, 52 E. coli strains were isolated and 33 were classified as multidrug-resistant (MDR). All the strains were resistant to cefpodoxime, followed by 89% to cefoxitin, 79% to streptomycin, 65% to cefotaxime, and 64% to tetracycline. Of the 52 strains, 46 and 32 strains were identified as AmpC- and ESBL-producer, respectively. The ESBL-producers were only isolated from the larger farm while AmpC-producers were detected in both farms (except the plasmid-mediated blaCMY−2 gene predominantly detected in the larger farm). The predominant E. coli phylogroups were B1 (35%) and C (33%). The subset of AmpC- and ESBL-producing E. coli sequenced in this study showed a diverse molecular relationship with eight sequence types identified. Overall, the isolation of the ESBL- and AmpC-producing E. coli was not associated with periods of elevated antimicrobial usage in the farms.Huang et al. determined the distribution and AMR phenotypes of 257 bacterial isolates from the intestine of 115 red swamp crayfish samples, which are one of the most popular and commercially farmed aquatic products in China. Most isolates corresponded to Citrobacter sp. and Aeromonas sp., with the majority being susceptible to all tested antibiotics. Pseudomonas sp., Aeromonas caviae, and E. coli were multidrug-resistant, with the last being identified as ST48 and carrying the carbapenemases gene blaNDM − 5, which is accepted as a last-line Antimicrobial Resistance gene. Because of the high potential for transmission to humans through the food chain, red swam crayfish has been pointed out for acting as a reservoir of last-line antibiotic resistance genes posing a serious public health risk.Cañada-García et al. analyzed 50 imipenemase-producing Enterobacterales (IMP-Ent) circulating in 19 Spanish hospitals over 9 years (between January 2012–December 2021) by deeply characterizing their population structure and resistomes, and evaluating different phenotypic methods for carbapenemase detection. Although still generally infrequent, their findings revealed that IMP-8-producing Klebsiella pneumoniae and IMP-22- producing Enterobacter roggenkampii constitute the most frequent IMP-producing Enterobacterales nationwide, that colistin and amikacin were the most active non-carbapenem antibiotics and, importantly, that inhibition with EDTA or dipicolinic acid presented false negative results in some IMP-producing strains. As they have already been linked to nosocomial outbreaks, active surveillance is continuously warranted to limit IMP-Ent dissemination.Sharma et al. developed an automated pipeline, Galaxy-ASIST, for the characterization of clinical isolates. Breakpoint mapping and phenotypic classification can be performed with the input of antimicrobial susceptibility profiles, while AMR determinants can be mapped based on whole genome sequencing data. This platform is able to reduce the complexity of data analysis and offers a user-friendly interface for mapping global guidelines for reporting antimicrobial susceptibility profiles, allowing non-bioinformatics researchers to perform analysis without the need for any coding skills. The current study focused on Acinetobacter baumannii but can be scaled for all priority pathogens in the future. This platform is freely available at: https://ab-openlab.csir.res.in/asist.Taken together, these studies illustrate the high quality of studies headed by diverse women scientists addressing one of the top 10 global public health threats of our times, which is Antimicrobial Resistance. We hope that these articles can engage readers working in the field of AMR to explore and tackle AMR from multi-disciplinary Public Health perspectives.All authors have contributed to this Editorial and approved it for publication.


Various conditioning activities (CAs) have been developed to generate PAP before training or competitions. However, whether extra equipment can enhance the effectiveness of CAs is understudied. Hence, this systematic review aims to introduce and examine the effectiveness of blood flow restriction-based conditioning activities (BFR-CAs). (2) Methods: a literature search was conducted via Web of Science, PubMed, SPORTDiscus, and CNKI (a Chinese academic database). The systematic review included the literature concerning BFR-CAs and non-BFR-CAs. The methodological quality of included studies was considered to be “moderate quality” and “good quality” based on the Physiotherapy Evidence Database Scale. (3) Results: five studies were included in this study. Four studies were on lower limb strength training, and three of them suggested a greater PAP in BFR-CAs than in non-BFR counterparts. One study on upper limb strength training also supported the advantage of BFR-CAs. (4) Conclusions: BFR-CAs may be an emerging and promising strategy to generate PAP. Compared with non-BFR-CAs, BFR-CAs might be more efficient and practical for inexperienced sports people or athletes in non-power sports. Strength/power production plays a critical role in athletic performance, including sprinting, jumping, throwing, kicking, and changing direction . Hence, In order to maintain the benefits of CAs and reduce the risks of high-load training mentioned above, it has been recommended that extra training equipment is incorporated with CAs. Blood flow restriction (BFR) is a training method that partially restricts arterial inflow and fully restricts venous outflow in working musculature during exercise . BFR canA systematic search was conducted via databases including Web of Science, PubMed, SPORTDiscus, and CNKI (a Chinese academic database). The time frame for the search was between the dates the databases were set up and June 2022. The search was performed using the following terms alone or in combination: (“PAP” [Title/Abstract] OR “post-activation potentiation” [Title/Abstract] OR “post-activation potentiation” [Title/Abstract] OR “higher motor unit activation” [Title/Abstract] OR “muscle excitation” [Title/Abstract]) AND (“blood flow restriction training” [Title/Abstract] OR “BFR training” [Title/Abstract] OR “KAATSU training” [Title/Abstract]). Additionally, we used a back-and-forth strategy to identify potential studies via the references of primarily included studies. For any unavailable papers, we tried to contact the authors for the full text.P (Participant): Involved subjects with no known medical conditions or injury.I (Intervention): BFR-CAs with clear load.C (Comparison): non-BFR-CAs with clear load.O (Outcome): Any validated measure of PAP  of the vastus lateralis and hamstrings; upper-limbs explosive performance via the bar velocity, power output of bench press), assessed using PAP indicators at both pre- and post-intervention. There must be a completely negative rest interval between