Bronchoscopy is critical in the treatment of patients with coronavirus disease (COVID-19), and its use is associated with the challenges of stringent sterilization and virus transmission risk. We developed a disposable and portable bronchoscope (YunSendo-R) and compared its safety and function with those of current reusable and single-use bronchoscopes using an animal model.We compared the YunSendo-R system with a commercially available reusable bronchoscope  and single-use bronchoscope . Eight physicians used the three types of bronchoscopes to operate on Guangxi Bama mini pigs. Each operator performed bronchoscopy and completed a 10-point Likert scale questionnaire for evaluating visual ability and manoeuvrability. Operation time and scores were collected.P < 0.05) and no significant difference in performance compared with the Olympus bronchoscope (P > 0.05). The YunSendo-R bronchoscope had similar manoeuvrability to the Olympus bronchoscope and better scope tip flexibility than the Ambu bronchoscope (P > 0.05). No relevant complications were reported.Operation time had no significant differences among the three bronchoscopes. In visual ability, the YunSendo-R bronchoscope showed superior performance to the Ambu bronchoscope in image clarity, colour contrast, and illumination (We have developed a new bronchoscopy system with the advantages of disposability and portability, which was effective and safe in an animal model. It has better visual ability than the Ambu bronchoscope and similar visual ability and manoeuvrability to the Olympus bronchoscope. The YunSendo-R bronchoscope is a promising device for clinical practice, especially in reusable-endoscope-transmitted infectious diseases such as COVID-19. Stenotrophomonas maltophilia, Escherichia coli, and Shigella species [Pseudomonas aeruginosa and mycobacteria, which affects patient health and increases medical expenses [The currently raging infectious coronavirus disease COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mainly presents with fever and respiratory symptoms. Patients with severe infection tend to develop hypoxia and dyspnoea, progressing to acute respiratory distress syndrome. Bronchoscopy has become essential in the treatment of COVID-19 patients; however, direct contact with reusable bronchoscopes in reprocessing, especially during aerosol-generating procedures, has a risk of virus transmission 9 caused . Additio species . Reusingexpenses , 6.Disposable endoscopes are beneficial equipment as they eliminate complicated sterilization procedures, saving cost on reagents and staff. Furthermore, single-use bronchoscopes minimise the risk of cross-infection and virus transmission among both patients and staff. Their use has been widely recommended by multiple associations and guidelines during the COVID-19 pandemic , 8.However, conventional bronchoscopy systems tend to be equipped with a heavy host, which has to be used in a specific room, thereby making them unavailable in settings such as emergency rooms and intensive care units. Patients in such settings have no access to immediate airway interventions. Portable system with ready accessibility can be used at a patient’s bedside in case of a serious condition, facilitating the use of urgent bronchoscopy when required .Our team has developed a portable endoscopic system with a single-use gastrointestinal endoscope and used it for patients with digestive tract bleeding associated with COVID-19 , 11. HerThis study was approved by the Institutional Animal Care & Use Committee (IACUC) of Chinese PLA General Hospital with number 2020-X16-36.We developed the YunSendo-R bronchoscopy system Fig. . It inclIn this study, eight physicians used three types of bronchoscopes, the YunSendo-R bronchoscope , the Olympus bronchoscope , and the Ambu bronchoscope , to operate on anaesthetised Guangxi Bama mini pigs. The order of bronchoscope was determined by drawing lots. The indexes used to assess the functions of the three types of bronchoscopes included image clarity, image colour contrast, image illumination, capture sensitivity, and field of view for visual ability evaluation, suction ability, working channel insertion, button sensitivity, and scope tip flexibility for manoeuvrability. Each item was scored using the 10-point Likert scale, where 1 corresponds to poor, 5 and 6 corresponds to neutral, and 10 corresponds to excellent  when non-normally distributed. Group comparisons were performed using the Wilcoxon rank-sum test or t-test (when appropriate). All statistical analyses were conducted using SPSS statistics version 21 . All three types of bronchoscopes could be used to identify segmental bronchus and simulate biopsy operation successfully without any complications Figs. , 3. The P > 0.05) and performed better than the Ambu bronchoscope in image clarity, colour contrast, and illumination assessments (P < 0.05). The YunSendo-R bronchoscope showed no statistical difference (P > 0.05) with the Ambu bronchoscope in capture sensitivity or field of view scores.Operator perception scoring results are reported in Table P > 0.05), while the YunSendo-R bronchoscope performed slightly worse than the Olympus bronchoscope in button sensitivity (P < 0.05). Compared to the Ambu bronchoscope, the YunSendo-R bronchoscope performed better in scope tip flexibility assessment (P < 0.05) and showed no statistical differences in the suction ability, working channel insertion, and button sensitivity score (P > 0.05). No complications were associated with all three bronchoscopes during the operation and until the 1-week follow-up.In terms of bronchoscope manoeuvrability, the score of the YunSendo-R bronchoscope was similar to the Olympus bronchoscope in suction ability, working channel insertion, and scope tip flexibility assessments (The YunSendo-R bronchoscope system is a user-friendly system that can be mastered in a short period. Results showed that its operation time was not significantly different from that of the other two bronchoscopes. Moreover, the YunSendo-R bronchoscope images appeared to be of high quality, meeting the basic requirement for clinical bronchoscopy. In this study, no relevant complications such as perforation, bleeding, or pneumothorax were observed. This new system can be used to perform bronchoscopy effectively and safely.Quality of images is a critical parameter during bronchoscopy as it has a direct and strong impact on the effectiveness of operation. Equipped with an advanced camera system including an integrated LED light and 12 megapixel lens, the YunSendo-R bronchoscope renders high-definition images to the monitor that are clear, sharp, and bright. There was no difference in the visual ability scores between the YunSendo-R and Olympus bronchoscope, which suggests that the YunSendo-R bronchoscope meets the basic clinical requirements in visual ability, similar to the reusable Olympus bronchoscope. Furthermore, the YunSendo-R bronchoscope performed better than the commercially available single-use Ambu bronchoscope on image clarity, colour contrast, and illumination assessments, indicating better perception of image for operators, which is conducive for the diagnosis and treatment of diseases.In terms of manoeuvrability evaluation, the YunSendo-R bronchoscope performed similar to the Olympus bronchoscope in suction ability, working channel insertion, and scope tip flexibility assessments, with the exception of button sensitivity where it requires further modification. Compared to the Ambu bronchoscope, the YunSendo-R bronchoscope had a higher score on the scope tip flexibility. The YunSendo-R bronchoscope has 210°/120° up/down bending angles Fig. , making The YunSendo-R bronchoscopic system has uniqueness of portability, disposability and expandability. Our results manifest that it performs similar in visual ability and manoeuvrability to Olympus BF-H290 bronchoscope system which is inconvenient to transport and disposal while YunSendo-R bronchoscope performs better in visual ability than portable and disposable Ambu bronchoscope. We also realize that there is a commercial available portable Olympus bronchoscope MAF, which has no disposability compared to Ambu bronchoscope and YunSendo-R bronchoscope. Under some circumstances, the YunSendo-R bronchoscope can be connected to a smaller pad Fig. , similarOur study has several limitations. First, evaluation on the bronchoscope was conducted using an animal model rather than human subjects. Human bronchus tends to be complicated in comparison to the simple and clear bronchus of an animal; thus, our results may not reflect the actual quality of the YunSendo-R bronchoscopy in human. The eight bronchoscopists may be influenced in their evaluation by knowing which bronchoscope they used and the inadequate number of participants could also lead to a potential sampling bias requiring expanded sample size.In conclusion, considering the ongoing COVID-19 pandemic, we developed a promising bronchoscopy system with the advantages of portability and disposability. We tested the safety and efficacy of the YunSendo-R bronchoscope system in an animal model. The system has similar visual ability and manoeuvrability when compared to a commercially available reusable Olympus bronchoscope and performs better than a current single-use Ambu bronchoscope in terms of image quality and scope tip flexibility. Further studies on the YunSendo-R bronchoscope’s efficacy and safety in humans are needed.


