Clarithromycin is widely used to treat various bacterial infections and has been reported to have potential cardiovascular risk. However, it is uncertain whether this association was dose dependent and confounded by indication bias in patients with stable coronary heart disease (CHD).This cohort study retrospectively analyzed a national health insurance claims data from Taiwan’s 2005 Longitudinal Generation Tracking Database. We used a new-user design and 1:1 propensity score matching. A total of 9,631 eligible clarithromycin users and 9,631 non-users in 2004–2015 were subject to final analysis. All patients were followed-up after receiving clarithromycin or on the matched corresponding date until occurrence of cardiovascular morbidity in the presence of competing mortality, all-cause and cause-specific mortality, or through the end of 2015. The effect of cumulative dose, exposure duration, and indications of clarithromycin on cardiovascular outcomes were also addressed.Clarithromycin use, compared with non-use, was associated with higher risk for all-cause , cardiovascular , and non-cardiovascular  mortality, but not for overall cardiovascular morbidity. Further analysis of individual cardiovascular morbidity demonstrated major risk for heart events  in clarithromycin users than non-users. However, there was no relationship of cumulative dose, exposure duration, and indications of clarithromycin on cardiovascular outcomes. Analyses of the effects over time showed that clarithromycin increased cardiovascular morbidity , especially heart events , all-cause , cardiovascular , and non-cardiovascular  mortality during the first 3 years. Thereafter, clarithromycin effect on all outcomes almost dissipated.Clarithromycin use was associated with increased risk for short-term cardiovascular morbidity  and mortality without a dose-response relationship in patients with stable CHD, which was not dose dependent and confounded by indications. Hence, patients with stable CHD while receiving clarithromycin should watch for these short-term potential risks. Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, and herpes simplex virus (C. pneumoniae was eradicated from atherosclerotic plaques using roxithromycin (a macrolide antibiotic) so roxithromycin might be helpful for patients with CHD. Therefore, several prospective, randomized, placebo-controlled trials investigated the role of macrolide antibiotics and the risk of cardiovascular events (Cardiovascular disease (CVD) is a growing worldwide burden, with approximately 17 million deaths globally in 2017, and is estimated to be over 23 million in 2030  by the end of 2010, allowing long-term follow-up studies . Due to This nationwide retrospective cohort study was based on a national health insurance claims data from Taiwan’s 2005 Longitudinal Generation Tracking Database (LGTD2005), which includes 2 million de-identified individuals who were randomly sampled in 2005 from all beneficiaries in Taiwan’s NHI program by the Health and Welfare Data Science Center of the Taiwan Ministry of Health and Welfare . All medp = 0.52) and provided fair discrimination between two groups . The index date of clarithromycin users was set on the day when clarithromycin administration commenced, and that of non-users was the corresponding day. A total of 19,262 patients with stable CHD were subjected to the final analysis.We identified all patients diagnosed with CHD by ICD-9-CM diagnosis codes (410–414) , 30 betwThe primary outcome was all-cause mortality; the second outcome was cardiovascular mortality comprising death from principle diagnoses of CHD, stroke, and PAOD, and non-cardiovascular mortality. We did not take into account the detailed causes of non-cardiovascular mortality during the follow-up. The third outcome was cardiovascular morbidity, including heart events (defined as experience of the above-mentioned unstable heart conditions or having principle diagnosis of CHD), stroke events (defined as having principle diagnosis of stroke), and PAOD events (defined as having principle diagnosis of PAOD). Both cohorts were followed from the index date to the development of study outcomes or the end of the study , whichever came first. Death was defined as withdrawal/dropout of the subject from the NHI program , 34.Preexisting comorbidities, including hypertension, diabetes, and chronic obstructive pulmonary disease as a proxy for smoking , 36 becat-tests for continuous variables and the chi-squared test for categorical variables. Death before cardiovascular morbidity was considered a competing risk event  and four  levels and mean cDDDs by two levels (<4380 vs. ≥ 4380). We also evaluated the risk of cardiovascular mortality and morbidity associated with short-term (≤7 days), medium-term (8–14 days), and long-term (≥15 days) dosing period of clarithromycin prescription. To assess the reliability of our main findings, we conducted several sensitivity analyses. First, we added three comorbidities , which were associated with cardiovascular risk. Second, we considered one confounding drug quinolone, which had the potential for cardiovascular risk  infections, as well as by dosing period of clarithromycin indications for acute respiratory tract infection and H. pylori infection. All data were analyzed using SAS . A two-sided p-value less than 0.05 was considered statistically significant.We estimated their mode cDDDs by two  in 2000–2016, male gender was significantly higher than female gender (p < 0.0001), mean age was 59 years, and the percentage of preexisting diabetes was 19% (data not shown). Among 12,915 clarithromycin users, 9,631 were propensity score-matched to a control set of 9,631 non-users at a 1:1 ratio , respectively (p < 0.0001). The incidences of cardiovascular mortality and morbidity did not differ between both groups.The clarithromycin users and non-users were followed up for a mean duration of 4 years . The 11-p < 0.0001), cardiovascular , and non-cardiovascular  mortality, not cardiovascular morbidity  in the presence of competing mortality.In multivariable Cox regression analysis , clarithvs. 4.0%; 3.3–4.7%) and risk for heart events   . Howeverp = 0.007) for unstable heart conditions in clarithromycin users, compared with non-users  and risk , not medium-term (8–14 days) and long-term (≥15 days), dosing period of clarithromycin use, compared with non-sue, was significantly associated with increased risk of cardiovascular mortality  and morbidity  .p = 0.036), especially heart events  rather than stroke and PAOD events, all-cause , cardiovascular , and non-cardiovascular  mortality during the first 3 years. Thereafter, the effect of clarithromycin on all outcomes almost dissipated.Helicobacter pylori infection  in patients with stable CHD occurred predominately during the first 3 years of follow-up, then almost dissipated afterward. We also found cardiac angiography without percutaneous transluminal coronary angioplasty, not percutaneous transluminal coronary angioplasty and cardiac electrophysiological study, seemed to predominately account for unstable heart conditions. Notably, we found no dose-response and dosing period relationships between clarithromycin use and cardiovascular outcomes, and no relationship between clarithromycin indications and cardiovascular outcomes.In this nationwide cohort study using a single-payer national healthcare insurance database over a 10-year period of follow-up, we used propensity score matching and new user design to demonstrate that the adverse effect of clarithromycin use torsades de pointes may occur after QT prolongation in patients with risk factors , body weight, blood pressure and sugar levels, and laboratory data, which may contribute to the risks of death and cardiovascular outcome. Second, the compliance of prescribed clarithromycin was not assessed in the administrative claims. Third, this study was not a prospective design. However, when we assumed the association between clarithromycin and cardiac harm existed, it was not reasonable to conduct a prospective study similar to the previous one. Besides, considering the overuse of antibiotics nowadays, it may be better to perform retrospective studies to evaluate the impact of clarithromycin in patients with CHD. Moreover, antimicrobials were chosen according to individual conditions, so it is not reasonable to randomly assign one patient with CHD diagnosed with infectious disease to receive clarithromycin and the other not when indicated. Fourth, the diagnosis of CHD was based on ICD-9-CM codes and misclassification is possible. However, this method has been used in prior NHIRD-based research , 30 and The nationwide retrospective cohort study documented that clarithromycin use was associated with increased risk for short-term cardiovascular morbidity  and mortality without a dose-response relationship in patients with stable CHD. This association was not dose dependent and confounded by indications. Hence, patients with stable CHD while receiving clarithromycin should watch for these short-term potential risks.The datasets utilized in this study cannot be made available in a public repository due to the “Personal Information Protection Act” executed by Taiwan’s government, starting from 2012. Requests to access these datasets should be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Institutional Review Board of the Dalin Tzu Chi Hospital (B10702014 and B11101016). Written informed consent for participation was not provided by the participants’ legal guardians/next of kin because: The NHIRD encrypts patients’ personal information to protect privacy and provides researchers with anonymous identification numbers associated with relevant claims information, including sex, date of birth, medical services received, and prescriptions. Therefore, patient consent is not required to access the NHIRD. This study was approved by the Institutional Review Board (IRB) of Dalin Tzu Chi Hospital; the IRB also waived the consent requirement.B-HY, Ye-CC, and Yi-CC contributed to study design. Ye-CC contributed to administrative support. B-HY, W-YC, and Yi-CC contributed to collection and data assembly. B-HY, Ye-CC, Y-DL, W-YC, and Yi-CC contributed to analysis and interpretation of data. Ye-CC and Yi-CC contributed to manuscript writing. Yi-CC was responsible for the overall content as the guarantor. All authors involved in revising the manuscript for important intellectual content and approved the final revision to be published, contributed to the article and approved the submitted version.