training and PAP test.S (Study design): Controlled trials, with RCT given priority.All the studies with full text were screened independently by two reviewers (HDT and HWL) according to the PICOS criteria ,25:P  study characteristics ; (b) subject demographics ; (c) CA protocols ; (d) rest interval (period between training and test); (e) study results (changes of indicators concerning PAP); (f) study conclusion. Then, data for the pre- and post-training means and standard deviations of the included were coded. Due to the limited number of included trials and the inconsistent training loads, quantitative analysis was deemed inapplicable to this study.The modified Physiotherapy Evidence Database (PEDro) scale was employed by 2 independent investigators to evaluate the methodological quality of the studies included in the review, and mutual agreement was obtained for any observed discrepancies. The original 11-item PEDro scale involves eligibility criteria (item 1), randomization (item 2), concealed allocation (item 3), similar baseline (item 4), blinding of all participants (item 5), blinding of all therapists (item 6), blinding of all assessors (item 7), more than 85% retention (item 8), intention-to-treat analysis (item 9), between-group comparison (item 10), and point measures and measures of variability (item 11). Since it is not generally feasible to blind the subjects and investigators in supervised exercise interventions, we removed items 5–7 from the scale, which are specific to blinding. This approach has been used in previous systematic reviews in the area of exercise . After rA total of 132 articles were initially identified, with 32 from the web of science, 93 from PubMed, 4 from SPORTDiscus, and 3 from CNKI. Then, 40 duplicates were removed, and 81 articles were excluded based on their titles and abstracts. After reviewing the full text, six articles were included for the review. Among the included studies, one tested peak power output, mean power output, peak bar velocity, and mean bar velocity to detect PAP . The remThe PEDro scores for the studies in this review ranged from 4 to 6 (mean = 5.2 ± 0.8) . Of the A total of five studies with 81 subjects were included in this systematic review . Their sThe main purposes of this study were to examine the role of BFR in eliciting PAP and to compare the effectiveness of BFR-elicited PAP and non-BFR counterparts. Given the limited number of included trials and variable training loads, quantitative analysis was rejected. Nonetheless, most of the identified studies suggested the advantages of BFR training in eliciting PAP over non-BFR training. In all included studies, only one study documented adverse effects of both BFR and non-BFR-CAs on vertical jump performance, and the BFR even led to lower PAP. Likewise, null or negative results were reported elsewhere, despite those studies using resistance training alone without BFR for eliciting PAP ,34,35. TMoreover, Chen et al.  observedp < 0.05), while no significant changes were elicited by its counterpart. In another study performing LL-CAs [p < 0.01). Apparently, the use of BFR boosted the elicitation of PAP. The results of these studies highlight the potential of BFR to enhance stretch-shortening cycle mechanics. They also indicate that there may be differences in time effects between BFR- and non-BFR-CAs.One included study indicated negative results. The others demonstrated that BFR-CAs managed to elicit a better PAP. In particular, when LL-CAs were put into practice, BFR turned out to be more beneficial. In the study of Doma et al.  in whichg LL-CAs , BFR-CAsg LL-CAs ,39,40. Hp < 0.01). In addition, the performances of both groups significantly increased from set 1 to set 2, and the peak power and bar speed of those in the BFR group (p < 0.01) were significantly higher than the peak power and bar speed of those in the non-BFR group (p = 0.01), yet only the performance of the BFR group decreased significantly (p < 0.01) from set 2 to set 3, which suggested that BFR-CAs may elicit PAP faster than non-BFR-CAs. Similar results were reported in the study of Doma et al. [Only one study reported the upper limb’s PAP elicited by BFR training. Wilk et al.  examineda et al.  . Most individuals, especially experienced trainees of these ages, are in good training condition. More experimental evidence on the effect of BFR-CAs on older or younger individuals (younger than 18) is needed.Determining pressure modality in advance is essential for BFR training. The amount of pressure needed to cease blood flow to a limb is related to a range of individual limb characteristics  and cuff width . HoweverIn the studies included here, most deployed a moderate cuff width of 6 cm, yet the pressures used were inconsistent. Miller et al.  and Wei Admittedly, the present study is limited by the small sample size and the inconsistent loads of the CAs in the studies included. The small sample size is due to the limited research available on this topic, even though a systematic search via three global databases and the most authoritative database in China was performed. In addition, it was found that the main subjects of the studies included are resistance trained men. The limited studies and the biased sampling profile may limit the generalizability of the findings. Nonetheless, the work in this study indicates BFR-CAs may be used to elicit PAP in inexperienced individuals. Furthermore, the inconsistent resistance loads of the CAs in the studies included highlights the fact that the substitution relationship between HL and LL-BFR remains ambiguous, for the only research which compared these two loads suggested negative results. Therefore, it is suggested that future studies should be conducted that systematically examine the effect of BFR-CAs on inexperienced or non-power-sports athletes and explore the substitution relationship between HL- and LL-BFR-CAs and their effect on PAP. Furthermore, if and how the BFR affects the time characteristics of PAP also remains to be explored.This review aimed to introduce BFR-CAs and compare their effectiveness in eliciting PAP with traditional CAs. Our results pointed to the advantage of BFR-CAs in inducing PAP. However, due to the limited number of relevant studies and the discrepancies in data synthesis, further research is warranted to re-examine the advantage of BFR-CAs when more studies appear. Moreover, since BFR itself can exert physiological stress to help induce PAP, BFR-CAs may require lower training loads to benefit untrained individuals and help save energy, and to reduce the risks of over-fatigue and injuries in athletes. This review thus highlights the possible value of BFR-CAs and the need to consider them further in future research.


