Overactive bladder (OAB) is a global problem reducing the quality of life of patients and increasing the costs of any healthcare system. The etiology of OAB is understudied but likely involves supraspinal network alterations. Here, we characterized supraspinal resting-state functional connectivity in 12 OAB patients and 12 healthy controls (HC) who were younger than 60 years. Independent component analysis showed that OAB patients had a weaker presence of the salience (Cohen’s d = 0.9) and default mode network (Cohen’s d = 1.1) and weaker directed connectivity between the fronto-parietal network and salience network with a longer lag time compared to HC. A region of interest analysis demonstrated weaker connectivity in OAB compared to HC (Cohen’s d > 1.6 or < −1.6), particularly within the frontal and prefrontal cortices. In addition, weaker seed  to voxel  connectivity was found in OAB compared to HC (Cohen’s d > 1.9). The degree of deviation in supraspinal connectivity in OAB patients (relative to HC) appears to be an indicator of the severity of the lower urinary tract symptoms and an indication that such symptoms are directly related to functional supraspinal alterations. Thus, future OAB therapy options should also consider supraspinal targets, while neuroimaging techniques should be given more consideration in the quest for better phenotyping of OAB. Overactive bladder (OAB) is a syndrome or symptom complex with the main lower urinary tract symptom (LUTS) urinary urgency, which is usually associated with urinary frequency and nocturia, with or without urgency urinary incontinence . It affeThe diagnosis of OAB is currently still based exclusively on anamnestic symptoms, whereby undefined “obvious” pathologies should be ruled out beforehand ,8. As a Given the nature of OAB symptoms and the complex neuronal control of the lower urinary tract (LUT), it is reasonable to assume that changes in this neuronal control are of relevance in the pathophysiology of OAB. The brain, in particular, plays a crucial role in controlling the LUT, as it learns to do so during infancy and contains the most relevant LUT control areas ,15. HoweResting-state functional magnetic resonance imaging (rs-fMRI) can help to identify alterations in central resting-state networks, such as the default mode network (DMN), frontoparietal network (FPN), and the salience network (SAN) ,19. ThesThe question under investigation in this exploratory rs-fMRI study is whether alterations in supraspinal connectivity, including the presence and interaction of central resting-state networks, such as the SAN and DMN, but also region of interest (ROI)-to-ROI and seed-to-voxel interactions are already present and measurable using rs-fMRI in female OAB patients (<60 years) without bladder task/stimulation compared to healthy controls (HC) and if such alterations in FC at least partly correlate with their OAB symptoms. Considering the aforementioned relevance of supraspinal processes in controlling the LUT, their potential role in the etiology of OAB, previous fMRI findings ,27,28, aWe enrolled right-handed females (age 18–55 years) who were suitable for magnetic resonance (MR) imaging and were either diagnosed with OAB or were healthy controls (HCs) without LUTS. In order to assess the absence or degree/severity of LUTS, anxiety, depression, and cognitive impairment, all participants were asked to complete validated German versions of a battery of standardized questionnaires. The International Consultation on Incontinence Modular Questionnaire  on LUTS for women (ICIQ-FLUTS) is a validated 12-item questionnaire consisting of three subscales  that has been widely used to measure lower urinary tract symptoms in women . The OvePrior to undergoing magnetic resonance imaging (MRI), all participants were required to refrain from consuming any products containing caffeine or nicotine for at least six hours. Upon arrival, participants emptied their urinary bladder, underwent urinalysis to rule out urinary tract infection (UTI) or pregnancy, and changed into standard scrubs with all ferromagnetic items removed. In order to monitor for adverse events such as UTI, participants were interviewed via telephone or email within one week after the MRI session.3, field of view: 256 × 256 × 180 mm, matrix: 256 × 256 mm, slices: 180 slices, scan time: 305 s, repetition time (TR) = 6.92 ms, echo time (TE) = 3.1 ms, no inter-slice gap, and flip angle = 8°).We collected structural and functional MRI (fMRI) data using a Philips Ingenia 3-Tesla scanner  equipped with a 15-channel Philips Sense head coil. The acquisition included high-resolution three-dimensional T1-weighted turbo field gradient echo pulse sequences that covered the entire cerebrum and cervical spinal cord  planar imaging pulse sequence. Thirty-four axial slices covered the entire cerebrum in ascending order . All images were obtained in an oblique axial orientation covering the entire brain, including the cerebellum and rostral brainstem (including the pons). The first four scans were dummy scans to reach steady-state magnetization. We examined rs-fMRI during an empty bladder condition .https://web.conn-toolbox.org/ (accessed on 12 September 2022)) [https://www.fil.ion.ucl.ac.uk/spm/software/spm12/ (accessed on 12 September 2022)) to perform fMRI data pre-processing and rs-fMRI connectivity analyses. CONN employs an anatomical component-based noise correction method (CompCor), which enhances specificity and accuracy, and enables greater consistency across scans [We used the CONN toolbox )  implemenss scans . Additioss scans . To furtss scans . SpecifiTo assess the FC pattern in OAB vs. HC, we applied four FC approaches: independent component analysis (ICA), ROI-to-ROI connectivity, seed-to-voxel connectivity, and directed connectivity:ICA: Twenty independent components (ICs) were extracted (default setting in CONN) for the rs-fMRI run across all subjects. ICs related to head motion or artifacts were not considered (ICs = 6). The remaining 14 ICs were labeled as follows: cerebellum, fronto-parietal attention network , DMN , early and higher visual cortex, somatosensory network, auditory cortex (2 ICs), SAN  only). Based on our hypothesis and to reduce the number of statistical comparisons, we focussed on three networks: bilateral DMN (1 IC), bilateral frontoparietal network , and bilateral SAN (1 IC).ROI-to-ROI connectivity: Connectivity was estimated from 146 ROIs based on the AAL atlas [AL atlas  and two AL atlas , i.e., tSeed-to-voxel connectivity: We used two seed regions based on our previous publication [lication : (a) rigDirected connectivity: The MATLAB GIFT toolbox (https://www.nitrc.org/projects/gift (accessed on 12 September 2022)) and Functional Network Connectivity Toolbox ) were used to estimate the temporal dynamics of FC between the DMN, FPN, and SAN (deduced from the ICA) [p-value is calculated as part of a permutation test and represents the proportion of permuted datasets in which the correlation between three networks at a given time lag is equal to or greater than the correlation in the original data . A lag p-value of less than 1 indicates that the observed correlation at the given time lag is higher than what would be expected by chance based on the corresponding permuted data. This suggests that the correlation is unlikely to have occurred by chance [the ICA) . In partthe ICA) ,40. In ty chance .p < 0.05 corrected, i.e., cluster-corrected [All analyses were calculated using two-tailed independent t-tests. All results are reported at orrected  or correorrected . For theCohen’s d = 2 t/√(df), with n1 (HC = 12) = n2 (OAB = 12) and degree of freedom (df) = 22 ,45,46.In addition, to assess the effect of the main clinical symptoms, i.e., urinary urgency, urinary frequency, and urgency urinary incontinence (UUI) episodes, we included the data from the 3-day bladder diaries on all three symptoms as covariates of interest into the statistical model and performed seed (right AIC and right VLPFC) to voxel Pearson correlations .Descriptive statistics of population characteristics are displayed as medians and range from the lower (25th percentile) to upper (75th percentile) quartile for all continuous and discrete variables , under tTwenty-four right-handed female participants, 12 with OAB  and 12 HCs without LUTS , were recruited and included in the analyses. According to their selection , OAB andThe results of the ICA showed a weaker presence of the SAN and DMN in OAB patients compared to HC, as depicted in The ROI-to-ROI connectivity analysis revealed that, across all examined regions, OAB patients exhibited weaker FC between various brain regions predominantly located in the prefrontal cortex, such as the inferior frontal gyrus (IFG), frontal operculum (FO), ACC, orbitofrontal cortex (OFC), and rostral prefrontal cortex (rPFC) . Only onp-voxel < 0.0001 with p < 0.05 cluster level correction), the connection between the right OFC and left rPFC remained weaker in the OAB group.At a more conservative statistical threshold . The right AIC seed demonstrated weaker connectivity in the OAB group with the ACC A, IFG, SThe directed connectivity analysis revealed that the SAN-FPN connectivity was weaker in the OAB group. In