Images from 660 patients were included. Segmentations by one expert reader were ground truth. A convolutional neural network (CNN) was developed and trained on a training set, and the performance was tested on a separate test set of 120 patients. The AI method was compared with manual segmentations performed by several nuclear medicine physicians. Assessment of tumour burden  and total lesion uptake (TLU)) was performed. The sensitivity of the AI method was, on average, 79% for detecting prostate tumour/recurrence, 79% for lymph node metastases, and 62% for bone metastases. On average, nuclear medicine physicians’ corresponding sensitivities were 78%, 78%, and 59%, respectively. The correlations of TLV and TLU between AI and nuclear medicine physicians were all statistically significant and ranged from R = 0.53 to R = 0.83. In conclusion, the development of an AI-based method for prostate cancer detection with sensitivity on par with nuclear medicine physicians was possible. The developed AI tool is freely available for researchers.Here, we aimed to develop and validate a fully automated artificial intelligence (AI)-based method for the detection and quantification of suspected prostate tumour/local recurrence, lymph node metastases, and bone metastases from [ Tumour burden has been shown to correlate with overall survival in patients with advanced prostate cancer PSMA PET-CT in patients with newly diagnosed high-risk prostate cancer and in patients with recurrent disease. Model performance was assessed on a lesion level, and the assessment of tumour burden was calculated from the automated segmentations. The AI-based method was compared with nuclear medicine physicians. A secondary aim was to make the AI-based tool freely available to other researchers.This study aimed to develop and validate a fully automated AI-based method for detecting and quantifying suspected prostate tumour or local recurrence, lymph node metastases, and bone metastases in [18F]PSMA PET-CT at Skåne University Hospital, Lund and Malmö, Sweden, from December 2019 to December 2020, were included, either due to initial staging of high-risk prostate cancer or for the detection of sites of suspected recurrent disease. The patients were injected with 4 MBq/kg of [18F]PSMA-1007. After a 2-h accumulation time, images were acquired on a Discovery MI PET-CT  from the base of the skull to the mid-thigh.A total of 660 patients referred for clinically indicated PSMA PET-CT images . The cloud-based annotation platform RECOMIA (https://www.recomia.org) was used for the manual segmentations and included basic display features for PET-CT images and segmentation tools PSMA-1007.To mark uptakes in the bone that could be metastases but, in general, not low-grade uptake in, for example, the ribs and pelvic bones, which is a common unspecific finding in PSMA-1007 PET-CT scans. We found a relatively high sensitivity within the range of nuclear medicine physicians and a significant correlation for tumour burden assessment (TLV and TLU) between the AI and manual segmentations.We developed and validated a fully automated AI-based method for detecting prostate cancer tumours and metastases and quantifying tumour burden in PSMA-1007 has increased tracer uptake in benign bone lesions in addition to bone metastases. Unspecific bone uptakes have previously been found in at least 50% of patients, most commonly in the ribs and the pelvis PSMA-1007 PET-CT images but only included patients referred for initial staging, and the AI method was only trained for the detection of suspected pelvic lymph node metastases. Furthermore, it only included 161 PET-CT scans for training (540 in the present study). A recent paper by Johnsson et al. [18F]DCFPyL PET-CT scans and 87% for bone lesions. However, they had a larger number of false-positive lesions per patient . The numbers in the present study were 2.8 for lymph node metastases and 3.0 for bone metastases.We have previously published articles on AI-based detection and quantification of PET-CT images in patients with prostate cancer ,26,27,28n et al.  found juThe rate of false positives and false negatives deserves further comment. If an AI-method is used for highlighting possible malignant lesions to be evaluated by a physician, it is important to keep the number of false negative lesions as low as possible. However, if the number of false positive lesions is very high, it will be time-consuming for the physician to consider and discard lesions marked by the AI. If the AI is used to quantify, for example, the tumour burden, the rate of false positives and false negatives should be balanced. When training the AI, it is possible to bias the networks towards either a high sensitivity  or having a high PPV . In this study, we aimed to keep the number of false negatives relatively low at the expense of a slightly higher false positive rate.Another emerging research field, closely related to this work, is radiomics. Through AI, it may be possible to automatically extract quantitative features in medical images, which can be used, for example, for risk stratification and response prediction. Most radiomics studies on prostate cancer are performed on magnetic resonance imaging, but some PSMA PET-CT studies exist ,31. When18F]PSMA-1007 PET-CT images and does not necessarily perform equally well if other PSMA radiopharmaceuticals are used.The results should be viewed in light of some limitations. All PET-CT scans were from a single institution, leading to selection bias in the patient material. It is also unknown how the AI algorithm performs for images obtained with different PET-CT protocols, including different accumulation times, PET-CT scanners, and reconstruction algorithms. The manual segmentations used as ground truth cannot be considered perfect. Ideally, histopathologic verification should be carried out, but it is often not feasible. The patients included in this study were biased toward a low disease burden. The model should also be validated in patients with a higher tumour burden. The method is trained on [18F]PSMA-1007 PET-CT scans. Tumour burden assessment by AI was moderate to strongly correlated to that of an expert reader. The difficulty in achieving high inter-observer reproducibility emphasises the need for automated methods. To further validate the method, we made our AI tool freely available to other researchers at www.recomia.org or by emailing contact@recomia.org.In this study, we showed that it was possible to develop an AI method with sensitivity on par with nuclear medicine physicians to detect prostate tumours or local recurrence, lymph node metastases, and bone metastases in [


We used composite amplitude scores (CAS) to analyze the severity of nerve conductions on peripheral nerve function. TCNS and CAS were higher in the diabetic CKD group . The NCS revealed the compound muscle action potential of ulnar and peroneal nerves and the sensory nerve action potential of ulnar and sural nerves , which was found to be significantly low in the diabetic group. CAS was significantly correlated with age , urine albumin-creatinine ratio (UACR) , free-form IS , sICAM-1 , sVCAM-1 , TBARS , and thiols . Linear regression revealed that only TBARS and free-form IS were strongly associated with CAS. The mediation analysis shows that the sVCAM-1 level serves as the mediator between higher IS and higher CAS. IS and oxidative stress contribute to the severity of peripheral nerve dysfunction in patients with CKD, and chronic glycemic impairment can worsen the conditions.Pieces of evidence support the view that the accumulation of uremic toxins enhances oxidative stress and downstream regulation of signaling pathways, contributing to both endothelial microangiography and cell dysfunction. This study is to address the impact of protein-binding uremic toxins on the severity of peripheral nerve function in patients with chronic kidney disease (CKD). Fifty-four patients with CKD were included in the Toronto Clinical Neuropathy Score (TCNS), nerve conduction study (NCS), and laboratory studies including protein-binding uremic toxin (indoxyl sulfate [IS] and  Chronic kidney disease (CKD) remains a significant global burden . The preEvidence supports the view that intestinal dysbiosis induced by an imbalanced or/and excess of nutrients leads to overproduction and accumulation of uremic retention solutes (URS)  in the intestine . The graThe mechanism of peripheral nerve dysfunction in CKD could be multifactorial ,12. PrevRegarding the research on protein-bound uremic toxins, most studies focus on CKD ,15 or itA total of 54 patients with pre-dialysis CKD (CKDs stage 3B-4) who visited the nephrology outpatient clinic at Kaohsiung Chang Gung Memorial Hospital in Taiwan were recruited for this study. CKD is defined as decreased kidney function that persists for more than 3 months, and all enrolled patients were regularly followed up for more than 6 months . The excAll patients underwent complete neurologic examinations, nerve conduction studies (NCS), Toronto Clinical Neuropathy Score (TCNS), electrochemical skin conductance (ESC), as well as biochemical testing including protein-bound uremic toxin. TCNS, which consists of large and small fiber evaluations, is a valid instrument that reflects the presence and severity of a wide spectrum of polyneuropathies . BaselinThe NCS was performed using Nicolet Viking machines . The recordings for the attributes measured in each nerve included distal latency, amplitude, and nerve conduction velocity (NCV), according to our previously published paper . All datWe measured the serum thiobarbituric acid-reactive substance (TBARS) for oxidative stress, while the serum level of total reduced thiols was measured for anti-oxidative capacity in response to the increased oxidative damage. Serum TBARS levels were measured using a commercially available assay kit  . The sert-test. Categorial data were compared by the mean of the Chi-square test or Fisher’s exact test. Those continuous variables that were not normally distributed were logarithmically transformed to improve normality and then compared using the independent t-test. Correlation analysis was used to evaluate the relationship between CAS and variables, including baseline cardiometabolic risk factors and biomarkers. Finally, those factors that were significantly correlated with the CAS value were enrolled into the multiple linear regression analysis models to evaluate the influence on the CAS. The protein-binding uremic toxin (IS) is a well-known uremic endotheliotoxin [p < 0.05 [Data are expressed as mean ± SD or median (interquartile range). Continuous variables between two patient groups (CKD and CKD with diabetes) were compared using the independent liotoxin . In thisliotoxin , illustrp < 0.05 . All staOf the 54 patients with CKD, 27 were non-diabetic (mean age = 67.0 years), and 27 had diabetes (mean age = 69.7 years). The baseline characteristics, underlying diseases, and cardiometabolic parameters are presented in p = 0.02 and 0.01, respectively). Concerning the parameters of the NCS study, the amplitude, including ulnar and peroneal CMAPs, and ulnar and sural SNAPs  