To assess the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes.A systematic review of the literature with network meta-analysis.Medline, Embase and CENTRAL databases were searched from inception until 17 October 2020.Randomised clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute).Forty-six RCTs (n=8765) were included; risk of bias was low in 9 trials (19.6%), unclear in 20 (43.5%), and high in 17 (36.9%). At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were: exercise (standardised mean difference (SMD) −1.40; 95% confidence interval (CI) −2.41 to –0.40), heat wrap , opioids , manual therapy  and non-steroidal anti-inflammatory drugs (NSAIDs) . Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants . Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%) and steroids (46.9%) trial arms.With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm–benefit balance. Low back pain is a common symptom in people of all ages and socioeconomic status. The worldwide point prevalence of low back pain  was 7.83% (95% CI 7.04 to 8.64) in 2017, with 577 million people affected at any one time.Despite its high prevalence, low back pain has a generally good prognosis. While a specific cause of low back pain can seldom be identified, the most prevalent type is mechanical, non-specific low back pain (NS-LBP).Most guidelines agree on the first line of care in case of acute episode: advice, reassurance and encouragement to engage in light physical activity.http://www.crd.york.ac.uk/) and published.et alThe systematic review protocol was developed using guidance from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement,10.1136/bjsports-2020-103596.supp1Supplementary dataRandomised controlled trials (RCTs) had to involve both adult men and women who had experienced pain for up to 12 weeks due to acute or subacute NS-LBP.The primary outcomes were pain intensity and disability. The secondary outcomes were any occurrence of adverse events . Follow-up was classified as immediate-term (closest to 1 week), short-term (closest to 1-month assessment), medium-term (closest to 3–6 months) and long-term effects (closest to 12 months).We searched the following electronic databases since the inception date up to 27 February 2019 and updated on 17 October 2020: Medline (PubMed), CENTRAL and Embase  using the appropriate Thesaurus and free-text terms (see the study protocol for the search strategy).We tested the eligibility criteria by piloting a small sample . Two independent reviewers screened the title and the abstract of the publications retrieved by the search strategy and assessed the full text for potential inclusion. Studies not meeting the inclusion criteria were discarded. Disagreements between reviewers were resolved by discussion and consultation with a third reviewer, if necessary. Covidence softwareWe designed and piloted a data collection form created with Excel (Microsoft). Two reviewers independently extracted the study characteristics and outcome data. Disagreements were resolved through discussion or with assistance from a third reviewer, if necessary. From each study we extracted: name of first author, year of publication, setting, number of centres and population definition (acute/subacute), number, sex and age of participants, type of intervention and its duration, primary and secondary study outcomes data at interested time point of follow-up.All relevant arm-level final value scores were extracted. When these were lacking, the final value data were derived from the difference between the baseline and the mean change values. The SDs were imputed .When per-protocol and intention-to-treat analyses were reported, we prioritised intention-to-treat data as the effect of assignment to intervention might be more appropriate to inform stakeholder about effects of interventions in a healthcare perspective.et al.Two reviewers independently assessed the RoB of the included trials. We assessed the RoB for each study using the following RoB assessment tools recommended by the Cochrane CollaborationIn order to obtain an overall RoB assessment,netfunnel command in Stata 15Small study effects were assessed for each outcome (when >10 RCTs were available) using the We assessed the certainty of evidence contributing to the network estimate of the main outcomes by means of the GRADE framework. The five GRADE domains were applied: study limitations, indirectness, inconsistency (heterogeneity and incoherence), imprecision and publication bias by Confidence in Network Meta-Analysis (CINeMA), a web application that simplifies evaluation of confidence in the findings from an NMA.Conventional pairwise meta-analysis for each outcome was performed using a random effects model for each treatment comparison with at least two studies.For the network analysis, according to the PRISMA-NMAs,To ensure transitivity and enough statistical power for robust conclusions, a sufficient number of trials and treatment comparisons with sufficient data were evaluated. Judgement of treatments’ network connection was presented and evaluated graphically by network plot.Transitivity is the assumption that the distributions of effect modifiers (covariates associated with intervention effects) are balanced across comparisons in the network in order to allow the estimation effects for indirect comparisons.After checking the shared nodes in the compared interventions and covariates for any effect modifiers, we assumed that people with NS-LBP meeting the inclusion criteria were, in principle, equally likely to be randomised to any of the eligible NS-LBP interventions.mvmeta command and network graphs package.Random effects NMA within frequentist setting was conducted for connected networks.Results were summarised using the standardised mean differences (SMDs) when different outcome measurements were reported for each trial. The uncertainty of all estimates is expressed with their 95% CI. Details on the analyses are provided in the published protocol.Variation in treatment effects between studies  and variation between direct and indirect sources of evidence  are two concepts related to the inconsistency.2 test). If the null hypothesis of inconsistency parameters being equal to zero was not rejected, we fit a consistency model. We presented local inconsistency estimates using forest plots and side-splitting for direct and indirect estimates in each available comparison  estimated by using NMA models.mparison . When glmetareg command in Stata using aggregate-level data to examine relationship between treatments effects and each specified covariate .We performed network meta-regression random effects within a frequentist framework with When inconsistency remains unexplained by meta-regression, we explored the treatments effects performing subgroup analyses into pharmacological and non-pharmacological interventions groups.After removal of duplicates, 6779 records were retrieved and 6389 records were discarded. The full text of the remaining 390 records was examined and 344 did not meet the inclusion criteria: 95 involved a different study population , 82 had mixed treatments , 25 described interventions not pertinent to the present study , 27 were head-to-head interventions , 10 reported outcomes not pertinent to the present study , 33 had a study design other than RCT, 8 were further duplicates, 25 were protocols, 16 were awaiting assessment for language  and in 23 instances the full text could not be retrieved. In total, 18 authors were contacted; four of the eight who responded provided useful data for our analysis. Finally, 46 studies were included  with a median of 39.5 participants each. Most studies involved people with acute NS-LBP . Overall, 22 were multicentre and 24 were single-centre trials. The median year of publication of RCTs was 2003 (IQR 1995–2013). The median age of participants was 40.4 years old (IQR: 37–43) and the median percentage of males was 52% (IQR 43.7%–60%)Pain was assessed in 35 studies at immediate-term (1 week) of follow-up, in 16 studies at 1 month, in 13 studies at 3–6 months and in 9 studies at 12 months. No evidence of publication bias was present . Under cUnder consistency , the NMA of pain at short-term (1 month)  , the NMA of pain at long-term (12 months)    , the NMA of disability at long-term (12 months)  reported adverse events. No events were reported for acupuncture, education, exercise or manual therapy. Mild-moderate events occurred with the use of heat wrap, muscle relaxants, NSAIDs, opioids, paracetamol, steroids and inert treatment. No study reported treatment-related disabling events or death and only one reported three severe adverse events (one in the NSAIDs arm and two in the inert treatment arm). Mild or moderate adverse events occurred most often in the opioids (65.7%), the NSAIDs (54.3%) and the steroids arm (46.9%). But because adverse events reporting was heterogeneous for number of people with NS-LBP and number of events, we cannot quantitate these data .We incorporated the GRADE judgments in To our knowledge, this is the largest NMA to date in the field of low back pain . We found that pharmacological and non-pharmacological interventions were more efficacious than inert treatment for reducing pain intensity and disability due to acute and subacute mechanical NS-LBP. Overall, the certainty of evidence ranged from very low to moderate, with high certainty of evidence for manual therapy compared with usual care and education.For reducing pain intensity, the most efficacious interventions at immediate-term follow-up (close to 1 week) were heat wrap, manual therapy, exercise, NSAIDS and opioids, whereas at short-term follow-up (closest to 1 month), the most efficacious treatment was manual therapy. For reducing disability, similar findings are found in the subgroup analysis showing that heat wrap, manual therapy, exercise and education for non-pharmacological group and muscle relaxants and NSAIDs for pharmacological group are effective at immediate-term follow-up. Manual therapy confirmed the effects also for decreasing disability at short-term follow-up (closest to 1 month). Limited evidence was found for steroids when compared with NSAIDs (one study) to reduce disability.The present analysis highlights a potentially minor role for medicines in the management of NS-LBP: initial treatment should be non-pharmacological as confirmed