addition, the SAN was activated on average 0.7 s later than the FPN in OAB patients compared to HC .Correlating the number of urinary urgencies, urinary frequency, and UUI episodes from the 3-day bladder diary with the seed (right AIC and right VLPFC) to voxel connectivity in the OAB group revealed positive (=increasing with the number of urinary urgency/frequency or UUI episodes) and negative (=decreasing with the number of urinary urgency/frequency or UUI episodes) correlations summarized in This study supports our biological hypothesis that patients with OAB exhibit reduced resting-state brain FC compared to healthy controls (HCs). Specifically, we observed weaker FC in components of the SAN as well as the frontal and prefrontal cortices among patients with OAB.In the context of LUT control, an intact SAN connectivity and interaction with the DMN and FPN would refer to the ability to timely detect ascending bladder signals, i.e., desire to void, to appropriately evaluate this information, i.e., how and to what extent has the desire to void increased over time and how strong is the desire to void in relation to the spatial and temporal possibility of going to the toilet, and to take according action, i.e., going to the toilette immediately or postpone it to a later more convenient time point. In patients with OAB, these abilities seem to be lost or at least impaired, represented by the reduced SAN, ROI-to-ROI , and seed  to voxel  connectivity.In line with our previous findings using task-based fMRI , demonstPrevious neuroimaging studies in humans have demonstrated the importance of the dorsal ACC/medial SFG and the bilateral AIC/FO brain regions during task control, involving task initiation, maintenance, and feedback/adjustment ,50. FurtWhile comparability with previous MRI studies investigating differences in resting-state FC between HC and individuals with OAB/UUI is often challenging and therefore needs to be viewed with some caution due to differences in population characteristics, imaging parameters, and statistical methods, our current results appear to be in general agreement with the few available similar studies ,54,55,56However, there is also evidence that the FC in OAB patients is not always inferior to that in HC in all areas. Zuo et al. showed that short-range FC strength was increased in OAB in the middle frontal gyrus, right precentral gyrus, and bilateral caudate nucleus, which was interpreted as compensatory pathways related to impaired response inhibition of the brain–bladder control network . Ketai eThese aforementioned apparently discrepant results may very well represent compensatory changes in the context of OAB/UUI, as described by the respective authors themselves. As a result, they would not necessarily be contradictory, but possibly even complementary, since they remain part of a spectrum of the same problem if one assumes, for example, that there are most probably different types and stages of OAB in relation to their development and clinical expression ,66,67. HThese findings may offer an explanation to the questions surrounding the current first-line therapy for OAB, which involves antimuscarinic drugs. Specifically, they may shed light on the reasons why there is a relevant placebo effect, as well as why many patients ultimately discontinue therapy due to a poor effect-to-side-effect ratio, despite the initial therapeutic benefit : The theDespite that, previous neuroimaging studies have indicated that altered supraspinal processes play a role in OAB ,26, yet The MRI investigation was only performed once; therefore, no statement can be made about the dynamics or development of the supraspinal connectivity. In this regard, longitudinal data would be relevant in the future in order to understand the course and development of the supraspinal changes in relation to the symptoms and clinical parameters. Despite all efforts to recruit a well-defined group of OAB patients for this study (i.e., strict in-/exclusion criteria according to current knowledge and standard with extensive screening, This rs-fMRI study demonstrates that OAB patients, compared to HCs, have deficits in resting-state brain connectivity. Particularly large-scale brain networks such as the DMN and the SAN, as well as their interactions, seem to be disturbed in OAB. Moreover, connectivity to and within frontal/prefrontal cortices is diminished in OAB compared to HCs. Such alterations correlated positively with symptom severity, i.e., the number of urinary urgency and UUI episodes. Hence, these findings provide further evidence that etiologies and, consequently, therapy targets of OAB must be considered beyond the LUT, i.e., on the supraspinal level. Especially concerning the efforts to improve the phenotyping of the OAB and to assess the effect of OAB therapies on neuronal LUT control, it will be increasingly necessary to consider and advance the use of neuroimaging methods in this area of functional urology and neuro-urology.


Automatic liver segmentation is a key component for performing computer-assisted hepatic procedures. The task is challenging due to the high variability in organ appearance, numerous imaging modalities, and limited availability of labels. Moreover, strong generalization performance is required in real-world scenarios. However, existing supervised methods cannot be applied to data not seen during training (i.e. in the wild) because they generalize poorly.We propose to distill knowledge from a powerful model with our novel contrastive distillation scheme. We use a pre-trained large neural network to train our smaller model. A key novelty is to map neighboring slices close together in the latent representation, while mapping distant slices far away. Then, we use ground-truth labels to learn a U-Net style upsampling path and recover the segmentation map.The pipeline is proven to be robust enough to perform state-of-the-art inference on target unseen domains. We carried out an extensive experimental validation using six common abdominal datasets, covering multiple modalities, as well as 18 patient datasets from the Innsbruck University Hospital. A sub-second inference time and a data-efficient training pipeline make it possible to scale our method to real-world conditions.We propose a novel contrastive distillation scheme for automatic liver segmentation. A limited set of assumptions and superior performance to state-of-the-art techniques make our method a candidate for application to real-world scenarios.The online version contains supplementary material available at 10.1007/s11548-023-02912-3. Despite efforts in computer vision (CV) and medical image analysis, the task is still considered unsolved. Recently, fully supervised deep learning methods have achieved human-level segmentation performance on synthetic datasets [Medical image segmentation is a key step toward automatic computer-assisted procedures. The high variability of organ appearance, numerous different modalities, the absence of texture contrast, and the limited availability of labels are some of the challenges of segmenting medical scans datasets –3. Howevdatasets , where adatasets . The lardatasets . The disdatasets  (a commodatasets  (a commoz-axis of the scans) are mapped close together in the latent space, while distant slices are mapped far away, when measured e.g. with cosine similarity. Then, we perform a U-Net-style upsampling to recover the segmentation prediction. An overview of the pipeline can be seen in Fig. Related to this, in this paper we address the problem of automatic liver segmentation in the wild. Our input data are 3D tomographic scans obtained from medical imaging, which are processed as a set of 2D slices along the axial direction. Our pipeline does not undergo any pre-training or self-supervised phase. We train on a small number of labeled inputs from one or more source domains and perform inference on the unseen target domains. Our method learns to construct a robust latent representation from abdominal scans with a novel contrastive “distillation” scheme. We transfer knowledge from a pre-trained large model to our smaller model under a contrastive framework by imposing that neighboring slices  self-supervised Vision Transformer (ViT) [vided in  and empler (ViT)  as featuContrastive distillation In the second step, we carry out contrastive distillation on the obtained features. Given a feature extractor x, y, the metric h, w) and , respectively:c is the channel dimension. Based on this, we determine the distillation loss x to learn a nonlinear transformation of the preliminary feature tensor:b is a hyper-parameter to prevent collapse. Here, ollowing . It is iduced in , \documeContrastive sampling strategy To work with a wide range of liver shapes and positions, our method takes into account the relative position of a slice in the scan. A sampling strategy with pre-defined thresholds provides false positives and negatives due to the high variance of liver metrics between patients. Therefore, we propose to obtain positives from neighboring slices . Fu. FuExperFor training, we employ the RAdam optimizer  that fac TorchIO  were empMetrics For comparison we use the DICE metric, which is the only metric consistently reported in