were significantly low in the CKD with diabetes group. The velocity, including ulnar, peroneal, and tibial MNCV, and median and sural SNCV, were significantly low in the CKD with diabetes group .Clinical scores, NCS, and ESC in patients with CKD are listed in p = 0.04), UACR (mg/g) , free-form IS (μg/mL)  (p = 0.02), sVCAM-1 (ng/mL) , TBARS (μmol/L)  (p = 0.045).The results of the correlation analysis used to test the influence of protein-bound uremic toxin and cardiometabolic risk factors on CAS are listed in = 0.007) A, sICAM-= 0.002) B, and thThe effects of the risk factors on CAS in patients with CKD relating to the correlation analysis are listed in p = 0.017 in the Sobel test)  on the severity of peripheral nerve dysfunction  was influenced by sVCAM-1 level (mediator) indirectly. The path model jointly tested three effects: (a) the effect of IS value (independent variable) on the sVCAM-1 level(mediator) ; (b) the effect of the sVCAM-1 level (mediator) on the CAS (dependent variable) ; and (c) the mediation effect a × b, which is defined as the reduction of the relationship between the IS and CAS (independent and dependent variables)  by including the sVCAM-1 (mediator) into the model . The mediation relationship was significant (el test) .Although indoxyl sulfate is an endotheliotoxin and is involved in the pathophysiology of cardiovascular events in CKD ,30,31, tEscherichia coli) can metabolize tryptophan to indole. Indole is absorbed by the intestine, circulates in the blood to the liver, undergoes hydroxylation and sulfation by the liver, becomes IS, and finally re-enters the blood circulation. PCS, another protein-binding uremic toxin, is a product of the metabolism of tyrosine and phenylalanine by the intestinal bacterium that is excreted by the kidneys [Concerning biochemical and physical properties, uremic toxins can be divided into three groups as follows: water-soluble, non-protein-binding, low molecular weight compounds ; larger or medium molecular weight compounds ; and protein-binding low molecular weight compounds  . Among t kidneys .The clinical impacts of IS levels on cardiac and renal development have been well-documented ,33,34. IOne recent large study enrolled 200 patients in the pre-dialysis stage, including 100 patients with CKD with diabetes and 100 other non-diabetic patients with CKD, and found that the prevalence of polyneuropathy was 45%. It was also noted that the parameters of the NCS were more severe in the CKD with diabetes subgroup in comparison with the non-diabetic CKD subgroup . The sevThis study has four limitations. First, this was a prospective cross-section observational study. Although our results showed that protein-binding uremic toxin, oxidative stress, and endothelial dysfunction might serve to drive the process of the severity of peripheral nerve dysfunction, a causal link connecting protein-binding uremic toxin, oxidative stress, and endothelial dysfunction with the severity of peripheral nerve function in CKD remains to be established. Second, patients with diabetes are prone to more severe peripheral nerve impairment than those without diabetes; however, the exact differences in pathogenesis in peripheral neuropathy between these two subgroups also should be clarified. A cell culture study showed that dipeptidyl peptidase-4 (DPP-4) inhibitors possess anti-apoptotic activity to ameliorate the IS-induced renal damage, which may be via regulating the ROS/p38MAPK/ERK and PI3K-AKT pathways as well as the downstream NF-kB signaling pathway . Our stuThe proteinuria-binding uremic toxin IS, but not PCS, contributes to the severity of peripheral nerve dysfunction in patients with CKD, and chronic glycemic impairment can worsen the condition. Besides protein-binding uremic toxin, oxidative stress might serve to drive the process.


Our analyses reveal that RCT-treated patients exhibited lower stromal T-helper, T-reg, and T-cyt cells compared to other treatment regimens. In conclusion, we demonstrated treatment-specific differences in the immune microenvironment landscape of rectal cancer patients. Understanding the underlying mechanisms of this landscape after a specific therapy will benefit future treatment decisions.Neoadjuvant therapy is the cornerstone of modern rectal cancer treatment. Insights into the biology of tumor responses are essential for the successful implementation of organ-preserving strategies, as different treatments may lead to specific tumor responses. In this study, we aim to explore treatment-specific responses of the tumor microenvironment. Patients with locally advanced adenocarcinoma of the rectum who had received neo-adjuvant chemotherapy (CT), neo-adjuvant radiochemotherapy (RCT), neo-adjuvant radiotherapy with a long-interval (LRT) or short-interval (SRT) or no neoadjuvant therapy (NT) as control were included. Multiplex-immunofluorescence was performed to determine the presence of cytotoxic T-cells , regulatory T-cells , T-helper cells , B cells (CD20+), dendritic cells (CD11c+) and tumor cells (panCK+). A total of 80 rectal cancer patients were included. Treatment groups were matched for gender, tumor location, response to therapy, and TNM stage. The pattern of response (shrinkage  In recent times, the prognosis of patients with rectal cancer (RC) has improved immensely . NeoadjuDifferent types of treatments have different clinical effects. A simple comparison of pathological complete response (pCR) rates already illustrates this. Neoadjuvant radiochemotherapy (RCT) has increased pCR rates, with an incidence of approximately 14% of patients . Lower pPrevious studies have shown the potential role of immune infiltrates in the prediction of radio-responsiveness to neoadjuvant RCT in rectal cancer . These iSince local treatment interferes with this microenvironment, investigating the repopulation of the immune infiltrate after each type of therapy is crucial to understanding the biology of the tumor response. Some studies have shown differences in the circulating subpopulations of immune cells throughout therapy or after it , 31, butHere, we explore the effects and interactions of the different types of treatment on tumor cells and microenvironment and correlate this with a biologically meaningful and clinically relevant response scoring method.From an original in-house cohort of 728 rectal cancer (RC) patients from the Radboud University Medical Center Nijmegen, a total of 80 patients with adenocarcinoma NOS (not otherwise specified) of the rectum were selected to be included in this study. Patients with known hereditary colorectal cancer were excluded. An opt-out system for ethical approval was in place. Patient material was obtained from the pathology archives of the Radboud University Medical Centre, Nijmegen, The Netherlands. Selected patients received one of four different treatment regimens between 2015 and 2019; neo-adjuvant chemotherapy (CT), neo-adjuvant radiochemotherapy (RCT), neo-adjuvant radiotherapy with a long interval (LRT), or neo-adjuvant radiotherapy with a short interval (SRT), with no neo-adjuvant therapy (NT) serving as control. Per group, 16 patients matched (as much as possible) for gender, tumor location, and cTNM stage were included -multiplex panel   used in routine diagnostics was used to determine any mutations that could clearly influence the immune phenotype of patients  Kit , was modified and optimized for rectal 4µm thick FFPE tissue sections . In shorImaging was performed using the VECTRA 3 Quantitative Pathology Imaging System (PerkinElmer) and Vectra V3.0.4 software . All standard epi-fluorescent filters were used; DAPI, FITC, CY3, Texas Red, and CY5. Whole slide scans were acquired using x4 magnification and subsequently scanned at x20 magnification for the multispectral regions of interest , 36.Slides were visualized and annotated by two independent researchers (C.G.M & S.K.O.) and unclear slides were resolved by consensus with an expert gastrointestinal pathologist (I.D.N.). Each sample was scored blindly following an externally validated classification diagram that we developed for patterns of tumor response in esophageal cancer  and rectStatistical analysis was carried out using RStudio version 3.6.2 . One-way ANOVA was done for comparisons between more than two groups in a parametric setting, while Kruskal Wallis one-way ANOVA was used in the non-parametric setting. Student’s T-test was done for comparisons between two groups. Correlations between non-parametric variables were analyzed using Spearman´s rank order correlation test. When comparing categorical variables, a chi-square test was used. A principal component analysis was conducted using singular value decomposition. A P-value lower than 0.05 was considered statistically significant.A total of 80 RC patients were included; despite matching, selection bias based on treatment indications remained between the groups Table 1.An excellent interobserver agreement was reached (κ=0.84). Upon histological evaluation, 14 patients were categorized as “non-responders”, as there was extensive tumor present and no evidence of regression such as fibrosis or mucin. Prevalence of shrinkage and fragmentation was significantly different across therapy groups (Targeted sequencing for microsatellite instable (MSI) markers and 47 cancer-related genes identified pathogenic mutations in 61 of the 64 patients (88%) and MSI in 3 of the 69 patients (4%). The percentages of TP53, KRAS, PIK3CA, and NRAS mutated cases were respectively 74%, 56%, 11%, and 7%. These percentages are in the range of other cohorts . The samThe relative distribution of stromal immune cells showed T-helper cells as the predominant immune cell populations across therapies   to reduce the dimensions of the high-plex data, different-sized ellipses of the different treatment groups could be observed  was also studied to investigate the immunophenotype as a result of this intense local form of therapy. Since three out of the five patients achieved a complete pathological response, we were only able to compare the tumor microenvironment in these five patients to those of the differently-treated patients, as a sample size of two for the tumor region would be biased and, therefore, not a reliable comparison. Strikingly, stromal T-helper, T-cyt, and T-regs showed very low immune densities compared to patients with other treatment regimens  affects the presence of T-cyt and T-helper cell populations the most. Strikingly, this is less evident with LRT, suggesting repopulation takes place in the interval that distinguishes SRT and LRT, which is in line with previous models , 24, 30.Moreover, considerably fewer T-helper and T-regs were found in the RT-treated group when it was compared to non-RT-treated  and statFinally, the synergistic effect of radiotherapy in combination with chemotherapy seems to increase the presence of T-cyt cells in the stroma and to decrease the presence of T-helper cells when compared to CT-only treated patients. Furthermore, differences in several immune cell populations were found when comparing LRT and RCT, despite the similar interval and RT regimen. Tumor-infiltrating DCs were found to be higher