by the SUCRA. However, only a minority of pharmacological interventions are included in the networks. In particular, steroids and opioids are under-represented (only three studies) and their desirable effects should be weighed against side effects. In fact, mild or moderate adverse events were most often recorded for the opioids, the NSAIDs and the steroids arms. This observation is shared by recent systematic reviews that found that at least 50% of people with NS-LBP taking opioids withdrew from the study owing to adverse events or lack of efficacy,Given that paracetamol offer limited or no benefit, its clinical value might be questionable. This finding is not reflected in all current guidelines, however.Also, our data support the National Institute for Health and Care Excellence (NICE) 2016 guideline which recommend the use of NSAIDs for acute low back pain and weak opioids when NSAIDs are ineffective or poorly tolerated.Moreover, two recent systematic reviews that found evidence for reducing pain and disability with the use of muscle relaxants recommended caution in interpretation of the findings as the evidence cannot be generalised because only two muscle relaxants were studied.Although the authors of previous published systematic reviews on spinal manipulation,We noted other limitations in our analysis. We excluded head-to-head comparisons of the same intervention since we did not aim to inspect different characteristics of delivery . This was an example of our narrow inclusion criteria, set at the protocol stage, in order to obtain a homogenous sample, preventing intransitivity.We addressed clinically important endpoints for recovery from episodes of low back pain; however, we did not include other endpoints possibly relevant for people with NS-LBP, such as health-related quality of life, social participation or return to work.Ultimately, understanding the balance between benefits and harms of non-pharmacological and pharmacological interventions is a key step to better serving people with NS-LBP. After first line of care, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability in the first week. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best net balance at immediate-term for pain and disability.Non-specific low back pain (NS-LBP) is a leading cause of pain and disability worldwide.Among the therapeutic interventions for NS-LBP, it is not clear which intervention offers the best benefit–harm balance.Uncertainty in the management of NS-LBP is reflected in the often discordant guideline recommendations.Among non-pharmacological interventions, pain and disability reduction were best achieved by heat wrap, manual therapy and exercise at immediate-term of follow-up.Among pharmacological interventions, pain and disability reduction were best achieved by NSAIDs and muscle relaxants at immediate-term of follow-up.Paracetamol had no benefit over inert treatments at any follow-up assessment; evidence was largely uncertain.10.1136/bjsports-2020-103596.supp2Supplementary data


Post-HCT, fewer FMT-MDRO patients required intensive care  or experienced fever . Intestinal MDRO decolonization occurred in 25% of FMT-MDRO patients versus 11% non-FMT MDRO patients. Despite the significant differences and statistically comparable patient/transplant characteristics, as the sample size was small, a matched-pair analysis between both groups to non-MDRO colonized control cohorts (2:1 matching) was performed. At 12 months, the MDRO group who did not have an FMT had significantly lower survival , and higher non relapse mortality  than their paired non-MDRO-colonized cohort. Conversely, there was no difference in survival  or NRM  between the FMT-MDRO group and their paired non-MDRO cohort. Collectively, these data suggest that negative clinical outcomes, including mortality associated with MDRO colonization, may be ameliorated by pre-HCT FMT, even in the absence of intestinal MDRO decolonization. Further work is needed to explore this observed benefit.The gut microbiome can be adversely affected by chemotherapy and antibiotics prior to hematopoietic cell transplantation (HCT). This affects graft success and increases susceptibility to multidrug-resistant organism (MDRO) colonization and infection. We performed an initial retrospective analysis of our use of fecal microbiota transplantation (FMT) from healthy donors as therapy for MDRO-colonized patients with hematological malignancy. FMT was performed on eight MDRO-colonized patients pre-HCT (FMT-MDRO group), and outcomes compared with 11 MDRO colonized HCT patients from the same period. At 12 months, survival was significantly higher in the FMT-MDRO group (70%  A more  pattern . In addion (CDI) , which ion (CDI)  and has on (CDI) . As suchon (CDI)  and MDROon (CDI) .via an initial retrospective analysis and subsequent case-control cohort study, we further evaluate the impact of FMT upon those MDRO-colonized patients with hematological malignancy, with regards to clinically-relevant hematological outcomes, including survival.In our recent observational study, we reported improved outcomes post FMT from an infection perspective in immunocompromised patients  colonized with MDROs , includivia rectal swab or stool screening via culture or PCR since 2015, and also during the course of their admission .This study was performed in a single center with approximately 1500 inpatient beds. We have been routinely screening all HCT recipients for MDRO prior to admission for HCT dmission . The aimThe study was approved by a UK Research Ethics Committee (REC reference: 19/LO/0112). All patients, including patients used as controls, provided informed consent authorizing the use of their personal information for research purposes. MDRO was defined as extended-spectrum beta-lactamase-producing Enterobacteriaceae, vancomycin-resistant enterococci, or carbapenem-resistant Enterobacteriaceae.In patients with MDRO intestinal colonization  during previous chemotherapy who were scheduled for HCT. Antibiotics were not given to patients as selective digestive decontamination of their colonizing MDRO. FMT was planned to be performed 2-6 weeks before initiation of the transplant conditioning regimen. At the time of FMT, patients had to be clinically infection-free and off antibiotic therapy.C. difficile infection. FMT recipients all received bowel purgatives on the day prior to the procedure, using a polyethylene glycol (PEG)-based preparation. Patients were administered oral proton pump inhibitor on the night prior to and the morning of the procedure and received metoclopramide approximately 30 minutes prior to FMT administration. Nasogastric tube insertion was performed either on the night before or morning of the procedure, with positioning confirmed using chest radiograph. The FMT used in all procedures had been previously prepared in house anaerobically and stored at -80°C for less than six months, using 10% w/v glycerol as cryopreservative  being a secondary endpoint. Probabilities of survival were calculated using the Kaplan–Meier method, with the log-rank test utilized for comparison of groups; probabilities of NRM were calculated using the cumulative incidence procedure, with disease progression being the competing risk. Gray’s test was used to compare groups. Days of fever were normalized for days of hospital admission, and compared by unpaired, non-parametric testing (Mann–Whitney U-test).P-values <0.05 were taken as statistically significant.Patient and transplant characteristics were compared using Fisher’s exact test and the Mann-Whitney U-test as appropriate. Statistically, whilst there were no differences in many key clinical variables between the MDRO-colonized patients who underwent FMT (‘FMT MDRO group’) and MDRO-colonized patients who did not have FMT , acute myeloid leukemia and advanced myelodysplastic syndrome (n=10), chronic myeloid leukemia (n=4), T-cell non-Hodgkin lymphoma (n=2). HCT was performed using peripheral blood progenitor cells from an HLA matched sibling (n=7), unrelated donors (n=8) and HLA haploidentical family donors (n=4). Myeloablative conditioning was used in 5 patients, while 14 patients received reduced intensity conditioning.Nineteen patients were colonized with an MDRO prior to an allogeneic HCT. These patients were transplanted for hematological malignancies including acute lymphoblastic leukemia (Eight of the 19 MDRO-colonized patients (‘MDRO-patients’) received FMT (‘FMT MDRO group’); FMT was well-tolerated in all cases, and no adverse events of note were observed that were attributable to the FMT. In seven of these patients, FMT was performed as originally planned 2-6 weeks prior to starting transplant conditioning therapy. None of these patients received antibiotic therapy between the FMT and hematopoietic cell infusion. In one patient, FMT was delayed until three days after the hematopoietic cell infusion due to pre-transplant infection requiring antibiotic therapy. Eleven of the 19 MDRO-colonized patients did not receive FMT (‘No FMT MDRO’ group). Demographics and HCT characteristics of these two groups are provided in p=0.044, versus 46%, p=0.045). MDRO-patients undergoing FMT had fewer days of fever when normalized for the number of admission days  for the whole cohort of MDRO-patients, the probability of survival at 12 months post-HCT was 51.0%. The probability of survival of MDRO-patients who underwent FMT was 70% at 12 months, compared to 36% in MDRO-patients who did not , and one MDRO-patient’s blood cultures were sterile during the two weeks prior to death.Causes of death were classified as clinical infection in one MDRO-patient in the FMT group, and in five MDRO-patients in the No FMT MDRO group. One additional patient in the No FMT MDRO group died of infection on a background of graft-Two of eight (25%) MDRO-patients who underwent FMT achieved MDRO de-colonization; in one MDRO-patient, a new MDRO  became detectable. Two of eleven (11%) MDRO-patients in the No FMT MDRO group spontaneously decolonized, and in one MDRO-patient a new MDRO  became detectable.Even though there were no statistically significant differences in MDRO-patient and HCT characteristics between the FMT and No FMT MDRO groups , but there was no significant difference in NRM between the FMT MDRO group (12.5%) and their matched controls .The No FMT MDRO group had significantly lower survival