related work. It estimates similarity of two samples via the number of pixels in common. Statistical significance of our results is examined via p-values from paired t-tests on directly compared DICE coefficients . Any standard deviations are computed across scans. In the following tables, the best statistically significant results , and obtained a DICE score of In addition to the DICE results reported above, we also examined two further salients: average symmetric surface distance (ASSD) and maximum symmetric surface distance (MSSD). The former computes the average distance between the predicted and the ground truth surface, while the latter considers only the maximum distance. These values are often not reported in related work, but we consider them useful from a clinical perspective. They evaluate the error on the real-world-dimensions of a scan, not just on pixels. The ASSD metric was under 1.3 mm in each experiment  interventions [ventions . An overAblation studies We conducted several ablation studies, on training data, pipeline, contrastive distillation loss, objective loss, and contrastive sampling strategy. For this, we examined inference on the BTCV dataset, as it showed the lowest performance . Results are reported in Table i-th slice of a scan I, where I. The target inference dataset is again BTCV. Sampling positive samples from neighboring slices, and negative samples from the farthest possible yielded overall the best performance.Next, we examined the influence of our sampling strategy for positive and negative samples. Different approaches for obtaining these samples were compared. Results are compiled in Table RS) or the usage of a different dataset (ACT-1K) did not influence the inference performance. Further, as expected, using more powerful backbones (ViT with patch resolution of 8) improved the performance. Regarding the loss functions, dropping the contrastive distillation (see row 9) yielded a significant drop in performance. We also note that omitting the Finally, we studied the influence of training data, different data splits, backbone sizes, and loss functions. The results are compiled in Table Comparison with state-of-the-art and limitations Overall, the experimental results show that our method surpasses the performance of state-of-the-art multi-DG methods with statistical significance. Our method also performed better than fully supervised methods in the case of LiTS inference. When comparing with single-DG methods, there is a significant performance improvement over the state-of-the-art [-the-art . FinallyAs a limitation, our method has difficulties in predicting the segmentation map at the bottom of the liver. We hypothesize the reason for this is the downsampling in the pre-processing steps, since it may misalign the learned convolution kernels with the tiny liver part. This could be solved by using higher-resolution slices. As evidenced by evaluations on the clinical scans, the scans in hepatic arterial phase are easier to segment than the other phases; the scans with no contrast enhancement are the most difficult to segment.Our novel contrastive distillation scheme showed great potential for automatic liver segmentation in the wild. Thorough ablation studies and empirical results on common test datasets and real-world scans support these findings. Our next steps aim at multi-modal multi-organ segmentation, as this is critical for computer-assisted hepatic procedures. Using powerful backbone architectures has a beneficial effect on performance, however, there is a clear discrepancy between what can be achieved in the natural imaging domain and the medical imaging domain. We will explore cross-domain knowledge transfer that was recently reported in other domains.3Supplementary file 1 (pdf 2438 KB)Supplementary file 2 (mp4 1112 KB)Supplementary file 3 (mp4 1446 KB)Below is the link to the electronic supplementary material.


Multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR TB) is a global concern, with 450,000 new cases and 191,000 deaths in 2021. TB and chronic kidney disease (CKD) have been associated since 1974, with suggested explanations such as oxidative stress, malnutrition, dysfunction in vitamin D metabolism, and a compromised cell-mediated immune response. End-stage renal failure patients are more likely to acquire drug resistance due to poor adherence, adverse drug reactions, and inappropriate dose adjustment. We then aim to evaluate the therapeutic outcome of multidrug-resistant TB of the lungs in patients who require hemodialysis in terms of successful treatment (cured and treatment completed) and the associated factors for a favorable outcome. Our secondary goal is to identify unfavorable treatment outcomes  and the underlying associated factors. We conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Guidelines for this systematic review. We included adults (>19 years old) with chronic kidney disease who needed hemodialysis and had microbiologically confirmed multidrug-resistant pulmonary TB, excluding patients who had a renal allograft transplant, were on peritoneal dialysis, had extrapulmonary TB, were children and pregnant patients. We searched PubMed, MEDLINE, PubMed Central, ScienceDirect, Public Library of Science (PLOS), and Google Scholar. Keywords were combined with the Boolean "AND" operator to gather results as well as the medical subject heading (MeSH) search strategy. After screening study articles by reading their titles and abstracts, the following tools were used to assess the risk of bias: the Newcastle-Ottawa scale for observational studies, the Assessment of Multiple Systematic Reviews (AMSTAR) checklist for systematic reviews, and the Joanna Briggs Institute (JBI) assessment tool for case reports. Primary and secondary outcomes were assessed, and a conclusion was made.We gathered 21,570 studies from the databases between 2013 and 2023, with 30,062 total participants. There were eight eligible studies for review. Patients with CKD, particularly those on dialysis, are at increased risk of TB due to a combination of factors that contribute to immunosuppression. TB reactivation is common in chronic renal failure patients. Diagnostic samples such as sputum and pleural fluid had lower sensitivity rates compared to tissue samples, which led to delays in diagnosis and treatment and, most importantly, contributed to drug resistance. All new dialysis patients should undergo interferon-gamma release assay testing. TB-infected patients with severe renal disease (eGFR 30 ml/min) had increased morbidity and mortality; however, the use of directly observed treatment, short-course (DOTS), and renal-dose adjustment of anti-TB medications significantly reduced these risks. Drug-induced hepatitis and cutaneous reactions were common adverse effects of anti-TB medications. A therapeutic drug monitoring guideline is required to reduce these adverse events and even mortality. Additional research is required to assess the safety and efficacy of therapeutic regimens, as well as their outcomes, in this population with multidrug-resistant TB. Tuberculosis (TB) is an ancient illness that has not yet been eradicated. In 2021, a projected 10.6 million people were infected with TB, a 4.5% increase over 2020's figure of 10.1 million [The connection between TB and chronic renal failure has been known since 1974, with suggested explanations such as oxidative stress, malnutrition, dysfunction in vitamin D metabolism, and a compromised cell-mediated immune response . Due to Patients with end-stage renal disease (ESRD) have a 92-day average delay in TB treatment due to their multitude of clinical presentations and radiographic findings . During In addition, inappropriate anti-TB drug dosage leads to treatment failure or increased adverse effects . DosagesManagement of multidrug-resistant TB is more intricate and requires second-line drugs with more adverse effects and an extended treatment period . RecommeBai et al. found that few studies are exploring the consequences of TB infection on dialysis patients . In theiEnd-stage renal failure patients are more likely to develop drug resistance due to poor patient adherence to the therapeutic regimen, adverse drug reactions, and inappropriate dosage adjustment. Multidrug resistance is uncommon in HD patients, but they are at increased risk for these reasons. There were negligible studies involving end-stage renal failure patients on HD afflicted with multidrug-resistant pulmonary TB and their treatment outcomes. Investigations regarding the relationship between these two were not yet exhausted, which could elucidate the factors resulting in poor treatment outcomes.Therefore, the aim of this review is to assess the treatment outcome of multidrug-resistant pulmonary TB in patients with end-stage renal disease who require HD in terms of successful treatment, including cured and treatment completed, as well as the associated factors. Our secondary goal is to identify unfavorable treatment outcomes, such as treatment failure, patient death, or loss of follow-up, and the underlying factors contributing to them.MethodsThis systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines .Eligibility criteriaInclusion and Exclusion CriteriaPopulation: We