in RCT-treated patients compared to LRT-treated patients. RCT-treated patients also showed lower stromal T-helper, B cells, and T-regs compared to LRT-treated patients. This suggests that the synergistic effect of combination therapy induces proliferation of T-cyt cells but depletion of other immune cells in the stroma and induces DC tumor infiltration compared to LRT-treated patients.To study spatial neighborhood relationships, we used multiplex immunohistochemistry, which allowed us to look at cell population interactions. High stromal densities result in more immune cells in the vicinity of the primary tumor, allowing infiltration. In addition, the study of multiple types of cells allows for the analysis of complex interactions. Indeed, as expected , 44, theFurther, we analyzed the spatial contexture of response in a broader sense, linking the histological classification of response with the immune microenvironment. We found that patterns of response could not be explained by a single or combination of multiple immune cell populations across different therapies. Nevertheless, a tendency towards higher stromal T-cyt, T-reg, and T-helper cells in patients exhibiting a shrinkage pattern of response compared to those with a fragmented pattern (Since our study included a heterogeneous group of patients (due to the different therapies given), outcome was not the main aim of our study and therefore we could not analyze immune populations for prognostic value. Nevertheless, a few studies had described a correlation between T-regs and improved survival , 24, whiThere were several limitations to this study. Firstly, it was a retrospective study with relatively small patient groups from one single institution. Since RCT is the standard therapy for locally advanced RC, we could not expand the other treatment groups without introducing significant selection bias for patient and tumor characteristics. No outcome data could be reported since there was no randomization between the different treatment arms. Similarly, outcomes such as downstaging could not be compared since the different treatment groups did not have the same interval between therapy and surgery. The objective of this study was to explore the spatial and immune contexture after neoadjuvant therapy in rectal cancer to provide insight into their interplay as we move towards local and tailored treatments. Our goal was to unveil the unique immune infiltrate of the tumor and tumor microenvironment of differentially treated rectal cancer patients.Further research should focus on unraveling the link between different patterns of response and the immune cell infiltrate. Potential therapeutic applications may arise as stimulating certain immune cell lineages could influence the pattern of response to treatment, which can be used to favor a shrinkage pattern environment instead of a fragmented or no response pattern. Moreover, the prognostic relevance of T-regs needs to be investigated in different regions of the primary tumor as its role in the stromal and tumor regions could be different.In conclusion, we believe that this study is the first to report the differential effects of specific neoadjuvant therapies on the immune contexture of advanced rectal cancer. We have shown that many immune populations  are affected mainly by radiotherapy treatment. The re-emergence (or lack) of specific immune cell populations after treatment over time might be linked to tumor regression. Therefore, a better understanding of the reorganization of the immune contexture after therapy is important for the appropriate management of locally advanced RC patients.The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.The following detailed Credit author statement is added by the corresponding author, who is responsible for ensuring that the descriptions are accurate and agreed by all authors:CG: methodology, formal analysis, data curation, writing - original draft preparation, visualization, and writing - review and editing. YB: methodology, formal analysis, data curation, and writing - original draft preparation. SKÖ: methodology, validation, and writing - review and editing. MA: interpretation of data, original draft preparation, and writing - review and editing. MG: methodology, data collection, interpretation of data, and writing - review and editing. SV: methodology and writing - review and editing. CM: conceptualization, data curation, writing - review and editing, and supervision. IN: conceptualization, methodology, validation, data curation, writing - review and editing, and supervision. All authors contributed to the article and approved the submitted version.This work received funding from the Dutch Cancer Society in two grants; Alpe d’HuZes/KWF program grant (KWF UL 2013-6311) and a KWF grant (10602/2016-2).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.


Background: In restorative proctocolectomy with ileal J-pouch, perfusion assessment is vital to prevent complications such as anastomotic leak (AL). Indocyanine green near-infrared fluorescence (ICG-NIRF) is gaining popularity, while its interpretation and relevance remain subjective. This study aimed to evaluate a standardized ICG-NIRF imaging protocol combined with a novel, software-based assessment to detect areas of impaired perfusion and a possible correlation with AL of the pouch. Methods: In this prospective study, patients undergoing ileal J-pouch for ulcerative colitis at an inflammatory bowel disease (IBD) referral center were included. Intraoperatively, strictly standardized ICG-NIRF visualization was performed and video-recorded. Postoperatively, a specific software was utilized to determine the change in fluorescence intensity per second (i/s) for systematic regions of interest, generating perfusion-time curves and a pixel-to-pixel map. These were analysed in detail and correlated with clinical outcome . Results: Four out of 18 included patients developed AL of the ileal pouch-anal anastomosis (IPAA). In the AL group, the perfusion curves on the area adjacent to the IPAA (pouch apex) displayed considerably lower ingress/inflow  and egress/outflow  values than in the non-AL group ; egress: median = (−1.1); range = 3.9; interquartile range = 1.0 i/s). This was confirmed by further novel parameters of pouch perfusion  and pixel-to-pixel analysis. Conclusions: This study presents the feasibility of a novel methodology to precisely assess pouch perfusion with ICG-NIRF, identifying comparable, quantifiable, and objective parameters to potentially detect perfusion-associated complications in surgery in real-time. Restorative proctocolectomy (RPC) with the construction of an ileal J-pouch and ileal pouch-anal anastomosis (IPAA) has been established as the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or familial adenomatous polyposis (FAP) and selected patients with Crohn’s colitis ,2,3. A tThe risk of AL is increased by an impaired blood flow to the pouch and IPAA ,19. ConsThis study aimed to evaluate a systematic approach of intraoperative ICG-NIRF imaging  combined with a software-based perfusion assessment for the detection of areas of impaired perfusion by correlation with postoperative outcome including AL of the pouch. We hypothesized that a dynamic depiction of fluorescence intensity over time would result in novel, quantifiable and objective indicators of pouch perfusion.This prospective cohort study (NCT04695184) was conducted from February 2019 to December 2020 at the Department of General and Visceral Surgery, Charité University Medicine Berlin, Campus Benjamin Franklin, a tertiary referral center for colorectal and inflammatory bowel disease (IBD) surgery. Study approval was given by the Charité University Hospital Ethics Committee  and all data were reported in conformity with the STROBE guidelines . Patients receiving RPC with an ileal J-pouch in either a two- or three-stage approach were included. In the two-stage approach, patients underwent proctocolectomy simultaneously with ileal J-pouch and protective ileostomy, followed by ileostomy reversal. Patients undergoing the three-stage approach received subtotal colectomy with end ileostomy in stage one, completion proctectomy with ileal J-pouch formation and loop ileostomy in stage two, and ileostomy reversal in stage three.Study inclusion required a diagnosis of medically refractory UC, indeterminate colitis (IC), Crohn´s colitis or familial adenomatous polyposis (FAP), age ≥ 18 years and an American Society of Anesthesiologists (ASA) physical status ≤ 3. Patients were excluded if they displayed a hypersensitivity to ICG or sodium iodide, iodine allergy, hyperthyroidism, thyroid nodules, a previously poorly tolerated injection of ICG, pregnancy or breastfeeding, a coexisting malignancy or liver dysfunction (with a Model End Score Liver Disease (MELD) score > 10).Informed consent for study participation was received at least 24 h prior to surgery.Following the standard surgical operating procedure of the tertiary IBD referral center, laparoscopic preparation was followed by fashioning of the J-pouch to a length of 14–16 centimetres (cm) by linear single-stapling. It was then ensured that the fashioned J-pouch had sufficient mobility to extracorporeally reach down to the symphysis pubis without tension, to enable tension-free IPAA. IPAA was achieved by circular mechanical double-stapling using an end-to-end anastomosis (EEA) 29 millimeter (mm) stapler. In cases where mucosectomy was required due to risk of malignancy, single-layer hand-sewn anastomosis was performed after completed mucosectomy. In cases where laparoscopic preparation was considered a risk for patient safety, open surgery was conducted.