To quantify the association between income and antibiotic misuse including unprescribed use, storage of antibiotics and non-adherence.We identified pertinent studies through database search, and manual examination of reference lists of selected articles and review reports. We performed a dose–response meta-analysis of income, both continuous and categorical, in relation to antibiotic misuse. Summary odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated under a random-effects random effects model.p-value = 0.954, p-value non-linearity = 0.429). Data were compatible with no association between medium and high income with general antibiotic misuse . Medium income was associated with 19% higher odds of antibiotic storage  and 18% higher odds of any aspect of antibiotic misuse in African studies . High income was associated with 51% lower odds of non-adherence to antibiotic treatment . High income was also associated with 11% higher odds of any antibiotic misuse in upper-middle wealth countries .Fifty-seven studies from 22 countries of different economic class were included. Overall, the data are in agreement with a flat linear association between income standardized to socio-economic indicators and antibiotic misuse (OR per 1 unit increment = 1.00, The association between income and antibiotic misuse varies by type of misuse and country wellness. Understanding the socioeconomic properties of antibiotic misuse should prove useful in developing related intervention programs and health policies. The misuse of antibiotics is defined as the intake of these drugs without medical advice (self-prescription) or their use when prescribed by the physician but without compliance with the physician’s instructions for treatment regimen in terms of timing, dosage and duration , 2. It iAntibiotic resistance causes at least 700,000 annual deaths worldwide , more thSeveral determinants of antibiotic misuse have been identified. These are mainly sociodemographic, including female gender, young adults and elderly, low educational level, difficult access to the healthcare system, unaffordability of the cost of physicians visit and accessibility to antibiotics , 13, 14.In 2012, a narrative review report about self-medication with antibiotics in developing countries analysed data of five studies and concluded that middle income is associated with antibiotic misuse . StudiesTo address this gap, we aimed in this study to carry out a meta-analysis of the association of income with antibiotic misuse. We present analyses standardized for socio-economic indicators.number deleted for blinding purposes). The outcome, antibiotic misuse, was defined as the use or purchase of non-prescribed antibiotics to treat oneself or another person, storage of leftover antibiotics, or nonadherence to the physicians’ instructions regarding the dosage, timing and treatment duration. Storage of antibiotics facilitates access to them and therefore is the first step towards their use without prescription ) OR (compliance) OR (adherence) OR (Nonprescription Drugs/administration & dosage* [MeSH]) OR (misuse) OR  OR (left-over)) and adapted for the other databases. We complemented our search by using free text words as follows: antibiotics AND (misuse OR "unprescribed use" OR leftover OR "adherence to treatment") AND (income OR "socioeconomic status" OR "socioeconomic level"). The reference lists of related reviews , 24, 25 Studies that met the following criteria were included: (1) reporting at least two levels of income with defined boundaries as an exposure, and (2) providing Odds Ratio (OR) or Risk Ratio (RR) and their 95% Confidence Interval (CI) as a measurement of the association of income and misuse of antibiotics by the general population, or sufficient data for their calculation.general study characteristics: author’s last name and year of publication, study period, participants characteristics (age and gender), and country where the study took place, (2) exposure: levels of monthly income, (3) measures of association: for each income level: number of subjects who practiced antibiotic misuse, total sample size, adjusted ORs and 95%CIs, and restriction, adjustment, or matching variables. When adjusted ORs were not provided, the crude estimates were registered, and (4) Type of antibiotic misuse: use without prescription, non-adherence, and storage of antibiotic leftover. When data was were provided for more than one type of antibiotic misuse, we extracted the data of all types of misuse. When the number of events of antibiotic misuse per income level was not available, we contacted the authors to request this information, but no reply was received [From each included study, we extracted: (1) received –28. We treceived , but dueper capita based on purchasing power parity (PPP) [per capita, expressed in US dollars [per capita based on PPP, and adjusted net national income per capita were extracted from their specific portals in the World Bank [We standardized the income to country-specific socio-economic indicators using two approaches. In the first approach, income was standardized to gross domestic product (GDP) ty (PPP) . PPP is ty (PPP) . In the  dollars . The hisrld Bank –33.Besides data reported in the studies, the classification of countries by economy , geograpStudies included in this meta-analysis presented income categorized into 2 to 6 levels, with an average of 3 levels. As an estimate of the dose, we used the midpoint assigned to an estimated contrast given the upper and lower boundaries of the income.per capita based on (PPP) and (2) adjusted net national income per capita.We carried out dose–response meta-analysis of income standardized to: (1) gross domestic product (GDP) The dose–response meta-analysis was performed using a one-stage mixed-effects model taking into account heterogeneity across studies , 38.We first used a linear function to estimate a summary OR of antibiotic misuse associated with an increase of 1 unit in income. We next flexibly modelled income using restricted cubic splines with 3 knots fixed at 10th, 50th and 90th percentiles of its distribution. Tests of hypothesis about the regression coefficients of the dose–response model were conducted using a large sample Wald-type test. To facilitate tabular presentation of the summary odds ratios, we further categorized income into tertiles using the lowest as referent.We stratified the dose–response analysis by type of antibiotic misuse ; WHO geographic classification, country economy ; literacy rate ; exposure ascertainment ; comparability ; and publication year . In 2015, WHO published the global action plan to combat the problem of antibiotic resistance .