than their paired cohort not colonized with MDRO  in comparison to antibiotic-treated patients . As such, to add robustness to interpretation, we went on to perform matched pair/case control cohort study with a strict matching strategy in an attempt to minimize any bias. There is a clear indication for further prospective, randomized studies to further investigate the clinical findings here. Further work is also needed to explore the biological explanations for the observed benefit of this therapy, and integrative studies of the interplay of gut microbial profile, their metabolites and gut barrier function are an important next step.Our study had certain limitations. The size of our initial cohort was small and non-randomized, with certain discrepancies in clinical characteristics between MDRO-colonized patients who received FMT While our experience has been accrued in patients with detectable MDRO in the intestinal microbiome, we hypothesize that these benefits may be more broadly applicable. Due to their previous exposure to broad spectrum antibiotics, chemotherapy, and/or the underlying disease process itself, prospective HCT recipients are recognized to have a relative decrease in diversity of commensal bacteria which are recognized to play a role in immune recovery . As suchThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by UK Research Ethics Committee (REC reference: 19/LO/0112). The patients/participants provided their written informed consent to participate in this study.BM and RG performed all FMTs. AJI, JA, EO, RP, EK, DM, EB, FD, and JP were involved in selection and care of patients. AI, BHM, RG, RS, JAM, MT, HW, JRM, and JP were involved in the design of this study. AJI, BHM, RG, RS, FD, JRM, and JP analyzed data and wrote manuscript. All authors were involved in review of and critical input into the final manuscript. All authors contributed to the article and approved the submitted version.The Department of Metabolism, Digestion and Reproduction, and the Centre for Haematology at Imperial College London receive funding from the National Institute of Health Research (NIHR) Biomedical Research Centre (BRC) based at Imperial College London and Imperial College Healthcare NHS Trust. BM and AI are the recipients of NIHR Academic Clinical Lectureships, and BM was previously the recipient of a Medical Research Council (MRC) Clinical Research Training Fellowship (grant reference: MR/R000875/1). JA is a NIHR Senior Investigator, FD receives funding from the Medical Research Council (MRC) Clinical Academic Research Partnership Scheme, and JAM was the recipient of a Wellcome Trust Institutional Strategic Support Fund Springboard Fellowship.BM reports consultancy fees from Finch Therapeutics Group, outside the submitted work. JRM reports consultancy fees from Enterobiotix Ltd., outside the submitted work.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The measures consisted of a psychiatric evaluation, objective sleep monitoring measured by an actigraph for 1 week, a subjective sleep self-report, and ED-related psychopathology questionnaires. Results: Objective sleep monitoring revealed significant group differences, with higher sleep efficiency in participants with BE-only and longer sleep durations for the NES-NI only group. Subjectively, the BE-only group described a significantly lower sleep quality than either the NES-NI only or the NES+BE groups. ED-related psychopathology was lower in the NES-NI-only group. A stepwise linear regression revealed that general psychopathology  was a significant predictor of subjective sleep quality. Conclusion: NES-NI-only was correlated with less psychopathology, but with more subjective and objective sleep disturbances. These results lend weight to the supposition that NES lies on a continuum of ED psychopathologies, and that NES-NI-only appears to be a separate entity from NES+BE and BE-only in terms of its psychopathology.Night eating syndrome (NES) is an eating disorder (ED) characterized by nocturnal ingestion (NI), evening hyperphagia, morning anorexia, as well as mood and sleep disturbances. This study compared subjective and objective sleep quality and ED-related psychopathologies in patients seeking treatment for ED. Method: The sample was composed of 170 women, aged 18–68, who were referred for an ED assessment from 2011 to 2020. The participants were divided into three subgroups: NES-NI only ( Night eating syndrome (NES) is a clinical entity characterized by both eating and sleeping disorders. NES was initially described by Stunkard in 1955 and is characterized by night ingestion (NI), evening hyperphagia (EH), morning anorexia, insomnia, declining mood that worsens in the evening, and emotional distress  who were referred to an ED institution in Israel for an ED assessment between 2011 and 2020.The exclusion criteria were individuals with SRED (based on a diagnosis of a sleeping disorder) , AN  included individuals diagnosed with NES ,  divided by height squared [m2]) and wake-up time . The participants provided signed informed consent.Data were gathered during evaluation meetings. Patients underwent a full clinical psychiatric assessment using the mini international neuropsychiatric interview  eating in the evening after dinner (EH) or waking up to eat during the night (NI), at least twice a week, and awareness of eating. In addition, at least three of the following characteristics were mandatory: morning anorexia, a desire to eat after dinner and after sleep onset, or in the middle of the night, insomnia, a belief that one should eat in order to fall asleep, and a depressed mood mainly during the evening. For inclusion, NES needed to have been linked to substantial emotional distress, for at least three consecutive months, and not be due to medical or other psychiatric disorders. After completing the psychiatric assessment, age, sex, weight, and height information was retrieved.Patients who agreed to participate in the study filled out self-report questionnaires and were given an actigraph to wear on their non-dominant wrist to monitor sleep for at least 5 days and nights. After returning the actigraph and the self-reported sleep questionnaire, the principal investigator analyzed sleep quality using the AW2 program . ThereafParticipants provided age, height, and weight data.The MINI-SCID is a structured diagnostic interview used to investigate 17 disorders corresponding to the DSM-IV. Comparison of the MINI-SCID with clinical psychiatric assessment according to DSM-IV for eating disorder diagnosis showed good sensitivity (0.92), and specificity (0.99) .The Pittsburgh Sleep Quality Index (PSQI) ,48 is a Objective sleep quality was assessed by actigraph , a small movement sensor that continuously records body motility data for long periods of time. The actigraph accumulates movements in bins of 1 min which cause the sensor signal to cross a fixed reference signal. Sleep/wake measures were estimated from actigraphy data using a validated algorithm. . The actOverall agreement rates with polysomnographic scoring range from 91% to 93% for the calibration and validation samples. Previous studies indicate that the actigraphs vary considerably in their sensitivity. Nevertheless, the validation results indicated that for normal subjects the agreement rates between the actigraph-based and polysomnographic recording, based minute-by-minute sleep wake scoring were above 90% . The actThe Beck Depression Inventory (BDI) 34], BED A stepwise linear regression revealed that general psychopathology (BSI) was a significant predictor of subjective sleep disturbances (PSQI) and explained 15.2% of the variance. This strengthens the assumption that subjective sleep quality is associated with the level of psychopathology rather than objective sleep quality, and is in line with previous results on patients with ED ,34,38,68A number of limitations should be taken into consideration. A larger sample size would have better differentiated between NES-NI and NES-EH, and the identification of possible differences in psychopathology and sleep patterns between groups. It is important to note that BED and NES-EH with binge episodes during the evening may meet the dual diagnostic criteria of both BED and NES and may confuse clinicians. Therefore, further research is needed to justify classification of NES-EH and NES-NI, given that NES currently includes both, since NES-EH is similar to BED and may be part of this diagnosis, whereas NES-NI could be a separate diagnosis.Secondly, an actigraph was used to evaluate objective sleep patterns. This procedure has been widely used in the last 30 years in studies estimating objective sleep patterns in populations with ED. However, it cannot describe all objective sleep disturbances; hence, further research with more detailed measurements such as polysomnographic recordings of sleep disturbances and sleep stages is suggested to further identify similarities and differences in sleep–wake cycles among ED groups.Finally, the current sample consisted of patients who were seeking treatment for ED, and who may tend to exhibit higher levels of psychopathology than those seeking treatment in non-clinical centers, usually for weight loss. Further research is needed on individuals with NES in a nonclinical sample that may help account for the differences between patients with ED and NES. It may also better situate NES on the ED psychopathology spectrum.The current study assessed objective and subjective sleep quality and level of ED-related psychopathology in patients seeking treatment for ED (BN or BED with and without NES and NES-NI only) using the newly suggested diagnostic criteria for NES ,3. It alThe NES groups (NES+BE and NES-NI) showed significantly poorer sleep quality and had significantly worse sleep efficiency than the BE-only group. In terms of psychopathology, body image, and social phobia were significantly lower in the NES-NI-only group. Subjective sleep quality was predicted by the level of psychopathology (BSI) and the ED group, in that subjective (vs. objective) sleep quality was associated with an increased level of psychopathology, mainly in the NES+BE and NES-NI groups.Overall, these results highlight the importance of a clearer clinical grasp and early evaluation of NES, subjective sleep disturbances, and levels of psychopathology in individuals with ED.