® Fluorescence Imaging Platform  at three consecutive, predefined measuring time points , protecting the IPAA while allowing manual air insufflation.At time point 1 (T1), prior to J-pouch formation, the terminal ileum was visualized to ensure adequate baseline perfusion. At time point 2 (T2), the J-pouch was visualized immediately after its formation by side-to-side stapled anastomosis. At time point 3 (T3), after trans-anal circular stapling, the completed ileal pouch-anal anastomosis (IPAA) was visualized. At time points 1 and 2, the Quest Spectrum of view B. At timAt each time point, the effect of surrounding light was minimized by turning off the operating room and surgical lights. Each visualization was video recorded for 120 s to enable postoperative analysis. Patient baseline, intraoperative clinical and technical imaging environment data were documented, as well as the timing between the measurements.Using the Quest Research SoftwareTM, the video recordings underwent a postoperative perfusion assessment by analysing the distribution of fluorescence intensity over time. To achieve this, 10 regions of interest (ROIs) were manually selected on each pouch visualization in a standardized, predefined order: 8 ROIs on the pouch body including the pouch appendage (blind end) as well as two ROIs at the pouch apex A,B. One www.r-project.org, the R foundation, Vienna, Austria; accessed on 1 December 2021). Additionally, a computed pixel-to-pixel analysis of fluorescence intensity over time was conducted for each video recording. In this assessment mode, the software utilized each pixel as an individual ROI, allowing an analysis for maximum ingress and maximum egress and its detailed depiction as a heat map.By depicting fluorescence intensity over time, a perfusion curve was generated for each ROI, resulting in an individual perfusion graph for each pouch. The shape and characteristics of each perfusion graph were analysed in R statistical software  were detected. Additionally, radiologic pouchography with contrast enema was performed 6–8 weeks after surgery.AL of the pouch as described within 30 postoperative days was defined as the primary end point. Baseline patient characteristics, 30-day postoperative morbidity and the imaging environment were defined as secondary end points, including sex, American Society of Anesthesiologists (ASA) physical status classification, underlying condition, disease category, preoperative immunosuppressive medication, type of surgery, two- or three-stage approach, hand-sewn ileal pouch-anal anastomosis (IPAA), intraoperative change of the anastomotic site, age at operation (years), body mass index (BMI) and the presence of autofluorescence in the imaging environment.We applied a novel assessment method investigating the correlation of novel perfusion indicators with clinical outcome, discriminating between cases of AL and no AL. No previous data investigating this specific correlation existed prior to study commencement to enable the prediction of a suitable sample size. Based on the results of this study, power analysis for sample size may be possible in future studies, taking into account the prevalence of AL.In total, 18 patients underwent ileal J-pouch with intraoperative ICG-NIRF visualization and video recording, follow-up, and statistical and perfusion assessment analysis . ReasonsThe software-based analysis resulted in a depiction of fluorescence intensity measured per pixel (i: intensity) over time in seconds (s) for the ROIs of each pouch, resulting in a rate of intensity change per second (i/s). A distinctive perfusion curve was generated for each ROI, allowing the differentiation between pouch body, pouch apex and pouch appendage. A general shape could be observed in most cases, which was similar and aligned synchronously with the other ROIs of the same pouch. A fluorescence ingress  phase was followed by an intensity peak and egress  phase A. egress). “Maximum intensity + 5 s” represented the time point 5 s after the maximum fluorescence intensity was reached. To calculate the slope for the egress phase (egress), the intensity value at the time point of maximum intensity (tmaxI) and the intensity value at the time point 5 s after the maximum intensity was reached (tmax+I5) were used (Formula (1)).Thus, recurring time points and characteristics of the perfusion curves were identified B: “IngreDifferences in the shapes of the perfusion graphs became evident by preliminary visual comparison. In the AL group, ROIs of the pouch apex (directly adjacent to the IPAA) predominantly showed weaker ingress, peak and egress as well as weaker overall fluorescence intensity when compared to the non-AL pouches B.The identified novel characteristics of the perfusion curve  were examined in depth for each pouch according to clinical outcome and ROI location on the pouch body or pouch apex . The corThe ingress of ROIs on the pouch body was similar in both AL  and non-AL cases . In contrast, the ingress of ROIs on the pouch apex was considerably lower in the AL group  than in the non-AL group , indicating an impaired inflow at the apex.The same distribution was evident for the maximum ingress, which represented the maximum positive slope of the perfusion curve.Concordantly, the egress of ROIs on the pouch body was similar in both AL –(−3.1)}; interquartile range = 0.7 {(−1.5)–(−2.2)} i/s) and non-AL cases }; interquartile range = 1.7 {(−0.7)–{{−2.4)} i/s). Contrarily, the ROIs on the pouch apex displayed considerably lower egress in cases of AL }; interquartile range = 0.5 {(−0.1)–(−0.6)}i/s) than in non-AL cases }; {0.0–(−0.7)}; interquartile range = 1.5 {(−0.5)–(−2.0)} i/s), indicating an impaired outflow at the apex. The maximum egress value of ROIs of the pouch body was again similar for both outcomes, while the ROIs of the pouch apex showed lower maximum egress values in cases of AL. In summary, ROIs on the pouch apex displayed lower ingress, maximum ingress, egress and maximum egress values in cases of AL, while ROIs on the pouch body showed no considerable difference. In non-AL cases, all parameters for both the pouch apex and pouch body had an overlapping range. Conversely, in cases of AL, there was a notable difference between pouch apex and pouch body. In the analysis of ingress versus egress , pouchesThe computed pixel-to-pixel analysis of the video recordings resulted in a parametric map for maximum ingress and maximum egress . The parIn the resulting parametric map, each pixel of the recording was analysed as an ROI for maximum ingress and maximum egress, respectively, resulting in an objective high-resolution map of each pouch. For clarity and to enable direct comparison, we have shown the parametric mapping for patient 1 (non-AL) and patient 2 (AL) from In maximum ingress mapping A, patienIn maximum egress mapping B, patienThe study presented here provides a novel, systematic methodology  to quantitatively assess anastomotic perfusion with ICG-NIRF and clinical outcome in ileal J-pouch surgery. Furthermore, this study describes a novel multi-step software-based assessment with objective indicators of pouch perfusion and areas of impaired perfusion, which are described for the first time in the medical literature.In studies investigating anastomotic perfusion with ICG-NIRF, the ICG dosage varies considerably, while the standardization of measuring time points, surrounding light, camera distance to target, device settings  are rarely ever mentioned ,24,33. HHowever, the combination of this systematic imaging approach combined with a novel software-based perfusion assessment resulted in quantifiable results. A graphic depiction of fluorescence intensity over time for defined ROIs resulted in perfusion graphs, which in turn were composed of perfusion curves following a reproducible pattern. So far, only a few clinical feasibility studies mention perfusion-time curves; however, none investigate the ileal J-pouch in a standardized manner or examine ingress and egress in detail ,40.For the first time in the medical literature, novel parameters of pouch perfusion were identified by examining the perfusion curves of the pouch apex and pouch body according to clinical outcome with regards to AL. The possible significance of the slope of the perfusion curve for AL in software-based assessment has previously been described, while ingress and egress have not . MaximumThe applied methodology resulted in perfusion graphs for each pouch consisting of repeatable, similar perfusion curves per ROI. Non-imaging related baseline patient and intraoperative factors did not show a statistical difference with regards to AL of the pouch, verifying high internal validity. The differences in the perfusion graphs of the AL and non-AL group are mechanistically comprehensible, as are the differences in ROIs of the pouch apex and pouch body. Impaired perfusion at the pouch apex is likely to contribute to AL of the IPAA. Interestingly, when ingress, maximum ingress, egress and maximum egress for all pouches (regardless of ROI location) were compared for regular outcome and AL, there was no considerable difference for cases of AL. However, when the differentiation was made between ROIs located on the pouch body and the pouch apex , there wThe novel, dynamic parameters of perfusion identified here represent the rate of inflow and outflow of blood at a region of surgical interest and are mechanistically comprehensible, enabling us to detect impaired perfusion not only due to reduced blood supply but also due to venous congestion. This is a feature that the widespread subjective real-time interpretation of ICG-NIRF has not been able to deliver. The relevance of this study is emphasized by the urgent need for objective and comparable intraoperative perfusion assessment and follow-up in ileal pouch surgery, which can only be achieved by systematic standardization of ICG-NIRF visualization and quantitative, software-based protocols such as those proposed here.Our study included a limited number of patients and can be improved, which we would like to address in the future by increasing the number of patients included, introducing randomization and blinded assessment to investigate statistical significance. The three time points of visualization had different degrees of relevance for predicting AL of the pouch. Time point T1  was designed to indicate baseline perfusion and to exclude an overall perfusion deficit, which was not the case in any patient. Time point T2 (J-pouch after fashioning) allowed visualization and assessment of the whole J-pouch, which is why it was given the highest priority for assessing pouch perfusion. Time point T3  had a high theoretical relevance to assess anastomotic perfusion locally at the IPAA. However, the intraluminal measurement was technically difficult to standardise in terms of the distance from the camera to the imaging site and reducing movement. Software-based assessment was not yet possible. This needs to be addressed in the future, when flexible ICG-NIRF endoscopes will offer additional intraluminal visualization possibilities. The parametric pixel-to-pixel mapping holds great promise for intraoperative real-time use, as it is highly accurate and removes further subjectivity and bias from the perfusion assessment . We have recently shown its feasibility for perfusion assessment in gracilis muscle interposition . HoweverRequiring less than one minute of computing time, the software-based perfusion assessment could have technically been performed intraoperatively in real-time; however, to increase patient safety, we decided to perform a retrospective analysis first to prove its feasibility before altering intraoperative decision making. To further investigate whether the novel parameters of perfusion identified here are indeed objective indicators of perfusion, larger, randomized and blinded trials are needed to investigate statistical significance.This study provides the feasibility of a methodology to objectively assess anastomotic perfusion with ICG-NIRF and clinical outcome in pouch surgery. By analysing and depicting fluorescence intensity over time dynamically, perfusion graphs could be characterized in detail and correlated with clinical outcome. Novel parameters of pouch perfusion such as ingress, maximum ingress, egress and maximum egress could be identified and confirmed by parametric pixel-to-pixel mapping. They have never been described before and have the potential to improve the objectivity and quantifiability of intraoperative perfusion assessment in the future in real-time, not only for pouch surgery, but also for intestinal surgery in general.