included adult (more than 19 years old) chronic kidney disease (CKD) patients who needed HD and had microbiologically confirmed multidrug-resistant pulmonary TB, excluding patients who had renal allograft transplant, were on peritoneal dialysis, had extrapulmonary TB, were children, and were pregnant.Intervention: We considered guideline (WHO)-directed treatment for multidrug-resistant pulmonary TB. We excluded studies in which intervention was related to the surgical technique and non-medical therapy.Outcome: To be eligible for inclusion, a trial had to use a defined clinical outcome related to successful treatment (cured and treatment completed) or a poor therapeutic outcome . Our primary outcome measure is the success rate of MDR pulmonary TB treatment among chronic renal failure patients requiring HD (cured and treatment completed). Our secondary outcome is the incidence of unfavorable treatment outcomes .Treatment outcome definition based on the WHOTreatment success - the total number of treatments completed and cured .Cured - a patient with pulmonary TB, bacteriologically proven, who started therapy with TB and finished treatment as advised by the national policy with evidence of bacteriological response and no failure evidence.Treatment completed - a patient who received the recommended course of therapy in accordance with national policy but whose results did not fulfill the criteria for cured or treatment failed.Treatment failed - a patient whose treatment plan must be stopped or switched permanently to another regimen or treatment approach.Died - a patient who passed away either before or during treatment.Lost to follow-up - a patient who has gone more than two months without receiving any treatment, or whose treatment was interrupted for more than two months.We included journals published within the last 10 years , which were in English language, had human subjects, and were peer-reviewed, in full-text, and open-access articles. Eligible studies included were randomized control trials, systematic reviews and meta-analyses, narrative reviews, case-control studies, retrospective cohort studies, prospective cohort studies, and case reports. We excluded papers published as gray literature and unpublished manuscripts.Information sources and search strategyFrom December 26, 2022, to January 15, 2023, we searched PubMed, MEDLINE, PubMed Central, ScienceDirect, Public Library of Science (PLOS), and Google Scholar using keywords such as Mycobacterium tuberculosis, pulmonary tuberculosis, multidrug-resistant pulmonary TB, chronic kidney disease, renal failure, and treatment outcome. Keywords were combined with the Boolean "AND" operator to generate results. Furthermore, the medical subject heading (MeSH) search strategy was used. The complete keyword and MeSH search strategy is shown in Table Selection processWe moved the articles to Endnote and eliminated duplicate records. The titles and abstracts of each study article were reviewed. GH (the first author) independently assessed these and used the inclusion and exclusion criteria to evaluate the full-text articles.Quality assessment of studiesWe used the Newcastle-Ottawa tool for observational studies, the Assessment of Multiple Systematic Reviews (AMSTAR) checklist for systematic reviews, and the Joanna Briggs Institute (JBI) for case reports to assess the risk of bias.Data collection processPrimary and secondary outcomes were assessed after articles were systematically reviewed and extracted. GH extracted information independently using a standardized form. The following information was gathered: authorship and year of publication, study design, study objective, study size, population, results, treatment outcomes, and conclusion.ResultsStudy Identification and SelectionOur literature search generated 21,570 results from the aforementioned databases. After applying filters , there were 13,885 studies discovered. We removed 21 duplicate articles. We discovered 140 studies after reviewing the titles and abstracts, of which 22 were eligible for analysis. We eliminated 17 publications for failing to meet eligibility requirements when evaluated in full text. There were eight papers integrated for the final review. The full search strategy for the literature is shown using the PRISMA flow chart in Figure Outcomes MeasuredThe primary outcome measured was treatment success (cured and treatment completed). The secondary outcome was unfavorable treatment outcome  and associated factors.Eight articles were evaluated for eligibility using the appropriate tools for quality assessment. Among the eight eligible studies, six observational studies  to determine the success of TB treatment . There wPark et al. discussed two case reports of male ESRD patients on HD from South Korea who were diagnosed with pulmonary MDR-TB and given bedaquiline-containing regimens to treat their condition . The aveSamuels et al. conducted a systematic review and meta-analysis study of 18 studies and 257 participants with MDR or XDR-TB and included 48 studies published from 1996 to 2016 with a median population of 235 (60-1768) . Their pTable DiscussionJuno and colleagues conducted exhaustive research on the relationship between end-stage renal disease and increased susceptibility to infectious diseases like TB . MucosalFurthermore, T cell populations such as gamma delta (gd) T-cells are thought to protect against Mycobacterium TB infection and can boost CD4+ and CD8+ T cell responses . T-cellsMDR-TB and XDR-TB are major impediments to global TB elimination . MultidrMDR TB Treatment Outcome in CKDIt is uncommon for end-stage renal failure patients to develop multidrug-resistant TB, and negligible studies are probing their association. From the facts gathered, we believe this is the first systematic review investigating the relationship between multidrug resistance in pulmonary TB and its therapeutic outcomes among patients with renal dysfunction requiring HD. There were two studies that assessed this relationship. Park et al. described two case reports of a successful therapeutic outcome for HD patients with multidrug-resistant pulmonary TB using a regimen containing bedaquiline . HoweverNovel Drug for MDR TBIn a case report by Park et al., treatment outcomes for a bedaquiline-containing regimen for two HD patients with multidrug-resistant TB were successful, without clinically significant cardiac events or significant QT prolongation . In end-Successful Therapeutic Outcomes of PTB in CKDIn a case report, Park et al. reported the favorable treatment outcome of two HD patients who developed multidrug-resistant pulmonary TB . The firA satisfactory treatment outcome was found in the research carried out by Metry and colleagues, as 84% of the patients diagnosed with renal failure were able to finish the prescribed course of anti-TB treatment . Due to Treatment success is essential for the management of TB since the failure of treatment encourages the spread of active TB and the development of resistance to anti-TB drugs . NonetheAdverse Effects of Anti-TB therapy in ESRD PatientsTwo studies reported several adverse effects of anti-TB medications in end-stage renal failure patients. ESRD patients treated with anti-TB drugs had a higher risk of developing drug-induced hepatitis and death while receiving treatment . AccordiPhysicians may briefly discontinue anti-TB medication depending on the severity of the reaction, and permanent discontinuation is done when undesirable effects recur . It is pFigure Risk Factors for Morbidity and MortalityBaghaei and Carr et al. found that patients who had chronic renal disease beginning at an eGFR of 45 ml/min had a higher risk of dying from any cause compared to TB patients whose eGFR was greater than 60 ml/min ,13. TheyAli et al. reinforced the concept that HD patients with pulmonary TB had a lower chance of survival due to a failure to detect drug resistance . ClinicaCarr and colleagues highlighted the role of severe renal dysfunction (eGFR<30ml/min) in TB-related mortality, which may be attributable to the additive effects of malnutrition and immunosuppression . They coLimitationsOur study was limited to a small sample of HD patients with multidrug-resistant pulmonary tuberculosis. As a result, the primary and secondary outcomes of interest were not thoroughly investigated.Patients with CKD, particularly those on dialysis, are extremely susceptible to tuberculosis due to the immunosuppression caused by multiple factors. This infection poses a threat of morbidity and mortality to the population. Controlling comorbidities, ensuring early tuberculosis detection and treatment, detecting drug resistance, and ensuring DOTS adherence can reduce these risks. All new dialysis patients should routinely undergo IGRA testing. In this population, drug-induced hepatitis and cutaneous reactions are the most common adverse drug reactions associated with anti-tuberculosis medication. Due to their altered drug metabolism, these patients require a therapeutic drug monitoring guideline in order to reduce adverse effects and even mortality. Additional research is necessary to determine the safety, efficacy, and outcomes of therapeutic regimens in this population with multidrug-resistant tuberculosis.