Introduction: Alzheimer’s disease (AD) is a major cause of the development of cognitive decline and dementia. AD and associated dementias (ADRD) are the major contributors to the enormous burden of morbidity and mortality worldwide. To date, there are no robust therapies to alleviate or cure this debilitating disease. Most drug treatments focus on restoring the normal function of neurons and the cells that cause inflammation, such as microglia in the brain. However, the role of astrocytes, the brain’s housekeeping cells, in the development of AD and the initiation of dementia is still not well understood.Objective: To decipher the role of astrocytes in the entorhinal cortex of AD patients using single nuclear RNA sequencing (snRNASeq) datasets from the Single Cell RNA-seq Database for Alzheimer’s Disease (scREAD). The datasets were originally derived from astrocytes, isolated from the entorhinal cortex of AD brain and healthy brain to decipher disease-specific signaling pathways as well as drugs and natural products that reverse AD-specific signatures in astrocytes.Methods: We used snRNASeq datasets from the scREAD database originally derived from astrocytes isolated from the entorhinal cortex of AD and healthy brains from the Gene Expression Omnibus (GEO) (GSE138852 and GSE147528) and analyzed them using next-generation knowledge discovery (NGKD) platforms. scREAD is a user-friendly open-source interface available at https://bmbls.bmi.osumc.edu/scread/that enables more discovery-oriented strategies. snRNASeq data and metadata can also be visualized and downloaded via an interactive web application at adsn.ddnetbio.com. Differentially expressed genes (DEGs) for each snRNASeq dataset were analyzed using iPathwayGuide to compare and derive disease-specific pathways, gene ontologies, and in silico predictions of drugs and natural products that regulate AD -specific signatures in astrocytes. In addition, DEGs were analyzed using the L1000FWD and L1000CDS2 signature search programming interfaces (APIs) to identify additional drugs and natural products that mimic or reverse AD-specific gene signatures in astrocytes.Results: We found that PI3K/AKT signaling, Wnt signaling, neuroactive ligand-receptor interaction pathways, neurodegeneration pathways, etc. were significantly impaired in astrocytes from the entorhinal cortex of AD patients. Biological processes such as glutamate receptor signaling pathway, regulation of synapse organization, cell-cell adhesion via plasma membrane adhesion molecules, and chylomicrons were negatively enriched in the astrocytes from the entorhinal cortex of AD patients. Gene sets involved in cellular components such as postsynaptic membrane, synaptic membrane, postsynapse, and synapse part were negatively enriched (p < 0.01). Moreover, molecular functions such as glutamate receptor activity, neurotransmitter receptor activity, and extracellular ligand-gated ion channels were negatively regulated in the astrocytes of the entorhinal cortex of AD patients (p < 0.01). Moreover, the application of NGKD platforms revealed that antirheumatic drugs, vitamin-E, emetine, narciclasine, cephaeline, trichostatin A, withaferin A, dasatinib, etc. can potentially reverse gene signatures associated with AD.Conclusions: The present study highlights an innovative approach to use NGKD platforms to find unique disease-associated signaling pathways and specific synthetic drugs and natural products that can potentially reverse AD and ADRD-associated gene signatures. Alzheimer’s disease (AD) is a major cause of the development of cognitive decline and dementia in the elderly . AD-relaAD is a neurodegenerative disease of the brain , and symAD and ADRD pathology differ by brain region, cell type, age, and gender . Genome-Recent advances in NGS applications such as single-cell RNA sequencing (scRNA-Seq) have enabled researchers to study and understand the dynamic transcriptomic profile of individual cells in brain tissue or other biological samples. RNA-sequencing of posterior cingulate astrocytes (PC) in AD patients revealed differential expression of mitochondria-related genes, including TRMT61B, FASTKD2, and NDUFA4L2. In addition, immune response genes such as CLU, C3, and CD74 were identified to play a central role in the generation or clearance of amyloid-beta . scRNASeThis study was exempt from Institutional Review Board (IRB) approval because it did not involve animal models or human subjects. It was performed using DEGs derived from the Single Cell RNA-seq Database for Alzheimer’s Disease (scREAD) based on publicly available and previously published single nucleus RNA sequencing datasets from the Gene Expression Omnibus (GEO).https://bmbls.bmi.osumc.edu/scread/to enable more discovery-oriented strategies  (GSE138852 and GSE147528). scREAD is a user-friendly open-source interface available at rategies . Datasetrategies . scREAD rategies . All snRadsn.ddnetbio.com  are available via an interactive web application at tbio.com . The chatbio.com .p-value cut-off of 0.05, and log2 fold change (Log2Fc) of ±0.3 in iPathwayGuide Software  to obtain 739, 241, and 639 DEGs. Further analysis of these DEGs using iPathwayGuide software showed that 93 DEGs were commonly regulated in all disease groups   compared with the healthy control group (AD00201). DEGs of AD groups  were further filtered using a e groups . The Kyoe groups , and thee groups  was usede groups . The iPae groups  to obtaite (FDR) . and Bonte (FDR) . The p-vrections .p-value was computed corresponding to the z-score Pz (One-Tailed) under the probability density function for a normal distribution, N   a network of connections or interactions from the Advaita Knowledge Base . The iPa N  .p-value) based on the number of consistent DE genes in the iPathwayGuide analysis. The Ppres  was calculated based on the hypergeometric distribution  genes, CDT u, DE genes downstream of u, DTA (u) were compared to measured target genes predicted by chance to be both DE and consistent. An over-representation method was applied to calculate the statistical significance  was calculated based on the hypergeometric distribution  was compared to the measured target genes predicted by chance to be both DE and consistent. The Pabs (ribution . Then thribution .DEGs were subjected to L1000 Fire Works Display (L1000FWD) analysis using the L1000FWD signature search application programming interface (API)  to identIn the present study, snRNASeq datasets of astrocytes isolated from the entorhinal cortex region of AD patients and healthy brains were obtained from the scREAD database for NGKD platform analysis . The scRSalmonella infection, human papillomavirus (HPV) infection, and human T-cell leukemia virus infection in the astrocytes of the severe AD groups (p < 0.01). Neuroactive ligand-receptor interaction based on KEGG pathways was significantly downregulated (p < 0.01), and cellular function of the transporter complex was also negatively enriched (p < 0.01). Similarly, genes associated with glutamate receptor activity, neurotransmitter receptor activity, glutamate receptor signaling, heterophilic cell-cell adhesion via plasma membrane cell adhesion molecules, cell-cell adhesion via plasma membrane adhesion molecules, and behavior were also negatively enriched (p < 0.01) in astrocytes from AD patients  and AD  datasets  The 93 DD groups  comparedpatients . Importap < 0.05) signaling effect in the astrocytes of AD patients  based on the L1000CDSAD is a neurodegenerative disease of the brain and a major cause of the development of cognitive decline and dementia in the elderly . ADRD coSalmonella infection, HPV infection, and human T-cell leukemia virus infection in the astrocytes of severe AD groups. Previous studies have shown that infections with Salmonella (We observed that Wnt signaling and PI3K/AKT signaling pathways were dysregulated or impaired in astrocytes from the entorhinal cortex of AD patients. Wnt signaling is very important at the synapse and necessary for synaptic plasticity and maintenance in the brain . The PI3lmonella , HPV (Lilmonella , and humlmonella  are assoin vivo (We have previously shown that natural products such as albiziasaponin-A, iso-orientin, and salvadorin can ameliorate the pathologies associated with AD in vivo  and thatin vivo . In addiin vivo . Therefoin vivo  and recein vivo . Our finin vivo  and our in vivo . The isoin vivo . Withafein vivo . Narciclin vivo . A recenin vivo . The hisin vivo  increasein vivo . Trichosin vivo . Importain vivo . HoweverThe present study provides a valuable method for analyzing snRNASeq datasets deposited in open-source repositories with NGKD platforms to decipher AD -specific pathways, genes, and drugs from synthetic and natural sources for the amelioration of AD-related disease pathologies such as ADRD. However, further studies are required to confirm these drugs and natural products that reverse the gene signatures of AD using appropriate experimental models to deduce the precise mechanisms of action, followed by appropriate clinical trials to evaluate the safety and efficacy of the likely therapeutic interventions for AD and ADRD in a typical clinical milieu. Our innovative approach of applying NGKD platforms to uncover AD-specific pathways and potential drugs and natural products that reverse the AD-specific signatures could be useful in the future for developing personalized medicine for AD patient care.