Autonomous mobile clinics, currently in prototype form, are self-driving vehicles equipped with medical diagnostic equipment, telemedicine capability and an artificial intelligence (AI) software that can perform some of the tasks of health professionals, such as disease screening and basic diagnostics. Such clinics have the potential to revolutionize health-care delivery by bringing health-care services to hard-to-reach populations.Each clinic contains several technologies, including traditional telemedicine, medical equipment integration, electronic health records, AI software and autonomous driving.Various types of on-vehicle medical equipment perform point-of-care testing, such as ultrasound and medical imaging equipment. However, until now, medical equipment manufacturers have enforced their own data standards – in structure, format and layout – preventing a seamless health-care delivery experience. Hence, a standard method of integrating and interpreting the enormous amount of sensing data is required.The autonomous mobile clinics use electronic health records to collect and store patient data gathered by the equipment on board, such as heart rate, blood pressure and oxygen saturation, among others. These records enable integrated care through the AI software or telemedicine. Combined with valuable diagnostic data from remote doctors, these records are essential for improving the AI software, since the effective machine learning algorithm training is often constrained by the availability of integrated health records. For instance, screening for some diseases, such as dengue, can be facilitated by AI software.During the coronavirus disease 2019 (COVID-19) outbreak in China, researchers demonstrated the feasibility of using self-driving vehicles for contactless goods transportation.The ability of autonomous mobile clinics to provide accessible and affordable care will contribute to achieving universal health coverage (UHC), an objective that is high on the political agenda.The pilot, still in its planning phase, will use a three-pronged approach: (i) screening for endemic diseases by using AI software, with specific algorithms for each type of disease; (ii) training autonomous vehicles to navigate remote and rural landscapes; and (iii) developing context-relevant solutions with local communities and health workers to form a health-care delivery package that connects the in-vehicle diagnosis, patients’ medical records, and referrals to telemedicine or in-person care as the next step, when necessary.In addition to providing accessible and affordable health care, autonomous mobile clinics have potential for health-care response during crises, such as infectious disease outbreaks or disasters. For instance, autonomous vehicles have been used in emergency medical services, such as transporting COVID-19 patients to prevent exposure of emergency medical service workers to high coronavirus infection risks.We believe that reaching scalable outcomes is possible, using autonomous mobile clinics to provide primary care to people who currently do not have access to health care. By connecting patients to health-care providers across the world through telemedicine and using AI software to improve health-care efficiency, inequities within health-care delivery can be reduced.


The ionization degree, charge density, and conformation of weak polyelectrolytes can be adjusted through adjusting the pH and ionic strength stimuli. Such polymers thus offer a range of reversible interactions, including electrostatic complexation, H-bonding, and hydrophobic interactions, which position weak polyelectrolytes as key nano-units for the design of dynamic systems with precise structures, compositions, and responses to stimuli. The purpose of this review article is to discuss recent examples of nanoarchitectonic systems and applications that use weak polyelectrolytes as smart components. Surface platforms , multilayers (coatings and capsules), processed polyelectrolyte complexes (gels and membranes), and pharmaceutical vectors from both synthetic or natural-type weak polyelectrolytes are discussed. Finally, the increasing significance of block copolymers with weak polyion blocks is discussed with respect to the design of nanovectors by micellization and film/membrane nanopatterning via phase separation. Thus, implementing this concept by combining tools from research fields including nanotechnology, (bio)material science, and organic and polymer chemistry has ensured that considerable advances have been made in the elaboration of dynamic materials and systems relying on reversible non-covalent interactions . In. In(i) D(ii) Post-assembly changes in pH and ionic parameters have been extensively studied as external stimuli to weak polyelectrolyte multilayers with respect to their response in thickness, porous structure, and encapsulation/release changes . T. T121]. With their high degree of functionality as well as their versatility, weak polyelectrolytes have been widely used to develop new tools for precision medicine in order to simultaneously address precision diagnosis and precision therapy. In this context, the use of polymer nanocarriers offers three topological regions which can allow functionalization: the inner cavity, the surrounding shell, and the external surface exposed to the microenvironment . PolyeleProcessing weak polyelectrolyte into gels and vectors has been a very active research field for the past few decades. A range of approaches yielding prominently biosourced single-polyelectrolyte gels have been proposed based on precipitation/coagulation through H-bonding, hydrophobic interactions, and crosslinking through reactions with either ionic or covalent crosslinkers ,153. Alt+ to Cu2+ cation exchange by complexation in the gel, enabling the in situ synthesis of catalytic nanoparticles . S. S220]. b-P2VP and poly(styrene-b-acrylic acid) (PS-b-PAA)), they form core-shell micelles in water with a hydrophobic core and polyelectrolyte corona ..207].b-P4VP [b-P4VP-based membranes, the P4VP segment is deprotonated at higher pH values and collapsed onto the pore walls, yielding a higher water permeability and larger pore sizes. Moreover, in PS-b-P4VP, the complexation of the P4VP segment with metal ions in the casting solution provides control over the pore formation [BCP membranes in the nanofiltration regime have also been obtained through the blending of different BCPs such A-B/A-C type blocks. For example, the combination of PS-P4VP and PS-PAA BCPs allows the formation of smaller pore sizes due to the hydrogen bonding occurring between PAA and P4VP blocks of the two blends. These complexes drive the morphological shift towards densely packed spherical nanostructures that form pores with smaller dimensions . Anotherb-P4VP  and polyb-P4VP . In the ormation .From surface platforms to colloids and gels, weak polyelectrolytes have enabled the development of a wide range of functional materials owing to their intrinsic response to stimuli, including solvents, temperature, pH, and salt. This review paper is focused on the latter two stimuli, as these simple parameters are able to induce several responses in weak polyelectrolyte chains at the molecular level, including changes in their ionization rate, charge density, H-bonding ability, and conformation. In turn, these changes are transmitted to the supra-molecular level, enabling nano-systems to respond in precisely predetermined manners, including by changing their stability, their structure, and their physical properties . Furthermore, the chemical variety of weak polyelectrolytes, encompassing natural and synthetic polymers with a range of available chemical functions and ionization constants (pKa and pKaH), enables the creation of varied biocompatible materials and vectors that hold promise for use in future biomedicine and pharmaceutical applications. Given this background and considering that weak polyelectrolytes can rely on external stimuli as both assembly and post-assembly triggers, it is not surprising that they stand as promising tools for the nanoarchitectonics of organic and hybrid systems. This dual role enables weak polyelectrolytes to act not only as functional nano-units conferring “smart” stimuli-responsiveness to materials but also as structure-directing agents. In this respect, prominent future developments can be anticipated in at least two research directions. First, pharmaceutically relevant systems based on biocompatible weak polyelectrolytes will gain improved precision and (multi)functionality for target drug delivery. Concurrently, nanostructured systems, including those based on BCP, will enable the confinement of weak polyacid/polybase nanodomains and pores to support the emergence of next-generation membranes and electrodes for use in energy and environment sustainability devices.


Sufficient information is the foundation for efficient and high-quality health care services. In the field of extramural health care, this challenge is particularly evident: missing or insufficient information can lead to underuse, overuse, or misuse of health care, e.g. due to the necessity of multiple assessments or lack of relevant information. The noticeable shortage of health care professionals further underscores the urgent need for efficient and quality-assured health care services. The aim of the project LICA - linked care - is to provide a platform for better coordination and information exchange between health professionals involved in home care, with a focus on ICT in nursing in Austria. The project is funded by the Austrian Research Promotion agency (FFG) as part of the “benefit - demografischer Wandel als Chance” program (April 2020-March 2025). The requirement analysis was conducted from April to December 2021. In light of the user-centered approach a mix of methods was chosen, consisting of: literature analysis, 5 guideline-based focus group interviews, guideline-based expert interviews n = 44 , documentation-analysis (4 care documentation systems - from participating project partners) and working diaries: n = 5 on 5 consecutive working days (=25 diaries). Therefore, three main target groups were identified: i) people in need of care, ii) healthcare professionals and iii) healthcare providers. The data were analyzed using a qualitative content analysis based on Kuckartz. The main results regarding the status quo are: i) different documentation systems are utilized, ii) lack of digitized documents, iii) currently no standardized documentation system is in use. Thus, following requirements could be identified: i) interoperability with existing systems, ii) setting comprehensive function, iii) usability, iv) interdisciplinary readability, v) error-management, and vi) proper data protection measures.• Healthcare systems are under great pressure worldwide. Innovative solutions can help maintain and improve the quality and efficacy of healthcare services.• Gapless and efficient information provision is a key essential to high quality healthcare. The project offers a user-centric approach to develop a platform for connectivity of existing systems.