There is emerging evidence that stimulants warrant further investigation as a treatment for bulimia nervosa (BN) including a recent open-label feasibility trial examining the use of lisdexamfetamine dimestylate (LDX) for BN. The current report presents the secondary outcomes and qualitative interview results from that feasibility trial. These outcomes explore several purported mechanisms that may explain how stimulants affect symptoms of BN: appetite, impulsivity, obsessive and compulsive symptoms, eating disorder psychopathology/impairment and reward-based decision-making.Twenty-three participants with BN received LDX for eight weeks. Questionnaires assessing appetite, impulsivity, obsessive and compulsive symptoms, eating disorder psychopathology and impairment were administered at baseline and post-treatment. Participants also completed a two-step reinforcement learning task to assess their decision-making. Semi-structured interviews took place at baseline, week 5, and follow-up.Reductions in hunger, food-related impulsivity, obsessive and compulsive features, eating disorder psychopathology and impairment were found. However, reward learning, as far as it is assessed by the task, did not seem to contribute to the effect of LDX on BN symptoms. Qualitative analysis suggested four themes: (1) reprieve from the eating disorder, (2) improvement in function and quality of life, (3) renewed hope for recovery, and (4) ability to normalize eating.This report suggests several potential mechanisms by which LDX may reduce symptoms of binging and purging in those with BN. Importantly, due to the open-label design, we are unable to attribute findings to the medication. Instead, our results should be interpreted as hypothesis generating to inform future studies such as adequately powered randomized controlled trials.Trial registration NCT03397446.The online version contains supplementary material available at 10.1186/s40337-023-00796-x. Recent research suggests that stimulant medications could be a potential treatment for bulimia nervosa (BN). Participants in this study took lisdexamfetamine dimesylate (LDX) for 8 weeks while their eating disorder symptoms and medical status were carefully monitored. As part of this study, twenty-three participants with BN completed several interviews, questionnaires and computer tasks at the start and end of treatment which were delivered to help researchers learn more about the how LDX impacts people with BN. Scores on questionnaires measuring different aspects of the eating disorder improved over time. Participants’ performance on the computer task which measures a type of decision making did not change during treatment. Interviews exploring participants’ experience taking LDX found four common themes: reprieve from the eating disorder, improvement in function and quality of life, renewed hope for recovery, and ability to normalize eating. This report suggests several potential ways LDX may reduce symptoms of binging and purging in those with BN. Importantly, due to the size and type of study, we cannot conclude that changes observed were a direct result of the medication. Instead, our results should be used to form new questions that can be explored by larger studies with controlled designs.The online version contains supplementary material available at 10.1186/s40337-023-00796-x. The limited effectiveness of existing treatments  for buliStimulants are purported to impact the symptoms of binge eating in BED and BN through multiple mechanisms including reducing appetite, impulsivity, obsessive and compulsive symptoms, and affecting reward-based decision-making , 5–7.Regarding reduced appetite, evidence from pre-clinical rat studies , 9 and LAnimal models of impulsivity  have shown the tendency of binge-eating rats to act without regard for future consequences (non-planning impulsivity) compared to non-binge-eating rats , 10. MorBinge eating has been associated with compulsive responding, or the tendency to engage in repetitive, or habitual behaviors despite negative consequences . ReductiLastly, there has been research interest in reward-based decision-making deficits in BN; specifically, three putative mechanisms warrant further examination: (1) goal directed (model-based) vs. habitual (model-free) control, (2) learning rate, and (3) the exploration/exploitation trade-off , with 18 completing the study . Please note that while one participant prematurely dropped out, they did so for non-exclusionary reasons, took their maintenance dose of LDX for 39 days, and completed their final data collection. As such, they are included in the completer analysis. See Dixon [Twenty-three participants with moderate to extreme BN were enrolled   which isThe Barratt Impulsiveness Scale, Version 11 (BIS-11) [The Yale-Brown Obsessive-Compulsive Scale Modified for Binge Eating (YBOCS-BE)  is a modThe Eating Disorder Examination 17.0D (EDE)  was seleThe Clinical Impairment Assessment questionnaire (CIA)  is a 16-The Two-Step Reinforcement Learning Task  is a comSemi-structured interviews were completed at baseline, following medication titration (week 5), and during the follow-up visit. Baseline interviews focused on expectations for treatment with LDX and prior experiences with ED treatments. The week 5 and follow-up interviews explored participants’ experiences with the medication for symptoms related to their BN. The interview guide was developed by LD and refined by ARK and other team members  results compared post or last observation carried forward (LOCF) to baseline, while Completer Sample (CS) results compared post to baseline. For the reinforcement learning outcomes, computational learning models were fit to subjects’ trial-by-trial behaviours to quantify (A) the likely decision-making strategy being used and (B) the degree to which specific model parameters, such as model-based/model-free control, exploration-exploitation balance, and learning rate were used at each time point . In qualitative interviews, participants described a greater degree of control over their binge eating and purging behaviors while taking LDX, including increased ability to consider the outcomes of binge eating/purging instead of acting impulsively on these urges . There were mixed responses regarding thoughts about body image/shape/weight as some participants continued to experience these thoughts while others noted these thoughts were less prominent or impactful.Both the CS and ITT sample demonstrated reduced impairment corresponding to large effect sizes. See Table At all time points, participants used habitual (model-free) control during the completion of the two-step task  reprieve from the ED, 2) improvement in function and quality of life, (3) renewed hope for recovery, and (4) ability to normalize eating. See Table  improvemIn this open-label feasibility study with 23 participants, reductions in hunger (without a corresponding increase in restraint as per the EDE and TFEQ), eating-related impulsivity, bulimia-related obsessions and compulsions, eating disorder psychopathology, and impairment were observed. The expected improvements in reward-based decision-making were not observed.too high at baseline and construed the LDX as reducing their hunger to normalized levels. However, since hunger measurement in this study was subjective, it is not clear whether participants were objectively experiencing excessive hunger at baseline. Instead, they may have been experiencing subjective distress about normal degrees of hunger and the LDX may have suppressed their hunger to below normal levels.Based on the TFEQ hunger subscale score changes and Themes 1 and 4, participants experienced a reduction in hunger that was often described as ‘excessive’ at baseline. In other words, these participants interpreted their hunger as Notably, despite observing decreased hunger per the TFEQ and decreased appetite , levelsResults demonstrated a large reduction in TFEQ Disinhibition (food/eating specific impulsivity), but only a small or negligible reduction in BIS-11 impulsivity scales . This difference may be accounted for by the degree to which each type of impulsivity was present in the sample at baseline. The average TFEQ Disinhibition score was clinically elevated at baseline and thus had the potential for significant improvement, while the BIS-11 impulsivity scales were not elevated at baseline relative to clinical norms, thereby leaving less potential for such improvement. Notably, participants with ADHD were excluded from the trial .Our results were not consistent with other studies that found improvements in non-planning impulsivity  and non-non-appetite related changes to brain regions involved in compulsivity .Reductions on all subscales and the Global score of the EDE were observed and these quantitative results are supported by qualitative findings. Participants generally described reduced frequency and intensity of eating disorder cognitions during the study. For some, one exception was concerns about weight and shape. Although reductions in scores on the Weight Concern and Shape Concern subscales were observed on quantitative measures overall, participants described varying experiences with changes in shape/weight concerns. Responses from participants varied from reporting no change to the degree of concern about their weight/shape and body image to reporting thoughts and concerns were absent or had decreased in frequency and importance. Given that overevaluation of weight and shape is known to maintain EDs  and contReduced CIA scores corresponding to large effect sizes were observed from Baseline to Post in both the CS and ITT sample. This finding was also captured in qualitative interviews ; for example, participants often reported improvements to various functional domains . Since the CIA focuses on impairment from the eating disorder it is possible that the reprieve from the eating disorder participants experienced  could account for reduced impairment. Having freedom from the consuming nature of eating disorder thoughts, urges, and behaviours may have allowed participants to engage in valued activities. It is also possible that the described functional improvements may be explained by stimulant mediated effects unrelated to changes in ED symptoms .Unexpectedly, reward-based decision making (as measured by a reinforcement learning task) did not improve with LDX treatment and was not associated with decreasing binge/purge behaviours. One explanation is that LDX does not mediate/moderate BN symptom reduction through reward-based decision-making processes. Alternatively, while it is unlikely that the reinforcement task lacked ecological validity, this should also be acknowledged as a possible reason why participant reward learning did not relate to a reduction in BN symptoms.Participants experienced an increased ability to normalize their eating  and hope for recovery , both of which have been found to predict ED recovery , 32. Mor2, limited psychiatric comorbidities, no history of anorexia nervosa, and minimally restrictive eating patterns at baseline. Full inclusion/exclusion criteria are listed in the Keshen et al. [Our study had a small sample size, was open-label, and not placebo-controlled. Additionally, the duration of treatment (8 weeks) and follow-up (1 week) in the trial was relatively short. Further, stringent inclusion/exclusion criteria limited the sample to a narrow subset of individuals with BN. For example, inclusion was limited to only those with moderate to extreme severity of illness, a BMI between 21 and 30 kg/mn et al.  supplemeThe results presented should be interpreted cautiously due to the absence of a control group and it should be recognized that participants were carefully monitored during treatment and aware of criteria for treatment discontinuation such as weight loss or increased dietary restriction based on weekly/bi-weekly assessment. Considering these limitations, the results should be interpreted as preliminary, and not as sufficient evidence to recommend routine clinical use of LDX for BN.Quantitative and qualitative results from this feasibility study suggest that participants experienced reduced hunger (without a corresponding increase in restraint), eating-related impulsivity, bulimia-related obsessions/compulsions, eating disorder psychopathology, and impairment while participating in the trial. Moreover, participants described experiencing a reprieve from their ED, improvement to their functioning and quality of life, and renewed hope for recovery from BN. Ideally, these findings will help generate hypotheses for future studies that explore mechanistic pathways and clinical outcomes with stimulants, such as LDX, in the management of this complex and debilitating disorder.Additional file 1. Information about the reinforcement learning task and complete qualitative interview guides.