(NM and AF) carried out the quality assessment, and disagreements were resolved by referring to a third epidemiologist (BT).As all studies retrieved were eventually of cross-sectional nature, we appraised the quality of the studies using the Newcastle–Ottawa Scale for cross-sectional studies . One poiPublication bias was checked visually using funnel plot and formally through Egger’s test , and theFigure p-value = 0.954, p-value non-linearity = 0.452). Similar results were obtained for the association of income standardized to adjusted net national income per capita and antibiotic misuse .Overall, the data from these 57 studies were compatible with a flat linear association between income standardized to GDP per capita based on PPP and antibiotic misuse , no association between income and general antibiotic misuse was observed: medium income (2nd tertile): OR 1.04; 95% CI 0.89, 1.20, and high income (3rd tertile): OR 1.03; 95% CI 0.82, 1.29 ,); nonetheless, we did not observe any significant association between high income and this type of misuse . It is noteworthy to mention that storage of antibiotics was evaluated in five studies carried out in China [non-adherence to antibiotics treatment  . Similar findings were obtained for high- income individuals  .medium 1.06; 95% CI 0.91, 1.24 and ORhigh 1.04; 95% CI 0.85, 1.27)  and in high income   and those from studies with higher-quality score (> 3 points) Table .p-value = 0.39) did not suggest evidence of publication bias. These findings were further confirmed by the Trim-and-Fill analysis that did not yield to the addition of any study.The funnel plot Fig.  and EggeAntibiotic resistance is an internationally growing multifaceted emergency that has been exacerbated by antibiotic misuse and has left devastating impact at the clinical, health and socio-economic levels. If not controlled, antibiotic resistance will convert into the major cause of death in 2050 .To the best of our knowledge, this is the first meta-analysis that assesses the dose–response association between income level and misuse of antibiotics. Our results agree well with the hypothesis of no association between income level and misuse of antibiotics. Subgroup analyses reveal a dose–response association of medium- and high- income levels with specific types of antibiotic misuse, i.e., storage of drug leftover and non-adherence, country wealth, geographic region and study period.Our primary findings suggest that the odds of misuse of antibiotics do not differ between poor and wealthy people. This is in line with the fact that both low- and high- income individuals tend to self-medicate. On the one hand, under constrained financial resources, especially in less developed economies where access to health facilities is limited, self-medication is the only available option of healthcare . By selfOur dose–response meta-analysis also showed that medium- income individuals have higher odds of storing antibiotic leftover than those with low income. This could be related to higher financial affordability by medium-income medium income individuals to purchase and store antibiotics. Our results also show a higher likelihood of misuse by high-income individuals in upper–middle wealth countries. Consistent with our findings, an earlier report about the economy of self-medication in general, indicated that the demand for self-medication declines with rising the income level of high- income individuals, but increases with increasing the income of low-income individuals, resulting in a null pooled effect between income and self-medication .We also reported that medium- income individuals in Africa have higher chances of antibiotic misuse, probably due to the poor enforcement of antibiotic dispensing regulations in those regions.Global Spending on Health, the expenditure on health is growing faster than economies, leading to a doubling of the out-of-pocket spending and very large differences between high- and low-wealth countries concerning health expenditure [We observed a marginal increase in the odds of misuse of antibiotics by medium- income and high- income individuals after 2015 than before this period. This could be related to two main motives;: first, as concluded by WHO in its report enditure , second,enditure . Consequenditure .The findings of this meta-analysis are unlikely to be affected by publication bias as revealed by the negative result of Egger’s test and the trim-and-fill analysis that did not suggest imputation of any additional study.This meta-analysis suffers from several limitations. All eligible studies were of cross-sectional design, which, theoretically, limited any causal inference. However, income is a relatively stable variable through time and, which mitigates this limitation. Furthermore, only one-fifth of included studies performed a complete control for socio-demographic variables, and higher OR estimates were obtained from studies with incomplete adjustment than in studies with complete adjustment. This reveals that our findings could be overestimated due to incomplete adjustment. Additional studies that control adequately for all potentially related socio-demographic variables are needed to confirm our results. Also, one-sixth of studies did not employ a pretested or validated questionnaire to ascertain the exposure and the outcome. However, this was unlikely to affect our results as constraining the analysis to the remaining studies did not introduce any change in the overall effect.Our analysis was based on random-effect models to account for heterogeneity between studies –58. HeteUnderstanding the socioeconomic properties of antibiotic misuse is crucial to develop related intervention programs and health policies, yet addition of high-quality studies that control for socio-demographic and socio-economic indicators are needed to confirm our findings.