The contribution of access to care to racial/ethnic disparities in cancer outcomes remains insufficiently investigated. Our study showed substantial racial/ethnic disparities in total mortality of the top five major cancers for U.S. men and women, across 4 major racial/ethnic populations. We found that the non-Hispanic (NH)-black and NH-white mortality disparity was most evident among patients with a high socioeconomic status (SES) or those who had private insurance, while the NH-white versus Hispanic and Asian disparities were more evident among patients with low SES, or those with no insurance or Medicare or Medicaid. Our findings highlight the need to develop racial/ethnic-specific strategies to reduce the disparity in mortality among cancer patients, and call for further investigation on factors other than access to care  for their contributions to the racial/ethnic disparities in cancer outcomes.Importance: The reasons underlying racial/ethnic mortality disparities for cancer patients remain poorly understood, especially regarding the role of access to care. Participants: Over five million patients with a primary diagnosis of lung, breast, prostate, colon/rectum, pancreas, ovary, or liver cancer during 2004–2014, were identified from the National Cancer Database. Cox proportional hazards models were applied to estimate hazard ratios (HR) and 95% confidence intervals (CI) for total mortality associated with race/ethnicity, and access to care related factors  for each cancer. Results: Racial/ethnic disparities in total mortality were observed across seven cancers. Compared with non-Hispanic (NH)-white patients, NH-black patients with breast , ovarian , prostate , colorectal  or pancreatic  cancers had significantly elevated mortality, while Asians (13–31%) and Hispanics (13–19%) had lower mortality for all cancers. Racial/ethnic disparities were observed across all strata of access to care related factors and modified by those factors. NH-black and NH-white disparities were most evident among patients with high SES or those with private insurance, while Hispanic/Asian versus NH-white disparities were more evident among patients with low SES or those with no/poor insurance. Conclusions and Relevance: Racial/ethnic mortality disparities for major cancers exist across all patient groups with different access to care levels. The influence of SES or insurance on mortality disparity follows different patterns for racial/ethnic minorities versus NH-whites. Impact: Our study highlights the need for racial/ethnic-specific strategies to reduce the mortality disparities for major cancers. Cancer is the second leading cause of death in the United States (U.S.), accounting for over 22% of all deaths ,2. The tThe racial/ethnic disparity in cancer burden is a longstanding concern . AfricanRacial/ethnic disparities in cancer outcomes may reflect unequal access to care, resulting from social determinants  . In earlHerein, we used data from the National Cancer Database (NCDB) to comprehensively investigate race/ethnicity on mortality disparity in the five cancers with the highest mortality among U.S. men and women  and evaluate the influence of factors related to access to care and high-quality care on the disparity.n = 1,233,424, 16.5%), whose TNM stages were inconsistent with those of site-specific metastasis , and those with missing follow-up records  or unknown race/ethnicity information  were excluded. Because the NCDB data were completely de-identified, this study was approved as Exempt Human Research by the Institutional Review Board of Vanderbilt University; thus, no consent was needed.A cohort of 7,472,305 patients with a primary diagnosis of lung, breast, prostate, colorectal, pancreatic, ovarian, or liver cancers were identified from the NCDB (2004–2014), which captures over 70% of newly-diagnosed cancer cases in the U.S. . PatientFollowing the 2010 Census of Population and Housing , the NCDDemographic characteristics were obtained from the NCDB, including age at diagnosis, sex, year of diagnosis, rural/urban residence, annual household income and educational attainment, insurance type, treating facility, region, and distance to care. Residential type  was defined by matching patients’ Federal Information Processing Standards codes against U.S. Department of Agriculture Economic Research Service records from 2003 (for patients who were diagnosed with cancer before 2013) or 2013 (for those who were diagnosed with cancer in or after 2013). Income and educational attainment (percentage of adults who did not graduate high school) were estimated by matching patients’ resident zip codes against American Community Survey data from 2000 (for patients who were diagnosed with cancer before 2012) or 2012 (for those who were diagnosed with cancer in or after 2012), and both were categorized into quartiles in the NCDB [Clinical and tumor characteristics were obtained from the NCDB and included histology type, grade, TNM stage, lymphovascular invasion, comorbidity (measured using Charlson/Deyo scores), and site-specific measurements , defined as months from cancer diagnosis to death of any cause or to the last contact. To better assess the neighborhood-level socioeconomic status (SES), we created a single 3-level measure based on a combination of income and educational level quartiles. Patients within the highest quartiles of both income and education were categorized as high SES; patients within the lowest two quartiles of both income and education were categorized as low SES; otherwise, was categorized as intermediate SES.Descriptive characteristics of different racial/ethnic groups were compared using chi-square tests for categorical variables and ANOVA for continuous variables. Five-year survival rates by race/ethnicity were estimated using the Kaplan–Meier method and compared by log-rank tests. Age, TNM stage, and treatment  adjusted 5-year survival rates were estimated using stratified Cox models. Cox regression analyses were first conducted to derive hazard ratios (HR) and 95% confidence intervals (CI) for total mortality associated with race/ethnicity with adjustment for age, sex (if applicable), clinical characteristics, and treatment received. Stage-specific and sex-specific  analyses were carried out to examine whether association patterns differed across stage or sex.To evaluate the contributions of access to care related factors  on racial/ethnic disparities in cancer outcomes, we first estimated HRs and 95% CIs for overall mortality associated with the above factors for each cancer type using a multivariable Cox proportional hazard model with adjustment for race/ethnicity, age, sex (if applicable), clinical, and treatment characteristics. Second, we conducted stratified Cox regression analyses by access to care factors to investigate whether these factors modify racial/ethnic-mortality associations. Multiplicative interactions between race/ethnicity and the above stratified factors were evaluated using log likelihood ratio tests. Cancer-specific or disease-free survival were not evaluated, as death cause and cancer recurrence are not recorded in the NCDB. Alternatively, we conducted landmark analyses  to explore the nature of observed mortality differences. We evaluated the proportional hazard assumption by plotting scaled Schoenfeld residuals and potential collinearity for covariates in the Cox models using variable inflation factors (VIF). We found no evidence of assumption violation or collinearity. Missing rates for study variables were low (<3%); missing data were treated as a category for nominal variables or replaced with overall (distance-to-care) or stage-specific median values  for continuous variables. We also conducted sensitivity analyses by excluding patients with missing information on access to care variables to evaluate the robustness of our analyses.p  < 0.05, with no adjustment for multiple comparisons. All statistical analyses were performed using R 3.5.1 .All statistical tests were based on 2-sided probability with significance levels set at A total of 5,077,413 patients with a diagnosis of breast, ovarian, prostate, colorectal, pancreatic, liver, or lung cancer were included in the final analysis . OverallOverall, for all cancers except pancreatic cancer, Asian patients showed the highest 5-year survival rate, followed by Hispanic and NH-white groups, and NH-black patients had the lowest survival rates. For pancreatic cancer, NH-white patients had a slightly lower survival rate than NH-black patients , and both were significantly lower than Hispanic and Asian patients , clinical factors, and treatment received . CompareFactors related to access to care were significantly associated with total mortality . Patientp values were significant for many of the multiplicative interaction tests.Significant interactions between neighborhood-level SES and race/ethnicity were observed for all cancers except liver cancer, although the pattern was similar for all cancers. For NH-black patients with breast, ovarian, prostate or colorectal cancers, compared with NH-white counterparts, excess mortality was most evident among patients with high SES , but smaller for patients with low SES . On the other hand, the lower mortality observed for Hispanic and Asian versus NH-white patients was more evident among patients with low SES than those with high SES . When stThese patterns were very similar for 3-year mortality . SensitiIn this large-scale registry-based study, we found a substantial racial/ethnic disparity in total mortality across seven major cancers in U.S. men and women. Of the four racial/ethnic groups evaluated in this study, NH-black patients experienced the highest mortality after cancer diagnosis. Hispanic and Asian patients, however, showed the lowest mortality post-cancer diagnosis. These racial/ethnic disparities presented across all patient subgroups with different access to care characteristics. NH-black and NH-white mortality differences were most evident among patients with high SES or private insurance, while Hispanic and Asian versus NH-white mortality differences were more evident among patients with low SES.It has been suggested that racial/ethnic disparities in cancer outcomes might largely reflect disproportionate poverty levels  and predHowever, our study does not support that the racial/ethnic mortality disparity is fully explained by unequal access to care. In contrast, we found that mortality disparity between NH-black versus NH-white patients with breast, ovarian, prostate, and colorectal cancers widened among patients with high SES or private insurance, compared to low SES or uninsured patients. In line with our findings, an earlier study also showed that death risk for NH-black compared to NH-white patients increased with higher neighborhood SES . It was In our study, Asian patients had a substantial survival advantage over NH-whites for all cancers evaluated. This may suggest that underlying genetic/biological differences, as indicated by studies on the mutational landscape in multiple cancers ,29,30, mIt is noteworthy that racial/ethnic disparities exist in all patient subgroups with different levels of access to care. This finding is consistent with data from the California Cancer Registry, in which neighborhood SES explained only 5–7% of mortality disparities between NH-white, NH-black, and Hispanic patients with breast, prostate, and colorectal cancers, and 18% with lung cancer . StudiesHigher mortality has been previously reported for almost all cancers among NH-black patients than NH-white counterparts ,35,36,37The mortality disparity after cancer diagnosis has been controversial for Hispanic compared with NH-white patients. Based on data from Surveillance, Epidemiology, and End Results (SEER) Program, the American Cancer Society reported similar 5-year survival between Hispanic and NH-white patients for almost all cancers , while sThe strengths of our study include the large number of patients and detailed information on clinical and treatment factors, which enabled us to account for a wide range of covariates and conduct subgroup analyses. We systemically evaluated the top five major cancer deaths in U.S. men and women in four major racial/ethnic categories. Using the NCDB, we included approximately 70% of eligible cancer patients diagnosed between 2000 and 2014 across the U.S., reflecting contemporary diagnostic and treatment patterns and ensuring high generalizability. There are also some limitations of our study. First, we employed neighborhood-level, rather than individual-level, education and income as a measure of SES in our study, so misclassification cannot be ruled out. Second, cancer-specific mortality and recurrence were not assessed in our study due to unavailable information. However, we carried out 3-year survival analyses and found similar disparity patterns. Third, each racial/ethnic group evaluated in this study was comprised of numerous subgroups with heterogeneous cultural and socioeconomic backgrounds; thus, the aggregated racial/ethnic group may mask the substantial heterogeneity by origin ,42. FurtIn conclusion, racial/ethnic disparities in mortality for the top seven major cancers in the U.S. exist across all populations with different access to care, even after an adjustment for a wide range of prognostic factors. Furthermore, NH-black and NH-white disparities widened, while disparities between NH-white, Hispanic, and Asian patients narrowed among patients with high SES or private insurance. While more research is needed to understand the underlying mechanisms for the different patterns of disparities across racial/ethnic groups, our findings indicate racial/ethnic-specific strategies are needed to deploy effective and targeted preventive measures.