The Cambridge Neuropsychological Test Automated Battery, specifically the spatial working memory, attention switching task, rapid visual processing and the spatial span, were used. Differences in neurocognitive performance measures indicated that white-collar workers were better able to detect sequences and make less errors than blue-collar workers. The heart rate variability differences showed that white-collar workers exhibit lower levels of cardiac vagal control during these neuropsychological tasks. These initial findings provide some novel insights into the relationship between occupation and psychophysiological processes and further highlight the interactions between cardiac autonomic variables and neurocognitive performance in blue and white-collar workers.The 21st century has brought a growing and significant focus on performance and health within the workforce, with the aim of improving the health and performance of the blue- and white-collar workforce. The present research investigated heart rate variability (HRV) and psychological performance between blue and white-collar workers to determine if differences were evident. A total of 101 workers ( In the 21st century, productivity is a crucial element in the strength and sustainability of a company’s gross business performance .Executive cognitive function refers to a family of mental processes that are recruited for concentration and attention . These en = 53 male, average age = 23 years) and found that the qualitative differences between task demands could be predicted by the subject’s cardiac vagal tone. Other researchers have investigated this connection, but vagal tone relationships remain largely unexplored [Heart rate variability (HRV) has been extensively used to reflect the sympathetic and parasympathetic activity of the autonomic nervous system . Furtherexplored . Furtherexplored  investigexplored   and blue-collar (n = 53) workers, further identifying the fundamental associations between working memory, attention, and HRV. Heart rate variability and executive function are evaluated in a sample of healthy blue and white-collar workers to better understand the cardiac autonomic vagal influence during neuropsychological performance and risk factors that may contribute to cardiovascular complications. It was hypothesized that (1) attentional states will increase cardiac vagal input, HF and RMSSD HRV in white-collar workers while indicating a decrease in blue-collar workers, and (2) spatial neuropsychological stress will exhibit a decrease in cardiac vagal input, HF and RMSSD HRV in white-collar workers and an increase in blue-collar workers.This study aims to investigate neuropsychological processes (working memory and attention) in two major working populations, white-collar (n = 101) were recruited from the community. Participants were required to abstain from caffeine and nicotine for 4 h and alcohol for 12 h prior to the commencement of testing. These factors are known to influence physiological measures and their restrictions enhance the reliability of the data. Additionally, participants with pre-study blood pressure (BP) measures greater than 160 mmHg (systolic)/or 100 mmHg (diastolic) were excluded [Healthy participants between the ages of 18–68 years (excluded . Testingexcluded  on the dTM) 2239, Tukwila, WA, USA).Participants were seated for 5 min prior to three BP recordings using an automated monitor . Three blood pressure readings were obtained both before and after the study protocol with 2-min intervals between each measurement . ParticiThe electrodes were placed in an inverted triangle to allow for positive deflections corresponding to the P, Q, R, S, and T waves . The negThe tasks performed utilized the Cambridge Neuropsychological Test Automated Battery (CANTAB) and tests included were the spatial working memory (SWM) task, attention switching task (AST), rapid visual processing task (RVP), and the spatial span (SSP) task . The SWMPrior to statistical analysis, ECG data was pre-processed to obtain time and frequency parameters of heart rate variability (HRV). The ECG data was imported into Kubios HRV software . The R-waves were automatically detected by applying the built-in QRS detection algorithm . Frequenp < 0.05. Independent sample t-tests were applied to establish significant differences in HRV parameters and neurocognitive performance measures between the blue and white-collar workers.Statistical analysis was performed using SPSS Version 22.0  IBM Corp  with stap < 0.001).The demographic data of the blue and white-collar groups are shown below in t-tests of neuropsychological performance showed significant differences in the tasks  between white (n = 48) and blue-collar (n = 53) workers. The significant findings are presenting in Independent sample p = 0.04). When the “side” cue was given, the white-collar worker group made more errors than the blue-collar worker group  (p = 0.02). Moreover, the white-collar worker group made significantly more correct responses than the blue-collar worker group overall  (t = p = 0.01).Attention Switching Task: During the AST, the white-collar sample group were found to make fewer errors when incongruent cues were given compared to the blue-collar worker group  (p = 0.002).Rapid Visual Processing Task: Throughout the RVP task, the ability to detect signals was significantly higher in the white-collar worker group as compared to the blue-collar worker group  (p = 0.003).Spatial Span Task: Finally, the SSP task saw the white-collar worker group make more total errors than the blue-collar worker group  (t-tests were used to compare HRV parameters between the white and blue-collar worker groups. The significant findings are summarised in Independent sample p = 0.004), log LF/HF  (p = 0.02), and log TP  (p = 0.02).Spatial Working Memory Task: Throughout the SWM task, the white-collar worker group, compared to the blue-collar worker group, had significantly higher log LF  (p < 0.001), log HF  (p = 0.03), log TP  (p < 0.001), and log SDNN  (p < 0.001).Rapid Visual Processing Task: The RVP task highlighted significantly lower HRV parameters in the white-collar worker group compared to the blue-collar worker group, particularly log LF  (p = 0.03).Spatial Span Task: During the Spatial Span (SSP) task, it was found that log HF was significantly lower in the white-collar worker group as compared to the blue-collar worker group   and healthy controls . Though the correlations were modest, the authors reported an inverse relationship between LF HRV and inflammatory biomarkers and, therefore, implicate sympathetic tone in CVD [During the SWM task, the LF, LF/HF, and TP parameters of HRV were all greater in the white-collar worker group compared to the blue-collar worker group. LF HRV was traditionally thought to reflect sympathetic activity, as previously mentioned, but recent research indicates it is influenced by both the sympathetic and parasympathetic branches of the ANS . This ine in CVD . This ide in CVD .The RVP task showed that the blue-collar workers had higher HRV parameters across the board, particularly LF, HF, TP and SDNN. This is an interesting finding as the RVP task is one of sustained attention, and it was therefore expected that the white-collar worker group would exhibit higher levels of cardiac vagal control, as indexed by HF HRV or RMSSD. The findings of the present research may reflect high levels of stress within the white-collar working population as shown by lower HF HRV. Previous research concluding which occupational group is more stressed is contentious, and the literature suggests a multitude of variables that may contribute. Dedele et al.  indicateThe final difference in HRV between the blue and white-collar worker group found in this study was related to the SSP task, whereby the blue-collar worker group showed higher vagal mediation than the white-collar worker group. This is indicative of better control and better performance. Moreover, it may indicate a more relaxed scenario, as the SSP task is designed to evaluate working memory capacity in the 3D space around them, an environment familiar to blue-collar workers.Occupation has been considered as an important predictor of cognitive ability and decline over time . Furthern = 1216, 61% Female, aged 70.7 ± 4.64 years) and white-collar workers . The authors gathered data using the Mini-Mental Sate Examination (MMSE) [The AST showed that the white-collar workers made less errors when the cues were changing and more errors when the “side” cue was given. However, in the task as a whole, the white-collar workers gave significantly more correct responses than the blue-collar workers. In a longitudinal study spanning 10 years, Kim et al.  assessedn (MMSE)  and othen (MMSE) . Primaryn (MMSE) .The white-collar workers showed significantly better performance during the RVP task, where their ability to detect sequences was much better. However, the white-collar workers made more errors during the SSP task. The relationship between mental workload and cardiovascular parameters is further illustrated by Capuana et al. . These aSeveral factors may be considered when assessing the performance and risks between the blue and white-collar worker populations. Most people spend a large portion of their life at work, and so the inherent risks related to employment are something that must be further researched. These risks may be a result of the complexity in given occupations, which was first touched upon by Schooler  and furtThe present findings show perhaps that changes in HRV are in fact influenced by various tasks, spanning all professions. Increased sample numbers in each profession would allow for stratification and observations within the same job type. For example, one white-collar worker may perform more administrative tasks while another may perform more data analytics and these differences in neuropsychological load may further influence HRV. Moreover, this cross-sectional design provides a snapshot in time of the measures. Therefore, a longitudinal study would allow for a more in-depth analysis of how a particular profession may influence these physiological variables over the course of one’s life. It is also acknowledged that, even though only 18% of the blue-collar worker group was made up of female workers, this is an accurate reflection of this population sample . Though Overall, the present research identified multiple significant differences in HRV parameters and neurocognitive performance measures between the blue and the white-collar workforce. Blue-collar workers indicated higher vagally mediated cardiac control during neuropsychological tasks with better performance in spatial working memory exercises, whilst white-collar workers had superior performance on attention-based tasks.Notably, reduced parasympathetic modulation of the heart, particularly in white-collar workers, was observed.