Multisystem inflammatory syndrome in children (MIS-C) is an uncommon but emerging syndrome related to SARS-CoV-2 infection. While the presentation of MIS-C is generally delayed after exposure to the virus that causes coronavirus 2019, both MIS-C and Kawasaki disease (KD) share similar clinical features. Multisystem inflammatory syndrome in children poses a diagnostic and therapeutic challenge given the lack of definitive diagnostic tests and a paucity of evidence regarding treatment modalities. We review the clinical presentation, diagnostic evaluations, and management of MIS-C and compare its clinical features to those of KD. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases emerged in the Wuhan Province of China in December 2019 and were later identified in January 2020 in the United States. Following the spread of coronavirus 2019 (COVID-19) globally, there were reported increases in cases of children presenting with prolonged fever, rash, and conjunctivitis similar to Kawasaki disease (KD).Children with MIS-C often present with fever, cough, upper respiratory symptoms, and gastrointestinal symptoms such as vomiting and diarrhea.In October 2020 we performed a literature search on PubMed along with a web-based search engine using the following Medical Subject Heading terms (performed October 2020): pediatric case reports COVID-19, Kawasaki disease, COVID-19, multisystem inflammatory syndrome in children, pediatric multisystem inflammatory syndrome, and SARS-CoV-2. This search produced 801 records that included scientific articles, editorials, and CDC reports. The sources were reviewed for articles that presented cases with etiology, management plan, treatment, and outcomes as the inclusion criteria for this systemic review. Excluded were records (n = 756) in other languages or without an abstract, review articles, adult-focused articles, pure KD articles, and non-relevant sources. We assessed only full-text articles for eligibility, and 11 studies were chosen for detailed review. The articles were reviewed by pediatric emergency physicians, who selected the articles based on the above inclusion and exclusion criteria. The first case of MIS-C was reported in the UK in April 2020.13Early cases of MIS-C were initially described in the UK, the Bergamo region of Italy, Paris, and New York City.18While no direct causal relationship between COVID-19 and MIS-C has been identified, the history of exposure to COVID-19 and the epidemiological spike in cases of MIS-C cases in areas with a high incidence of COVID-19 suggests that the two diseases may be related.21Population Health Research CapsuleWhat do we already know about this issue?Multisystem inflammatory syndrome in children (MIS-C) is a rare and serious emerging manifestation of SARS-CoV-2 as a late immune response diagnosed clinically.What was the research question?We review MIS-C presentation, evaluation and management, and compare its features to the similar inflammatory syndrome such as Kawasaki Disease (KD).What was the major finding of the study?MIS-C will require early recognition and initiation of therapy. With a need for monitoring in an intensive care unit, and depending on the severity of the illness and organ system involvement, a multidisciplinary team of specialists need to be on hand during supportive care.How does this improve population health?This review will aid in its prompt recognition and enable the early initiation of therapy, which has been shown to reduce its morbidity and mortality in all age groups.Multisystem inflammatory syndrome in children has been proposed as a post-infectious process occurring during the development of acquired immunity. This concept is supported by the observation that each surge of cases occurring regionally follows the peak of acute COVID-19 infections by 2–4 weeks. The majority of these children had a negative SARS-CoV-2 polymerase chain reaction (PCR) test but a positive immunoglobulin G (IgG) serology, although some had both positive IgG serology and positive PCR tests.23The most significant clinical features in children with MIS-C are cardiovascular manifestations. Published case studies have reported shock as the initial presentation in at least 50% of cases.Published case series of MIS-C in the US and Europe have demonstrated common features with KD. Fever is present in all patients with MIS-C with a median duration of 4–5 days.Gastrointestinal symptoms occurred frequently in MIS-C and less commonly in patients with KD. Most MIS-C case series reported that at least 80% of children with MIS-C presented with abdominal pain, diarrhea, and/or vomiting.33Skin rashes in MIS-C exhibited variable distribution and presented as maculopapular, scarlatiniform, diffuse erythroderma, or erythema multiforme . Patient32The diagnostic evaluation of MIS-C herein described is geared toward rapidly identifying life-threatening conditions that require prompt intervention. It is focused on recognizing the constellation of symptoms and findings that are consistent with this syndrome, while concurrently exploring the possibility of alternative diagnoses. In the setting of this emerging new syndrome and the possibility of rapid clinical deterioration, a high index of suspicion should be maintained when evaluating children with fever. This is especially the case when coupled with abdominal symptoms or other features commonly observed in children with KD.The CDC guidelines for identifying suspected MIS-C cases have been described as follows: 1) An individual aged <21 years presenting with fever , laboratory evidence of inflammation (elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, D-dimer, ferritin, lactic acid, lactate dehydrogenase (LDH), interleukin-6 (IL-6), elevated neutrophils, reduced lymphocytes, low albumin), and evidence of clinically severe illness requiring hospitalization, with multisystem (greater than two), organ involvement ; 2) AND no alternative plausible diagnoses; 3) AND positive for current or recent SARS-CoV-2 infection by PCR, serology, or antigen test; or COVID-19 exposure within the four weeks prior to the onset of symptoms.9Common laboratory and diagnostic tests are combined with additional testing directed at identifying a hyperinflammatory state, examining end-organ dysfunction, and exploring infectious etiologies to evaluate children with clinical suspicion of MIS-C. A complete blood count and comprehensive metabolic panel is obtained to evaluate for infectious and inflammatory states, metabolic derangements, renal or