NewWave, a scalable R/Bioconductor package for the dimensionality reduction and batch effect removal of single-cell RNA sequencing data. To achieve scalability, NewWave uses mini-batch optimization and can work with out-of-memory data, enabling users to analyze datasets with millions of cells.We present NewWave is implemented as an open-source R package available through the Bioconductor project at https://bioconductor.org/packages/NewWave/Bioinformatics online. Dimensionality reduction is a key step for the analysis of single-cell RNA-seq (scRNA-seq) data. Principal component analysis (PCA) is a simple and efficient method that can be employed for this step. However, it suffers from several drawbacks, e.g. it assumes that the data are Gaussian and does not allow to correct for technical variability and biases. While transforming the data  can ameliorate these problems, count-based factor analysis models often yield better low-dimensional data representations , known gene covariates  and latent factors (W) that define a low-dimensional space that describe the unknown biological signal  the use of shared memory objects in PSOCK clusters to avoid redundant data copies, (ii) the use of mini-batch optimization algorithms to speed-up computations and (iii) the use of out-of-memory data representations (such as HDF5 files) to limit memory usage.The three main strategies that The optimization procedure can be represented as a cycle of three steps, iterated until convergence: (i) optimization of the dispersion parameters (either common dispersion or gene-wise dispersion); (ii) optimization of gene-wise parameters and (iii) optimization of cell-wise parameters.One of the main advantages of our model specification is that it naturally results in an embarrassingly parallel task. In fact, except for the optimization of the global dispersion parameter , all the steps use only one gene (cell) at a time for the optimization of gene (cell) parameters. In addition to parallelization, this setup is ideal for mini-batch optimization strategies. At any one step, we can use a random subset of cells (genes) to estimate the gene (cell) parameters.DelayedArray package  and Akaike Information Criterion (see The application of NewWave to remove unwanted variation, we applied it to two datasets with known batch effects and showed that it leads to a good mix of batches and a good separation among putative cell types (Strikingly, the negative binomial model outperforms its zero-inflated counterpart, confirming that this is a preferable model for UMI data . To evalll types .NewWave in terms of RAM usage (In addition to speed, we measured the scalability of AM usage . As expeAM usage .NewWave is available as an open-source package through the Bioconductor project. The package includes a vignette with a tutorial. In addition, the code to reproduce all the analyses presented here is available at https://github.com/fedeago/NewWave-script.TileDB format, to speed-up data access and computations.Future work will be focused on leveraging sparse matrix formats, either in-memory or on-disk, e.g. through the This work was supported by the AIRC Foundation for Cancer Research in Italy [AIRC 21837 to C.R.]; the National Cancer Institute of the National Institutes of Health [2U24CA180996 to D.R.]; the Chan Zuckerberg Initiative DAF [CZF2019-002443 to D.R.] an advised fund of Silicon Valley Community Foundation and by University of Padova Strategic Research Infrastructure Grant 2017: ‘CAPRI: Calcolo ad Alte Prestazioni per la Ricerca e l’Innovazione’.Conflict of Interest: none declared.http://data.nemoarchive.org/biccn/lab/zeng/transcriptome/. The 10X Brain data are available through the TENxBrainData package available at https://bioconductor.org/packages/TENxBrainData. The RNA mixture data are available at https://github.com/LuyiTian/sc_mixology/.All datasets used in this paper are publicly available. The BICCN data can be downloaded from btac149_Supplementary_DataClick here for additional data file.


Conclusion: (1) Physical activity in the post-epidemic era negatively predicted anxiety and depression in school-isolated college students. (2) Emotion regulation self-efficacy in the post-epidemic era partially mediates the relationship between physical activity and anxiety and depression.Objective: To investigate the relationship between physical activity and negative emotions among college students in the post-epidemic era and determine if emotional regulation plays a mediating role between physical activity and negative emotions. Methods: 479 college students  who were under closed campus management during the epidemic period were surveyed using the physical activity rating scale (PARS-3), the self-assessment scale for anxiety (SAS), the self-esteem scale for depression (SDS), and the emotion regulation self-efficacy scale (RES). Results: (1) Physical activity, negative emotions, and emotion regulation self-efficacy among college students were significantly different by gender ( In December 2019, novel coronavirus pneumonia (COVID-19) emerged in various parts of China and has since been highly proliferative and unpredictable, seriously endangering the physical and mental health of the public. The global outbreak is still at a high level, the virus is still mutating, and there is still great uncertainty about the final course of the epidemic . This caThe psychological view of exercise is that physical activity can improve negative emotions, such as anxiety, depression, and frustration, giving individuals positive emotional experiences and improving mental health . AccordiEmotion regulation self-efficacy is an application of self-efficacy theory to emotion-regulation theory, which is developed based on emotion-related theories and refers to a degree of confidence that individuals have in managing their emotional states, which can reduce emotional tension, effectively alleviate anxiety and depression, and promote mental health ,19. AccoIn summary, this study systematically examines the relationship between physical exercise, emotion regulation self-efficacy, anxiety, and depression among college students under closed management during the new crown epidemic and the mediating role of emotion regulation self-efficacy between physical exercise, anxiety, and depression.We conducted a cross-sectional study from April to May 2022 in Yangzhou City, Jiangsu Province, located in the eastern region of China. We used college students from a university in Yangzhou City, Jiangsu Province, China, as the research object and selected a university that implemented closed management during the normalization of the epidemic through a preliminary investigation and research. Data were obtained from 479 college students aged 17–26 . We used a QR code in our study that participants could scan with their cell phones to obtain the electronic questionnaire. A total of 593 questionnaires were recovered to ensure that the data collected were rigorous and valid; the recovered questionnaires were screened and sorted, excluding questionnaires that were completed too early, randomly answered, had the same answer for every question, or had incomplete answers. A total of 479 valid questionnaires were recovered, with a valid recovery rate of 80.8%. The study protocol was approved by the Ethics Committee of the Medical College of Yangzhou University.The Physical Activity Rating Scale (PARS-3), revised by Liang Deqing, was used . The scaThe “Anxiety Scale (SAS-CR)” developed by ZUNG was used , which iThe “Depression Self-Rating Scale (SDS)” developed by ZUNG was used . The scaThe “Emotional Regulation Self-Efficacy Scale (RES)” developed by Caprara et al. was used, as modified by Wen Feng et al. . The scaThe collected data were subjected to descriptive statistics, independent samples t-test, Pearson correlation analysis using SPSS 26.0 for Windowsand the bootstrap method to test for mediating effects.Since we only used subjects’ self-reported answers to collect data in this study , the resA total of 479 college students participated in this study. The characteristics of the participants are shown in p < 0.01). Physical exercise was also significantly and negatively associated with anxiety and depression . Emotion regulation self-efficacy was significantly and negatively correlated with anxiety and depression .Pearson correlation analysis was performed for all variables . The resp < 0.01) and significantly positively predicted self-efficacy (p < 0.01); the negative predictive effect of physical activity on anxiety and depression remained significant (p < 0.01) after the inclusion of the variable of self-efficacy for emotion regulation. Thus, emotion regulation self-efficacy plays a partially mediating role between physical activity and anxiety and depression , −0.104 (44.07%); −0.167 (84.34%), and −0.031 (15.66%), respectively .The results of this study showed that male college students scored higher than female college students in physical activity when the campus experienced closed management during the epidemic, which is consistent with previous studies ,35,36. TThe results of the correlation analysis showed that physical activity significantly and negatively predicted anxiety and depression, and hypothesis 1 was valid. Participation in physical activity during the Newcastle pneumonia epidemic can improve individuals’ negative emotions, reduce stress, and improve college students’ mental health ,40. A loThe results of the mediation effect analysis showed that emotion regulation self-efficacy partially mediated the relationship between physical activity and negative emotions, and research hypothesis 2 was tested. It was shown that individuals’ physical activity participation was positively related to emotion regulation self-efficacy, which in turn was indirectly negatively related to anxiety and depression. It has been shown that the direct effect of emotion regulation self-efficacy on anxiety and depression is greater than that of physical exercise and that the effect of physical exercise is mostly manifested through indirect effects , which iThere are also some limitations to this study. First, the measurements in this study were all online self-assessment data, which lacked objectivity, and future studies should construct more objective measurement indicators with the help of modern instruments and equipment. Second, this study is cross-sectional, which means it can be analyzed from a longitudinal perspective in future studies. Finally, this study analyzed only the total score for the variable of emotion regulation self-efficacy, which can be analyzed in a multidimensional way in future studies to further investigate the mediating role played by this variable.Physical activity in the post-epidemic era negatively predicts anxiety and depression in school-isolated college students.Emotion regulation self-efficacy in the post-epidemic era partially mediates the role between physical activity, anxiety, and depression.