Self-compassion, sharing some commonalities with positive psychology 2.0 approaches, is associated with better mental health outcomes in diverse populations, including workers. Due to the COVID-19 pandemic, there is heightened awareness of the importance of self-care for fostering mental health at work. However, evidence regarding the applications of self-compassion interventions in work-related contexts has not been systematically reviewed to date. Therefore, this systematic review aimed to synthesize and evaluate the utility of self-compassion interventions targeting work-related well-being, as well as assess the methodological quality of relevant studies. Eligible articles were identified from research databases including ProQuest, PsycINFO, Science Direct, and Google Scholar. The quality of non-randomized trials and randomized controlled trials was assessed using the Newcastle-Ottawa Scale and the Quality Assessment Table, respectively. The literature search yielded 3,387 titles from which ten studies met the inclusion criteria. All ten studies reported promising effects of self-compassion training for work-related well-being. The methodological quality of these studies was medium. All ten studies recruited workers in a caring field and were mostly conducted in Western countries. The Self-Compassion Scale or its short-form was used in almost all instances. Findings indicate that self-compassion training can improve self-compassion and other work-related well-being outcomes in working populations. However, in general, there is need for greater methodological quality in work-related self-compassion intervention studies to advance understanding regarding the applications and limitations of this technique in work contexts. Furthermore, future studies should focus on a broader range of employee groups, including non-caring professions as well as individuals working in non-Western countries. In the United Kingdom, workplace mental health problems resulted in 16 million lost working days in 2016  pandemic. For example, a recent literature review identified that workplace stress and depression were associated with the pandemic due to threat and worry about contagion, infobesity , quarantine and reduction of social contact, stigma, and job insecurity , a new form of positive psychology that aims to attain the best in individuals, organizations and society, by communicating with the dark side of human existence through an understanding of ying-yang dialectical principles, rather than a liner interpretation of happiness as characterized by traditional first wave positive psychology approaches Wong, . All emoNotwithstanding the aforementioned challenges for mental health in the workplace as well as the promising findings for self-compassion as a remedial approach, a systematic review specifically focusing on the evidence for self-compassion interventions in a workplace context has not been undertaken to date. Therefore, the purpose of this paper was to conduct a systematic review of self-compassion interventions focusing on outcomes relating to improving workplace well-being.A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses , papers that had “work*,” “occupation*,” “profession*,” “staff,” “job,” “employee*,” “management,” “business,” and “organization*” in the title or abstract were shortlisted for further examination (n = 203). The selection of such terms was informed by prior systematic reviews evaluating psychological interventions in the workplace  be published in a peer-reviewed academic journal written in English language, (ii) report an empirical intervention study  of a self-compassion intervention, and (iii) involve full-time or part-time workers as participants. Papers were excluded if they (i) did not evaluate an intervention , (ii) employed a single-participant design , and/or (iii) did not assess work-related well-being outcomes see .Annual Review of Organizational Psychology, Organizational Behavior, and Human Resource Development Quarterly) during the last 5 years . The second author reviewed the selection process to minimize any potential bias. Once the second author had reviewed the selection process, full-texts of the shortlisted articles were examined by both authors independently, who then met to discuss which studies met the eligibility criteria. Forward and backward reference searches of relevant articles identified no additional eligible studies.The lead author comprehensively reviewed all the search results, and if the title of the article implied a fit with the eligibility criteria, the articles were shortlisted for possible inclusion  was used to appraise the methodological quality and risk of bias for non-randomized studies  for “yes,” blank for “no,” and “NA” for “not applicable,” as the primary interest was whether each research item was adequately reported. These assessments were performed by both of authors independently, who discussed any disagreement. The star rating ranged from 0 to 14; high risk: 0-4, medium risk: 5-9, low risk: 10-14.The Quality Assessment Table of Randomized Controlled Trials .Six studies were conducted in Europe  recruited more females than males, including one study that recruited women only Delaney, . The samParticipants in eight studies worked in healthcare fields including doctors, nurses, social workers, human service professionals, and disability support workers  how effective self-compassion is for work-related well-being outcomes, and (ii) what quantity and quality of evidence has been reported. Ten intervention studies (nine pre-post within-subject studies and one RCT), comprising a total of 512 participants, met all of the eligibility criteria for in-depth review and assessment. Self-compassion was shown to improve in all studies, including those deemed to be more methodologically robust (e.g., Beshai et al., The total length of the interventions varied from 1 to 60 h, however high-quality studies (Beshai et al., The majority of studies included in this review were conducted in Western countries. However, self-compassion can be perceived differently between cultures (Montero-Marin et al., In the studies included in this systematic review, self-compassion was measured using the SCS Neff,  and SCS-The quality of the included studies overall was medium: eight studies were assessed to bear a medium risk of bias (Rao and Kemper, per se, future systematic reviews could employ a broader definition of self-compassion.While this systematic review offers helpful insights into the applications of self-compassion in a workplace context, several limitations should be noted. Unpublished studies or studies not published in English language were not considered, meaning that some relevant evidence pertaining to self-compassion at work may have been overlooked. Furthermore, this review only included interventions that explicitly described the target intervention as incorporating a notable self-compassion component, and may thus have excluded studies of interventions where self-compassion is taught more implicitly. For example, positive reframing to provide compassionate views on one's own and others' weaknesses has been reported as an effective workplace technique by Japanese senior managers (Kotera and Van Gordon, The ten studies included in this systematic review indicate that self-compassion training can be effective for improving work-related well-being outcomes. However, research in this area is relatively new and has largely focused on key workers who work in caring and education professions, primarily in Western countries. Evaluating the applications of self-compassion in other work contexts is important because studies have shown that individuals working in, for example, construction, are not always comfortable with the self-compassion construct and relate it to more as self-pity (Kotera et al., The original contributions presented in the study are included in the article/YK: conceived, designed this systematic review, collected, and organized the data. YK and WVG: performed the analysis and wrote the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To quantitatively analyze retinal vascular morphological features, such as vascular density, caliber, and tortuosity, in rhegmatogenous retinal detachment (RRD).A total of 244 patients with RRD and 400 healthy controls (HC) were included. Retinal fundus images were collected using OPTOS PLC Daytona P200T. Retinal images were divided into RRD and non-RRD regions of interest (ROIs). All visible retinal fundus vessels were then extracted mainly based on edge detection within ROI to form the whole-vascular image. Retinal vasculature parameters, such as vascular density, caliber, and tortuosity, were calculated.p < 0.001). A consistent tendency of significant vascular density was increased from non-RRD to RRD (p < 0.001). The average and median diameters of normal controls were both significantly larger than RRD (p < 0.001). The average and median diameters were also appeared significantly thinner in non-RRD. Unweighted and width-inversely-weighted vascular tortuosity in RRD and non-RRD comparison exhibited non-significant differences. All types of tortuosity calculated from HC were significantly larger (p < 0.001) in values compared to RRD. All types of tortuosity values of HC were significantly higher than non-RRD. Compared with non-RRD, RRD was significantly larger in area-weighted, length-weighted, and width-weighted vascular tortuosity.For the absolute density, the mean rank (MR) value of normal controls was significantly higher than that in non-RRD (This study showed that RRD affects both the quantity and morphology of retinal vasculature, such as RRD and non-RRD areas. Smaller average and medium vascular diameters and tortuosity values were found in RRD. However, the absolute vascular density, the average and median diameter, and tortuosity values were also reduced in non-RRD although the retina is still attached. This work indicates that RRD may affect the retinal vasculature beyond the detached retina. Retinal detachment (RD) is a vision-threatening medical emergency, in which the neurosensory retina is separated from the retinal pigment epithelium (RPE). It often presents with a central or peripheral painless vision loss, flashes, or floaters. Rhegmatogenous retinal detachment (RRD) is the most common category of RD caused by a subretinal fluid due to retinal break, with an annual incidence of 13.3–42 cases per 100,000 inhabitants , 6. The This study was approved by the Medical Ethics Committee of Shenzhen Eye Hospital, Shenzhen, China. A total of 400 healthy control (HC) participants and 244 patients with pre-operative RRD were included. All retinal fundus images were collected using Optos cSLO (OPTOS PLC Daytona P200T) with a field of view of 200°.The highest incidence rate of RD was 0.042%, which WAS mentioned in the previous literature . We calcn represents the expected minimum sample size, z is a score transferred from a confidence level, p is the population proportion, and ε is the margin of error  and Red, Green, and Blue (RGB), we managed to extract different aspects of the character from the image. All images were pre-processed by HSV filter, which displayed superiority in sharpening bright area as represented by the optic disk when the value-channel (brightness) information is kept in the grayscale image. RGB filter enhanced the contrast between blood vessels and the background when the red-channel information was removed (red-free), whereas differences between the brightness of arteries and veins are most notable under green-channel (green-only). The red-free and green-only images were converted into the grayscale images, respectively. All visible retinal fundus vessels were then extracted mainly based on edge detection within ROI to form the whole-vascular image.The statistical analysis of vessels was based on vasculature parameters. They are vascular density, caliber, and tortuosity. Detailed calculation method could be found in Wang et