hepatic dysfunction, and disease processes associated with hypotension and hypoperfusion. Testing for COVID-19 via SARS-CoV-2 PCR should also be performed. Since MIS-C is believed to potentially be antibody mediated, the presence of serum antibodies to COVID-19 should also be determined to aid in confirming the initial suspicion of viral exposure.A urinalysis may be used to identify the presence of sterile pyuria associated with KD.Other components of evaluation include an electrocardiogram (ECG), chest radiographs (CXR), and point-of-care ultrasound (POCUS). In addition to serum evaluation for troponin-I and BNP, an ECG is performed to evaluate for cardiac dysfunction and acute myocarditis, manifested by sinus tachycardia, alterations in the PR interval, as well as findings consistent with myocardial damage including diffuse ST changes. The CXRs are used to evaluate for pulmonary infiltrates consistent with acute bacterial pneumonia, acute respiratory distress syndrome, or acute COVID-19 respiratory disease. The POCUS cardiac evaluation may be useful in evaluating global function, which is diminished in myocarditis associated with MIS-C. In addition, changes in the expiratory and inspiratory diameter of the inferior vena cava are indicative of disseminated or cardiogenic shock.34The management of MIS-C in the ED begins with the overall evaluation and classification of the patient into categories based on symptom severity: mild, moderate, or severe. Current treatment of children with severe presentation consists of supportive care with fluid resuscitation and inotropic support, along with directed therapy for respiratory failure, cardiac dysfunction, a hyperinflammatory state, and evaluation for possible thrombosis. In our review, the use of immunoglobulins, corticosteroids, or anticoagulants may be indicated based on the clinical symptoms and the presence of elevated serum inflammatory markers. Application of antiviral and immune modulator therapy remains variable. Early management strategies should be developed in consultation with experts in pediatric infectious disease, intensive care, cardiology, rheumatology, and hematology. Clinicians should maintain a high level of suspicion for MIS-C in children with known or suspected COVID-19 infection who develop fever for several days with no identifiable cause or who have developed shock. Hospitalization may be necessary for patients with suspicion for MIS-C who have significantly elevated serum inflammatory markers, even if symptoms are mild, as some patients may rapidly decompensate and require aggressive resuscitation. Patients who are ill appearing, hemodynamically unstable, require invasive respiratory support, or have evidence of end-organ dysfunction should be admitted to a pediatric critical care unit.Patients with severe MIS-C can develop hemodynamic instability from cardiac dysfunction, as well as a decrease in peripheral vascular resistance. Furthermore, secondary bacterial infection can also lead to sepsis and hypotension. Many children with COVID-19-related MIS-C have presented with shock. In several reports, clinical deterioration occurred rapidly; therefore, the importance of continuous monitoring with frequent blood pressure measurements cannot be overemphasized. Hemodynamic instability should be treated according to established pediatric septic shock guidelines.16Intravenous immune globulin (IVIG) has been used as a first-line treatment in most cases of MIS-C with an overall improvement in cardiac function and decreased inflammatory state. Patients in some case reports with IVIG resistance received a second dose of IVIG, with or without corticosteroids.30In children who are ill-appearing with fever, hypoxia, and hemodynamic instability, IV fluids should be initiated immediately, and the child should be admitted to a critical care unit. A CXR is recommended initially to identify interstitial pneumonia and cardiac enlargement. Shock evaluation should include an ECG and echocardiogram to evaluate ventricular function.Patients who have features of MIS-C without shock or cardiovascular dysfunction  should be evaluated with both a laboratory panel and a cardiac evaluation . It is recommended that these patients should be admitted to an inpatient unit.Patients with clinical manifestations and abnormal laboratory findings consistent with MIS-C should be hospitalized for close monitoring and supportive care. Children with severe MIS-C disease and those with hypotension or shock requiring vasopressor support should be admitted to the pediatric intensive care unit. A multidisciplinary team approach involving cardiology, infectious disease, immunology, rheumatology, hematology, and intensive care can be helpful in optimizing patient outcomes in an inpatient setting. Thus far, the long-term impact and sequelae among survivors are not known, and careful long-term follow-up is needed to assess future cardiac function.Other differential diagnoses to consider are related to bacterial and viral infection. Staphylococcal and streptococcal toxic shock syndrome (TSS) present with fever and shock, and both can present with rash/conjunctivitis, gastrointestinal symptoms  as a close resemblance to MIS-C, whereas the latter will have cardiac and respiratory features.Common viral infections such as enterovirus, adenovirus, parvovirus, and measles can mimic some features of MIS-C including fever, rash, and conjunctival injection. Gastrointestinal symptoms such as abdominal pain, vomiting, and diarrhea may be present in MIS-C, but can also be commonly associated with adenovirus, enterovirus, rotavirus, and Norwalk virus. Epstein-Barr virus (EBV) can cause multisystem organ failure in the central nervous system, liver, lungs, and heart by inciting a hyperinflammatory state similar to MIS-C.One of the clinical features and potentially poor prognostic indicators of MIS-C is markedly elevated inflammatory markers and pro-inflammatory cytokines. The efficacy of immune modulatory therapies such as IL inhibitors , corticosteroids, or convalescent plasma from patients who have already recovered from COVID-19 remains unclear for patients suffering from MIS-C. Anakinra, an IL-1 receptor antagonist, has been used successfully in the treatment of highly refractory KD.Convalescent plasma has been used in a small number of children with SARS-CoV-2 infection with some beneficial results, although its effectiveness is unclear in patients with MIS-C.Acute infection with SARS-CoV-2 has been associated with an increased risk for