Multiple myeloma (MM) is a hematological malignancy characterized by clonal proliferation of plasma cells. Although therapeutic advances have been made to improve clinical outcomes and to prolong patients’ survival in the past two decades, MM remains largely incurable. Single-cell sequencing (SCS) is a powerful method to dissect the cellular and molecular landscape at single-cell resolution, instead of providing averaged results. The application of single-cell technologies promises to address outstanding questions in myeloma biology and has revolutionized our understanding of the inter- and intra-tumor heterogeneity, tumor microenvironment, and mechanisms of therapeutic resistance in MM. In this review, we summarize the recently developed SCS methodologies and latest MM research progress achieved by single-cell profiling, including information regarding the cancer and immune cell landscapes, tumor heterogeneities, underlying mechanisms and biomarkers associated with therapeutic response and resistance. We also discuss future directions of applying transformative SCS approaches with contribution to clinical translation. MM is a hematological cancer characterized by uncontrolled proliferation of malignant plasma cells (PCs) in the bone marrow (BM) which remains largely incurable . MM acco+ [+ [Despite the impressive progress in understanding the molecular pathogenesis of MM, in developing new therapies and improving in transplant technology , many im+  and CD24+ [+  have bee+ [+ , 24–26. + [+ , 28. TheTraditional microarrays and NGS assays require bulk DNA or RNA from large number of cells, and they are limited to providing average information of a population of cells. Furthermore, rare cell populations or unique cellular states could be critical in tumor transformation and pathogenesis, such as cancer stem cells (CSCs) or immune cell subsets, which might not be detected in bulk analyses . The advBreakthroughs in single-cell capture, sequencing technologies, and analytical bioinformatics have led to rapid progress in SCS analysis methodologies which have been reviewed extensively elsewhere –43. The Single-cell RNA sequencing (scRNA-seq) is a procedure that enables non-targeted quantification of transcripts in individual cells . This te+ cell samples [In recent years, a number of droplet-based platforms for high-throughput scRNA sequencing have attracted attention, including 10X Chromium Genomics, inDrop and Drop-seq , 47, 93. samples  showed t samples . Althoug samples .Single-cell spatially resolved transcriptome technologies have been developed and improved rapidly in recent years, with a unique capability of capturing cellular spatial distribution and revealing local networks of intercellular communication acting in situ, which cannot be achieved by scRNA-seq. Although there are numerous spatial transcriptomic (ST) methods, current ST protocols can be generally divided into two major groups according to their detection strategies. Most ST techniques use either a spatial indexing or imaging-based approaches to measure and quantify mRNA molecules in situ. In spatial indexing approaches such as 10X Visium and Slide-seq, barcodes are locally hybridized to RNA molecules, then gene expression profiles are quantified by NGS. This approach relies on polyA hybridization, which pose a challenge in fresh-frozen and formalin-fixed paraffin-embedded (FFPE) tissues as mRNA integrity varies in these samples. Further solution on this issue is desirable as clinical samples are often stored in FFPE blocks. Furthermore, achieving single-cell resolution remains a technical and computational challenge. Imaging-based approaches use fluorescent tagging of mRNA molecules in situ, and high-resolution fluorescence microscopy to detect and differentiate between single mRNA transcripts. These methods can achieve single-cell resolution but are still constrained by limitations on probe design, and low in situ mRNA abundance and degradation. Despite these challenges, ST technologies have added a new dimension to single-cell omics and extensively broadened our understanding of cancer biology.The ST profiling and temporal lineage tracing enable multi-faceted investigations into the surrounding environment and molecular dynamics within a single cell , thus adSingle-cell genomics aims to extend our understanding of genetics by bringing the research of genomes to the cellular level. Thus, rare and unique mutations and copy-number variations (CNVs) can be detected faithfully to reveal the clonal heterogeneity and evolution, which may be involved in disease processes. Sequencing an entire genome of a cell requires whole-genome amplification (WGA) by three major methods including degenerate oligonucleotide primed PCR (DOP-PCR), multiple displacement amplification (MDA) and multiple annealing and looping based amplification cycles (MALBAC) . DOP-PCRResearch into epigenetic regulation at the single-cell level has helped to define epigenetic landscape by profiling DNA modifications, chromatin accessibility and histone modifications. A variety of epigenomic sequencing approaches at single-cell level have been developed, such as single-cell reduced-representation bisulfite sequencing (scRRBS) to measure DNA methylation , single-For better understanding of genomic organization, in situ genome sequencing (IGS) has been used by researchers for simultaneous in situ imaging and sequencing of the genomes within the same single cell . This prProteins are essential macromolecules that are responsible for the main functional machinery within a cell, including regulations of gene expression, signaling pathway and catalytic reaction. Proteome measurements based on mass spectrometry (MS) have historically been limited to bulk samples containing thousands or millions of cells. The rise of single-cell proteomics leads to an in-depth and unbiased profile of protein expression within single cells. This emerging technology is mainly based on two methods: MS-based method, in which the proteomic content of the cell is digested and analyzed; and antibody-based method, which typically target a certain number of predefined proteins . The useMulti-omics single-cell methods interrogate multiple levels of molecular information from a single cell, such as DNA & RNA, RNA & protein, or three layers combined . By comb.A growing number of studies have begun to investigate the genomic, epigenetic, and transcriptional landscape in MM at the single-cell level, as summarized in Table Fig. .Table 2SMM is a clonal disease with strong inter- and intra-tumoral heterogeneity, and these heterogeneities are reflected genetically, epigenetically, and phenotypically , 7, 143.In the initial studies of scRNA-seq, samples were taken from patients at multiple time points in order to trace the dynamic tumoral evolution. In an early single-cell whole-exome sequencing (WES) study of six patients with t MM, it was found that there were two to six major subclones present at the time of the diagnosis of MM and the existence of clones with both linear and branching evolution patterns . As a reBy examining scRNA-seq data from patients with MGUS, SMM, MM, and light chain amyloidosis, the authors found that myeloma heterogeneity persisted throughout these different disease stages . In addiMultiple relapses and drug resistance are hallmarks of MM . In receIn MM, clonal PCs accumulate in the BM, resulting in bone destruction and focal lesions . The numCollectively, by integrated analysis of single-cell sequencing, these studies elucidated multiple layers of complexity regarding myeloma heterogeneity, including inter- and intra-patient heterogeneity across disease progression from precursor stages to active MM and relapse status, as well as additional spatial assessment in bone lesions. These data have proved fruitfully in resolving intricate molecular dynamics of MM pathogenesis and disease relapse by SCS technologies.The main goals of anti-myeloma therapy are to achieve greater depth of response and improve outcome of MM patients. Drug-induced changes possess the potential to reveal important insights into the molecular mechanisms in action of chemotherapeutics. A better understanding of the specific molecular signatures changed during the course of treatment is key to understand the detailed mechanisms behind drug response or resistance. With the capacity to investigate tumour-intrinsic transcriptome profiles, and tumour heterogeneity, scRNA-seq analysis combined with dynamic sampling and detailed genetic profiling could largely support the identification of drug-response genes and the understanding of drug-induced changes in the clonal dynamics. A recent scRNA-seq analysis of BM cells derived from 20 RRMM patients revealed that MM consists of diverse genetic clones with marked