al. .Absolute density was calculated based on the number of pixels within vessels, divided by corresponding ROIs. For the images of the patients, RRD and non-RRD ROIs were specialized settled for individual image. As for HC images, their ROI areas were the oval in the general cover.Vascular caliber-related parameters were computed based on segmented vessels and qualification of vascular segments. Criteria about inner segment's area and enclosing rectangle area; length of the long side of segment's minimum enclosing rectangle; and acute angle between this and the line passing through optic disk center; and the distance between nearest neighboring circle and optic disk center were settled to select vessel segments.The width of each caliber-computable vascular segment's minimum enclosing rectangle was considered the diameter of this vascular segment. Average and median diameters of all caliber-computable vascular segments were then computed as vascular average caliber and median caliber. These two parameters were computed on whole-vascular for all three groups of images, respectively, to acquire 2 vascular caliber-related parameters of each image.The computation of vascular tortuosity-related parameters relied on the identification of tortuosity-computable vascular segments and corresponding adjacent vascular segments. Such criteria were also similar with the qualification of computable caliber segments.Varies of tortuosity parameters were applied to capture different aspects of vascular tortuosity. They were unweighted, area-weighted, length-weighted, width-weighted, and width-inversely-weighted vascular tortuosity. Area-weighted tortuosity was a parameter combined length and width weighting information. Length-weighted tortuosity was mainly contributed as a calibration for bias due to small and large vessels due to the segmentation process. Width-weighted tortuosity was applied to eliminate different impacts on tortuosity due to the variant of vascular caliber. However, the width-inversely-weighted vascular tortuosity aimed at inversely eliminating the different impacts on tortuosity for the caliber variation compared to the width-weighted tortuosity. Equations for the computation process were mentioned below.Tnormal was computed as follows:Unweighted vascular tortuosity x represents the inter-segment angle of marginal vascular segment x, which is the acute angle between the lines parallel to the long sides of segment x and its unique adjacent segment's minimum enclosing rectangles, respectively. θy represents the inter-segment angle of intermediate vascular segment y, while θy1 and θy2 were acute angles between the line parallel to the long side of segment y's minimum enclosing rectangle and the lines parallel to the long sides of its two adjacent segments y1 and y2's minimum enclosing rectangles, respectively. n was the number of marginal and intermediate vascular segments. θi was the inter-segment angle of vascular segment i.θTarea was computed as follows to compensate for the unevenness of divided vascular segments (see reference 12 for details).Area-weighted vascular tortuosity Tlength was computed as follows to adjust variance among lengths of vascular segments (see reference 12 for details).Length-weighted vascular tortuosity Twidth was computed as follows to amplify the tortuosity of thick vessels (see reference 12 for details).Width-weighted vascular tortuosity Twidthinv was computed as follows to mainly reveal thin vessels' tortuosity (see reference 12 for details).Width-inversely-weighted vascular tortuosity Both comparisons of vessel parameters between HC vs. RRD ROIs, HC vs. non-RRD ROIs were performed by the non-parametric independent sample Mann-Whitney U test. On the contrary, comparisons of vessel parameters between RRD vs. non-RRD ROIs were applied by the non-parametric Wilcoxon signed-rank 2-tail test.The computed sample size was almost equal to 1 due to the relatively small incidence rate. Therefore, the number of cases in the present study largely exceeded the needs. A summary of the statistical result was illustrated below as radar plots . FurtherU scored as 40761.00 . Meanwhile, we speculated a consistent tendency of significant vascular density increased from non-RRD (MRRD<non−RRD = 117.98) to RRD (MRRD>non−RRD = 125.05) by the Wilcoxon test .As measured by absolute density, the mean rank (MR) value of the HC in our study was 342.60, which was significantly higher than that in non-RRD (MR = 289.55) with Mann-Whitney In summary, non-RRD ranks the smallest in the variation of absolute density among all HC, non-RRD, and RRD.MRaverage = 373.97, MRmedian = 374.25) were both significantly larger than RRD  with the Mann-Whitney test . Unsurprisingly, both caliber measurements, average and median diameters reflected common tendency. Moreover, the average and median diameters were also appeared significantly thinner  in non-RRD  compared with HC .Average and median diameters of HC (MRRD<non−RRD(average) = 121.03, MRRD<non−RRD(median) = 132.07) to RRD (MRRD>non−RRD(average) = 122.59, MRRD>non−RRD(median) = 113.23) was observed in both average and median diameter measures.However, no significant difference was found between RRD and non-RRD in vascular caliber-related parameters by the Wilcoxon non-parametric test, only a slightly tendency of increase from non-RRD  were always discovered to be significantly larger  in values compared to RRD , no matter which weighting method was conducted.Unweighted and width-inversely-weighted vascular tortuosity in RRD and non-RRD comparison exhibited non-significant differences. All types of tortuosity calculated from HC  significantly higher  than non-RRD , regardless of weighting methods.Similar to comparisons mentioned above, we found all types of tortuosity values of HC . In area-weighted tortuosity, MRRD>non−RRD = 124.61, MRRD<non−RRD = 119.30; whereas in length-weighted tortuosity, MRRD>non−RRD = 124.14, MRRD<non−RRD = 120.18. Last, in width-weighted vascular tortuosity, MRRD>non−RRD = 127.96, MRRD<non−RRD = 115.51.Compared with non-RRD, RRD was significantly larger in area-weighted, length-weighted, and width-weighted vascular tortuosity  for the publication of any potentially identifiable images or data included in this article. No potentially identifiable human images or data is presented in this study.XY, JZ, and JW conceived and designed the experiments. BF and WS performed the experiments. BF, WS, JW, XY, and JZ analyzed the data. BF, WS, XY, and JZ wrote the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the grants JCYJ20200109145001814 from the Research Foundation of Science and Technology Plan Project, Shenzhen, China, KQJSCX20180329171913184 from the High-level Overseas Talents Research Project, Shenzhen, China, Shenzhen Fund for Guangdong Provincial High-level Clinical Key Specialties (No.SZGSP014), and 81970790, 31771195, 81790640, 82021002 from the National Natural Science Foundation of China, a Shanghai Municipal Science and Technology Major Project (2018SHZDZX01), ZJLab and Shanghai Center for Brain Science and Brain-Inspired Technology, Sanming Project of Medicine in Shenzhen (SZSM202011015), Research and Development Fund of Zhongshan Hospital (2020ZSFZ19).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Even within a single type of cancer, cells of various types exist and play interrelated roles. Each of the individual cells resides in a distinct microenvironment and behaves differently. Such heterogeneity is the most cumbersome nature of cancers, which is occasionally uncountable when effective prevention or total elimination of cancers is attempted. To understand the heterogeneous nature of each cell, the use of conventional methods for the analysis of “bulk” cells is insufficient. Although some methods are high-throughput and compressive regarding the genes being detected, the obtained data would be from the cell mass, and the average of a large number of the component cells would no longer be measured. Single-cell analysis, which has developed rapidly in recent years, is causing a drastic change. Genome, transcriptome, and epigenome analyses at single-cell resolution currently target cancer cells, cancer-associated fibroblasts, endothelial cells of vessels, and circulating and infiltrating immune cells. In fact, surprisingly diverse features of clonal evolution of cancer cells, during the development of cancer or acquisition of drug resistance, accompanied by corresponding gene expression changes in the circumstantial stromal cells, appeared in recent single-cell analyses. Based on the obtained novel insights, better optimal drug selection and new drug administration sequences were started. Even a remaining concern of the single cell analyses is being addressed. Until very recently, it was impossible to obtain positional information of cells in cancer via single-cell analysis because such information is lost during preparation of single-cell suspensions. A new method, collectively called spatial transcriptome (ST) analysis, has been developed and rapidly applied to various clinical specimens. In this review, we first outline the recent achievements of single-cell cancer analysis in analyzing the molecular basis underlying the acquisition of drug resistance, particularly focusing on the latest anti-epidermal growth factor receptor tyrosine kinase inhibitor, osimertinib. Further, we review the currently available ST analysis methods and introduce our recent attempts regarding the respective topics. A detailed understanding of cellular diversity and constituting ecosystems of cancers is expected to serve as a foundation for cancer eradication and control. Particularly, heterogeneity of cancer cells derived from clonal evolution during anticancer drug treatment is directly related to drug resistance and thus is crucial for treatment success. The selection of the optimal drug and drug administration procedure is not always based on molecular evidence, considering the possible emergence of drug-resistant cells. To this end, conventional omics analysis approaches such as RNA-seq, chromatin immunoprecipitation sequencing (ChIP-seq), and whole-genome/exome sequencing (WGS/WES) have limited power, although they may be comprehensive regarding the covered genes and genome. These methods usually use the “bulk” for the material. Inherently, they measure the average value of a large number of component cells; therefore, they cannot detect the behavior of minor cells or the presence of heterogeneous cellular populations therein. For this purpose, an individual cell analysis, so-called single-cell analysis, is needed. Indeed, several papers have been reported. For example, Kim et al. combined single-nucleus RNA-seq, single-nucleus DNA-seq (for copy number profiling), and bulk exome sequencing .Despite the substantial advantages of single-cell analysis, the current single-cell analytical methods have been argued against due to several drawbacks. The most significant drawback is that the positional information of various cells is lost when single cells are dissociated from the tissue. With this disadvantage, it is sometimes difficult to grasp the whole picture of the interconnected structure of the precancerous, cancer, drug-resistant, and transient cells of those stages. Spatial transcriptome (ST) analysis was recently developed to address this flaw. Here, we review recent single-cell analysis approaches for a better understanding of cancer heterogeneity. A particular focus will be placed on the molecular mechanisms underlying drug resistance. Additionally, we introduce ongoing ST analysis-based studies aimed at further exploring the spatial heterogeneity of cancer cells. Finally, perspectives on the integration of these two approaches are discussed.During cancer progression, tumor cells proliferate with an accumulation of genomic mutations. Single-cell genome sequencing is potentially the most direct method for analyzing intratumor heterogeneity and cancer evolution. However, it is practically