thrombotic complications due to an amplified inflammatory response and a state of hypercoagulation.While some children with MIS-C have evidence of acute SARS-CoV-2 infection at the time of diagnosis, a large number of children have tested negative on PCR and are positive for serum COVID-19 antibodies. Therapy with the antiviral agent remdesivir has been used in ≥12 years patients with severe complications from acute SARS-CoV-2 infection. However, the risks and benefits of this antiviral treatment remain uncertain. Its benefit is not indicated as MIS-C is considered an immune-mediated phenomenon that occurs weeks after a primary SARS-CoV-2 infection. Consultation with pediatric infectious disease and critical care experts on the use of remdesivir is recommended if suspected or confirmed MIS-C patients are not responding to other treatment options.Published management guidelines for MIS-C emphasize both short- and long-term follow-up for MIS-C patients who were admitted to the hospital. Close follow-up is recommended for all patients with KD features, cardiac dysfunction, or evidence of coronary artery abnormalities. Repeat echocardiograms should be obtained to screen for coronary artery dilation, aneurysm, and thrombus formation. Patients should be followed up by a primary care physician within a week after discharge from the hospital. Furthermore, follow-up with specialists in infectious disease and rheumatology should also be considered.Multisystem inflammatory syndrome in children differs from other inflammatory disorders such as KD by its novelty in clinical presentation and patient demographics. The number of COVID-19 cases in children continues to rise, with new variants emerging frequently. With this rise in pediatric COVID-19 cases is an expected rise is MIS-C cases; however, the effect of new SARS-CoV-2 variants on the development and progression of MIS-C is unknown. The need for strict MIS-C identification and management guidelines is thus imminent. Mild to severe cases with cardiac dysfunction require early recognition and management for successful prognostic outcome, and for the majority of patients outcomes are generally good with little to no significant medium- or long-term sequelae.Multisystem inflammatory syndrome in children is a relatively new condition; thus, there is limited literature available to review. As the pandemic evolves and additional waves of infection spread, the identification and management of MIS-C will continue to change. We have attempted to identify the highest quality published evidence and methodology described within this small pool of limited literature. Hence, it has been difficult to draw any definitive conclusions regarding the overall generalizability of our findings.Multisystem inflammatory syndrome in children should be suspected in children presenting with fever and the symptoms described above following the diagnosis of, or exposure to, SARS-CoV-2. Kawasaki disease has similar clinical characteristics when compared to MIS-C. Early recognition and testing of suspected MIS-C patients will result in earlier treatment initiation and will likely limit the patient’s generalized immune-mediated decline. Managing children with respiratory and cardiovascular dysfunction requires caution and continued surveillance. Long-term studies are required to determine the association of MIS-C with COVID-19 infection and the effect of COVID-19 vaccination on MIS-C, and to understand the effect of new SARS-CoV-2 variants on the development and progression of this condition.


Antibiotic-resistant bacteria, and more specifically, carbapenem-producing Enterobacterales (CPE) strains, are increasing worldwide. Despite their growing prevalence, in most high-income countries, the detection of CPE is still considered a low-frequency event. Sporadically, patients co-colonized with distinct CPE strains and/or different carbapenemase enzymes are detected. In this paper, we present three cases that illustrate the underlying mechanisms of co-colonization, focusing on horizontal gene transfer (HGT) and patient-to-patient transmission. We also demonstrate the diversity of CPE species and discuss the potential consequences of co-colonization. The emergence and spread of bacteria with multi-drug resistance (MDR) is a major public health concern worldwide, declared by the World Health Organization (WHO) as one of the top 10 global public health threats . Of the While some bacteria are naturally resistant to carbapenems, the rapid spread of CRE across the globe is mainly driven by acquired resistance, with susceptible bacteria gaining resistance by acquiring genes that encode for a variety of carbapenem-hydrolyzing enzymes , thus beKlebsiella pneumoniae carbapenemase (KPC) and New Delhi metallo-beta-lactamase (NDM), focusing on the variety of the underlying genetic, microbiological, and epidemiological mechanisms.Typically, a single strain of CPE, carrying a single carbapenemase gene, is identified in a colonized patient. Occasionally, the co-carriage of two carbapenamases in the same strain is detected. However, as there is potential to acquire multiple CPEs exogenously (patient to patient), and for HGT to then occur across different species within the gastrointestinal tract, patients may have a substantial risk of becoming colonized with more than one CRE species. Whilst this phenomenon is now beginning to be investigated ,21,22, tOver the last 3 years, 95.6% of the total cases of CPE carriers reported to the National Registry of the National Centre for Infection Control (NCIC), Israel, had a single carbapenemase gene, while 4.4% of the CPE carriers had more than one type of carbapenemase. In 62% of those cases, the two carbapenemases were present in the same isolate, while in the remaining 38%, the different carbapenemases were present in different bacterial species.Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacter cloacae. Subsequently, the patient had multiple hospitalizations and was transferred between different geriatric centers, and repeated CPE screening samples returned results positive for KPC-producing Enterobacter cloacae until the date of his next hospitalization, nearly two years later. The patient was hospitalized in a CPE cohort ward. The following month, a second CPE acquisition was identified—the patient’s wound culture was positive for New Delhi metallo-beta-lactamase (NDM)-producing K. pneumoniae. Two months later, whilst hospitalized in a geriatric medical center, he was screened for the presence of MDR bacteria, as part of a point prevalence study carried out by the NCIC. He was found to be positive for both KPC- and NDM-producing Enterobacterales. The rectal sample was found to contain NDM-producing K. pneumoniae and KPC-producing K. pneumoniae, whilst the skin sample contained NDM-producing E. coli and KPC-producing K. pneumoniae . In addition, the E. coli strain contained an IncX3 plasmid. Further Sanger sequencing of the NDM-producing E. coli and K. aerogenes from patients C–G detected the presence of the blaNDM7 variant  by multiplex polymerase chain reaction (PCR) based on Israeli National Policy for CPE Screening [K. pneumoniae.Case Study 1: Point prevalence study. Rectal and skin samples were used to inoculate liquid brain heart infusion (BHI) broth. After overnight incubation at 37 °C, the broth was sub-cultured on selective agar media for CPE . Both the BHI broth and suspect CPE colonies (when present) were tested for the presence of carbapenemase genes , isolates were sub-cultured on CPE-selective media, and suspect CPE colonies were tested as outlined for Case Study 1. In Case 2, an additional immunochromatographic assay was performed, which was able to detect and differentiate between KPC, OXA-48-like, VIM, IMP, and NDM carbapenemases .https://github.com/tseemann/mlst (accessed on 5 May 2022)). The capsular polysaccharide (KL) and lipooligosaccharide outer core (OCL) synthesis was determined using Kaptive [https://cge.cbs.dtu.dk/services/ResFinder/ (accessed on 5 May 2022)). Plasmids were detected using PlasmidFinder (https://cge.food.dtu.dk/services/PlasmidFinder/ (accessed on 5 May 2022)). Sanger sequencing of blaNDM PCR products was performed by Hy laboratories, Israel.Whole genome sequencing (WGS): Sequencing was performed by the Sequencing Core at RUSH University, Chicago, IL, USA. Libraries were prepared using the Nextera XT  kit, followed by sequencing on the Illumina NovaSeq (Illumina Inc.) using the high-output 2 × 150 bp kit (Illumina Inc.). De novo assembly was achieved using CLC Genomics Workbench protocol with default parameters. Strain MLST typing was determined with MLST software  or infected (Case 2) with CPE during their stay in the hospital. The combination of the documented screening results in Case 1 and the positive CPE results from both patients obtained by the NCIC Reference Laboratory allows us to conclude with high certainty that both secondary CPE acquisitions of a different carbapenemase gene occurred on the CPE isolation ward. This demonstrates that the inappropriate cohorting of patients with different carbapenemases is a risk factor for co-colonization with CPE and can lead to the acquisition of additional resistance mechanisms by previously resistant or susceptible bacteria.blaNDM7-producing E. coli strain, transmitted between six patients and leading to their colonization. Most noteworthy in Case Study 3, however, is the clear evidence of HGT, which occurred in patient E. The rapid global spread of NDMbla in different bacterial species is extensively reported in the literature, because this gene is carried on a broad host range of conjugative plasmids [blaNDM-7 was transferred between IncX3-carrying E. coli and K. aerogenes (Case 3) and (2) blaNDM-1 was transferred between K. oxytoca and E. cloacae (Case 2), both carrying IncX3. Despite the lack of detailed data on all CPE-positive isolates in Case Study 1, it is possible that HGT occurred twice in this patient: (1) blaKPC-3 was transferred between E. cloacae and K. pneumoniae ST512, and (2) blaNDM-1 was transferred between K. pneumoniae ST417 and E. coli. The repetition of this event in our results suggests that cross-species transmission occurs more frequently than is currently believed, especially during co-colonization events [Another example of the results of failure to isolate a CPE carrier was reported in Case Study 3. In this case, an outbreak was caused by a clonally related plasmids ,29. Heren events .blaNDM-7 and blaNDM-5) within three different bacterial species in Case 3. Additionally, the WGS analysis of isolates from Case 1 and 2 identified two distinct K. pneumoniae and two different E. cloacae strains, belonging to different ST types. In each case, the different strains carried different carbapenemase genes. Without sequencing to determine the exact ST type and the specific allele within each species, the complex picture of co-colonization would have remained unclear.One reason for the underestimation of the frequency of co-colonization events is the in-depth WGS analysis needed for its detection. The WGS analysis performed by NCIC Reference Laboratory identified two distinct NDM variants (The diversity of co-colonization described here highlights the importance of sub-classifying patients according to the carbapenemase genes carried by their CPE strains, rather than just according to the detection of CPE. Previous studies have suggested that multiple colonization with CPE may increase the risk of further infection with these organisms . This coThe inappropriate isolation and cohorting of patients with different resistance mechanisms increases the likelihood of co-colonization. Therefore, to improve patient outcomes, patients should be separated whenever feasible. Not detecting the presence of CPE allows transmission to occur, increasing the risk of co-colonization. The screening of patients with CPE or those who are at risk of CPE is essential for detecting changes in colonization status and allows fast action to prevent transmission or acquisition.There are several limitations to this study. Not all isolates were available for WGS and plasmid extraction, and therefore the genetic analysis was not complete. In addition, the identification of all potential CPE species from screening swabs is subject to microbiological and technical limitations, and therefore the CPE detection results may have been underestimated.We demonstrate here that there is no single CPE status: multiple different CPE strains may be present in a single CPE-positive patient. The diversity of resistance genes and the presence of natural HGT mechanisms increases the potential of the spread of multiple carbapenemases between different currently susceptible bacterial species, allowing the possible combinations of CPE to become infinite. It is therefore of vital importance to continue global efforts to control the spread of these MDR organisms through appropriate cohorting, increased screening, and performing real-time in-depth genetic analysis in clinical settings.