impossible to obtain precise single-cell genome data simply because an individual human cell has only two DNA copies. In addition, substantial sequencing depth is needed to cover the entire human genome. Single-cell copy number analysis has been employed in several studies to elucidate cancer genomic diversity instead of in-depth whole genome sequencing. From relatively shallow genomic sequence data, an evolutionary model for each critical phase of cancer, including clonal proliferation, invasion, relapse, and metastasis, was successfully constructed –5. It waFurthermore, epigenomic and transcriptomic features change during cancer progression, providing a gene expression base for malignant phenotypes, such as dedifferentiation and epithelial-mesenchymal transition (EMT). scRNA-seq analysis is the most powerful tool for inferring the transition statuses of cancers. For this purpose, a computational method called pseudo-time analysis was employed. In glioblastoma, for example, transcriptomic heterogeneity and their transition during the differentiation of cancers have been analyzed. In 2014, Patel et al. reported scRNA-seq analysis using 430 primary glioblastomas cells. They classified cells at various stages as cells having stem-like to fully differentiated signatures . In receThere have been a large number of single-cell studies focusing on non-tumor cells and their microenvironment. The first study of such an approach, designated as a “cancer ecosystem” study, was conducted for metastatic melanoma , in whic+ T cells, regulatory T cells, dendritic cells, and tumor-associated macrophages (TAMs). For example, a research group at Stanford University reported immune cell profiling using scRNA-seq before and after anti-PD-1 treatment for basal cell carcinoma patients [In recent years, tumor-infiltrating lymphocytes (TILs) have received much attention. Their omics features might be associated with patient prognosis and efficacy of immunotherapies, such as immune checkpoint inhibitors (ICIs) . Numeroupatients . They fopatients  , which can process the data analysis from QC to enrichment analysis and provide detailed gene expression profiles. They compared SAKE with known scRNA-seq data analysis tools, SC3, Seurat, SINCERA, CIDR, and RaceID, and demonstrated its accuracy and robustness. They applied SAKE to reveal the mechanism of resistance to BRAF inhibitors using the Fluidigm C1 system, 10x Genomics Chromium, and bulk RNA-seq and indicated that a rare population of resistant cells to BRAF-i exists ab initio .SOX2 and SOX9 play a role in this drug-induced adaptation [Sharma et al. focused on the resistance mechanism of both phenotypically homogeneous and heterogeneous cell lineages using patient-derived primary oral squamous cell carcinoma (OSCC) cell lines. They showed that cells with high heterogeneity have an advantage in the selection of intratumor heterogeneity. In contrast, cells with high homogeneity utilize tumor evolution via epigenetic changes, and the stem cell factors aptation .Kim et al. conducted single-cell DNA/RNA analysis of breast cancer specimens before and after chemotherapy to elucidate that cancer cell heterogeneity is a cause of drug tolerance. Samples from 20 triple-negative breast cancer (TNBC) patients undergoing neoadjuvant chemotherapy (NAC) showed pre-existing and drug-induced selection of NAC-resistant tumor cells . SchneppJerby-Arnon et al. reported that there are multiple mechanisms of resistance to an ICI. They conducted scRNA-seq and bulk RNA-seq of 33 melanoma tumors. Based on the results, they demonstrated that their predictive biomarkers and combination therapy are effective .Collectively, it has been revealed that both of the following mechanisms are possible and have been observed: (i) the primary mechanism to acquire drug resistance is a series of genomic mutations and their clonal expansion at the same time as the clonal evolution for further fitting the niche; (ii) the tumor-forming cancer cells have a certain diversity, originally including already drug-resistant cells; and (iii) gene expression was reprogrammed after responding to chemotherapy and changed to a newly acquired expression profile.EGFR genes are detected in 10–30% of NSCLC cases. These mutations promote downstream pro-survival and anti-apoptotic signals [EGFR mutations show dramatic responses to first- and second-generation EGFR-TKIs, such as gefitinib and erlotinib, and afatinib and dacomitinib, respectively, the majority of patients subsequently acquire resistance within 2 years [Our study focused on the mechanism of resistance acquisition to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in non-small cell lung cancers (NSCLCs). Resistance to EGFR-TKIs in tumors is known to be complex. The most well-elucidated somatic mutations in the  signals , 24. Alt 2 years . Osimert 2 years , 27. We  2 years , 29. Fir 2 years . We also 2 years . Schemathttps://www.10xgenomics.com/products/single-cell-multiome-atac-plus-gene-expression).Until very recently, for the scRNA-seq and scATAC-seq analyses, the sample was prepared independently due to technical limitations. Therefore, it was impossible to associate epigenomic and transcriptomic features for each single cell directly. Recently, a novel method called GEX-ATAC sequencing has been developed. In this method, it is possible to conduct both scRNA-seq and scATAC-seq simultaneously for a given single cell. The representative commercial kit was released from 10x Genomics. Although most of the workflow for library preparation is similar to that of previous scRNA-seq or scATAC seq, GEX-ATAC employs several unique processes. First, GEX-ATAC utilizes nuclei as a material Fig. a. TherefAs described above, in a substantial number of cases for various cancer species, analyses have been performed to characterize the diverse behavior of individual cells in a given cancer. However, it has been argued that a novel approach is needed to quantify single cells that retain pathological spatial information. The field of ST analysis has emerged to address this issue. Recently, this field has expanded rapidly, and new methods have been developed one after another. These large numbers of methodologies have fundamentally different approaches, with advantages and disadvantages unique to each method and many issues to be resolved, such as dependence on sensitivity, effort, and organizational type. None of the single methods can use all of these important parameters. In this chapter, we outline the available ST analysis techniques in four groups according to the differences in their approaches: 1) microdissection-based, (2) in situ hybridization-based (ISH), (3) in situ sequencing-based (ISS), and (4) in situ capture-based (ISC). Table  microdisThe most robust method for obtaining spatial gene expression information is to perform gene expression profiling of the targeted areas visually specified from the tissues. In laser-capture microdissection (LCM), after physically excising the target area with a laser beam under a microscope, RNA is extracted in vitro, and the gene expression information is acquired , 34. In A method that physically resects and acquires localized spatial gene expression data and LCM thinly slices tissue samples and prepares individual sequencing libraries from each slice. In 2014, RNA tomography (tomo-seq) was performed, in which zebrafish embryos were sliced along the body axis at a thickness of 18 μm, and RNA was extracted from each frozen section (~ 100 sections) to obtain gene expression information. They then computationally reconstructed the 3D transcriptional profile of the embryo by overlapping RNA-seq information from all frozen sections .The transcriptome in vivo analysis (TIVA) was published in 2014 to perform ST analysis of any region using photonics . This meIn 2017, Medaglia et al. developed NICHE-seq as a method that used photoactivation to determine the cellular and molecular composition of the microenvironment and demonstrated the experiment using mice expressing photoactivatable GFP . In thisIn medicine and molecular biology, the term “in situ” refers to “the original place in the organism where the cells belong.” Instead of the abovementioned approach of resecting individual cells (or parts) in the tissue and extracting RNA molecules, ISH-based methods are available by directly visualizing RNA where it should be. ISH uses a probe complementary to the nucleic acid and hybridizes it in a cell. This technology has existed since the 1960s and has been used to visualize gene expression since the late 1970s . The sinIn the ISH-based methods described above, the spatial gene expression in tissues or cells was detected by barcoding the fluorescent materials and probes to “see” the expressed genes in the cells. In contrast, ISS-based methods attempt to detect nucleotide sequences by directly “reading” them. In 2013, the first ISS approach using a padlock probe (PLP) targeting a known gene was reported , 46. ThiAlthough ISH and ISS enabled the identification of molecules at the cellular level resolution, they require large systems. In contrast, ISC-based methods, an approach that conducts ex-situ sequencing after capturing RNA in situ, may facilitate gene analysis while maintaining the spatial organization of the tissue relatively easily.The spatial transcriptomics technology was developed in 2016 at the Karolinska Institute, Sweden, as the first technology to adopt this approach . In thisNext, we profiled the spatial gene expression of breast cancer specimens via STseq using the Visium platform of 10x Genomics , which is a commercial version of ISC-based ST analysis . Figure As the experimental instrument technology developed, bioinformatic tools for spatial transcriptome are up coming. We introduce the paper using two different tools for STseq. Zhang et al. revealed the spatial trajectory of NSCLC samples from the data of 4 LUAD and 8 LUSC, lung squamous carcinoma using Visium dataset . In addiWe first reviewed a recent approach to better understand the molecular mechanisms underlying drug resistance. We introduced our recent single-cell analysis of osimertinib-resistant lung cancer cells. In the latter section, we reviewed the currently available ST analysis methods.Single-cell analysis technologies allow for a bottom-up view of the organs and tissues from the perspective of cells. As a result, we can define various aspects, such as development, cancer heterogeneity, and infectious diseases, with a new and entirely different view. scRNA-seq revealed intratumor and intertumor heterogeneity. Recently, an increasing number of clinical samples, including anticancer therapy-resistant tumors, have been analyzed in combination with other single-cell level omics technologies. These single-cell multiomics analyses are expected to provide new findings.Conversely, once the cellular architecture is destroyed during single-cell suspension preparations, the intuitive information viewed top-down is lost. STseq is a powerful method that can provide gene expression information without compromising the positional relationship between cells. Using 10x Genomics’ Visium, which is already commercially available, it is now possible to measure gene expression comprehensively and quantitatively with relative ease. However, the resolution of this method is insufficient.The spatial concept within a cell is important to delve into the microenvironment within individual cells. It is possible to estimate the critical information related to the actual biological implications from the intracellular localization of the RNA molecule. Although ISS using PLPs, such as FishSeq and HybISS, may identify the genes at the subcellular level, the number of genes to be identified is limited due to the large size of RCPs and the short sequences to be decoded. In the future, it will be necessary to use both technologies in combination for analysis. We expect rapid progression of single-cell spatial omics technology that can capture time and space.