transcriptional changes and clonal dynamics before and after treatment . Gain/amLongitudinal monitoring during treatment and remission allowed the researchers to evaluate disease status, drug response and provide real-time notification of clonal emergence or reduction for clinicians. ScRNA-seq analysis can be incorporated with longitudinal sampling and intensive genetic and transcriptional profiling, which would bring a deeper understanding of treatment-induced alterations in the clonal dynamics and identification of drug-response genes. Masuda et al. performed scRNA-seq on MM cells from a patient with relapsed MM by temporal sampling during multiple anti-MM drugs . AlthougBased on the capability of predicting drug response, scRNA-seq can be used in clinical trials to predict resistance and guide therapy development for resensitizing tumors to treatment . In thisThe interplay between myeloma cells and the BME is crucial for tumor development, treatment and disease progression , 156–158− or CD45+ cell populations) from patients with MGUS, low-risk or high-risk SMM, and active MM, the authors revealed early alterations in immune cell composition at the precursor stages, with substantial T cells enrichment in particular [+ T cells and an increase of Treg together with CD8+ Eff 2 cells with an inhibitory phenotype. These two single-cell studies jointly demonstrated that early alterations of T cell populations have arisen in asymptomatic conditions of MGUS and SMM stages [T cells play central roles in anti-tumor immunity. In recent years, a variety of reports have revealed quantitative and functional T cell abnormalities in MM patients –168. Earrticular . This strticular . To incrrticular  to perfoM stages , 172. Id+ and CD8+ T cells in MM patients with advanced-stage [Except for these quantitative changes, MM patients also exhibited relevant defects of T cell functions. Early studies showed that under the influence of TGF-β, released by regulatory immune cells and myeloma cells, T cells presented a remarkable reduction in IL-2-mediated autocrine proliferation , and dived-stage . A combied-stage . In parted-stage . Additioed-stage . Notablyed-stage , and theed-stage . Interesed-stage . And in ed-stage . The fined-stage –180 sugg+ T effector cells and natural killing (NK) cells with high tumor infiltration exhibited distinct metabolic features with comparison to those with low tumor infiltration and HD [Recent studies have illustrated that defective metabolic flexibility related to cancer cells can lead to an inefficacy in anti-tumor immune response and linked to cancer progression –183. Then and HD . The abnHigh T cells mainly localized within activated CD4+ cells. Furthermore, in the CD8+ T cell subset, CARHigh T cells showed a pre-exhausted feature. They then demonstrated that CAR density was associated with differential activation of regulatory networks, evident by activation of transcription factors NR4A1 and MAF, low active SATB1 regulon in CARHigh T cells, which could explain their exhausted phenotype. Therefore, single-cell omics enables the high-resolution molecular characterization of the activation and functional states of T cells, thus holding great potential for understanding CAR-T cell behavior. Given the very active clinical research on CAR-T cells in MM ongoing currently [Chimeric antigen receptor (CAR) T-cell therapies have achieved impressive efficacy in MM but also bring its own set of challenges including durability of CAR-T cells, toxicities and therapeutic resistance –188. A rurrently , 191, we+ NK, CX3CR1+ NK and a less frequent CD56bright NK population, and showed that NK cell proportion is frequently increased in the precursor stages indicating an early onset of an immune response [+ NK cells from NDMM BM samples, have also acknowledged the CD56bright NK population [NK cells have been identified as the primary effector cells of innate immunity –194. Numresponse . Anotherpulation . They fupulation . Their f+ NK cell subset was also found in nonkeratinizing nasopharyngeal carcinoma exhibiting similar exhausted phenotypes with upregulated LAG3 and TIGIT expressions [+ NK cell present in cancer context and highlight potential roles of ZNF683 in regulating NK cell function. These findings were uncovered mainly based on scRNA-seq profiling on NK cells in both studies, and we believe it may largely rely on the sensitivity of single-cell technology in capturing low abundant cells that conventional methods cannot provide.Through conventional measuring methods, such as flow cytometry and bulk RNA-seq, the exhausted phenotype of NK cells in MM has been described in previous studies, reflected by expressions of immunosuppressive molecules, such as PD-1 , 200. Horessions . These cAmong the most important regulators of inflammation, monocytes and macrophages play important roles in cancer-associated inflammation , 203. Th+CD16−), intermediate (CD14+/− CD16low), and non-classical monocytes (CD14−CD16+), and the latter subset is considered to harbor a tumor-promoting phenotype [+ and CD206+ TAM infiltration are associated with worse prognosis [bright cells [Currently, a number of surface markers have been used to characterize TAMs , and two major functional macrophage states have been identified: M1 , activating during infections and M2  involving in wound healing and angiogenesis. Notably, M1 and M2 macrophages should be considered as two extremes instead of a continuum, however TAMs often exhibit a mixed transcriptional profile –211. Conhenotype . In the rognosis , 213. A rognosis . Anotherrognosis . Additioht cells .Dendritic cells (DCs) are vital antigen-presenting cells (APCs), which serve as a bridge between innate and adaptive immunity in response to various pathogens . These cCollectively, the DC impairment in MM leads to dysfunctional capability of antigen presentation and pro-tumor activity. Through improved understanding of the interactions between myeloma cell, cDC and pDC via single-cell methodologies, targeting the crosstalk between these cells may pave the way to successful DC-targeting immunotherapies in the future.As an important component of the nonimmune microenvironment, mesenchymal stromal cell (MSC) has been reported to promote MM proliferation and induce drug resistance , 220. DeTaken together, high-throughput SCS technologies enhance the ability of researchers to comprehensively characterize the cellular heterogeneity, temporal/spatial evolution of tumor cells and infiltrated immune and stromal cells in MM. These approaches provide insights into the mechanisms of drug resistance, immune suppression, and disease relapse in individual MM patients, thereby contributing to develop more effective and personalized anti-myeloma therapeutics.Our understanding of myeloma biology has been improved dramatically, owing to the rapid development and application of single-cell technologies. Some remained fundamental questions in myeloma research can be further explored by SCS. First, MM is an extremely complex disease whose origin and inheritability remain controversial and require detailed investigation. To explore myeloma origin, a comprehensive strategy for the identification of MMSCs could be aided by advanced SCS techniques. Owing to its ability to capture rare cell population with high-purity, and to unravel initiating point along the differential trajectory, SCS holds promise to detected the MMSCs population and identify its real markers. Indeed, scRNA-seq have been utilized to unravel the hierarchies of tumors and their progenitor cancer stem cells (CSCs) in many cancer types –227. In SCS technologies also offer powerful tools for unbiased discovery of novel drug targets for MM treatment. For example, Frede et al. showed that in RRMM patients, treatment induced significant changes in chromatin accessibility by scATAC-seq, and they identified a surface protein CXCR4 as an attractive candidate as surface markers that can be targeted by immunotherapy . FurtherPreclinical models including human-derived cell lines  and mousBeyond being exploratory tools, SCS technologies can undoubtedly achieve more values when translated and adopted into clinical practice. Regarding the clinical utility, in our view, SCS assessments should be conducted based on the clinical needs, thus help to resolve problems encountered in the clinic. For instance, accurately monitoring measurable residual disease (MRD), identifying high risk patients and overcoming drug resistance represent three of the major unmet medical needs in MM. For the MRD measurement, a recent study has developed a single-cell MRD (scMRD) assay by combining flow cytometric enrichment of the targeted precursor/blast population in AML samples with integrated scDNA-seq and immunophenotyping, and achieved significantly high sensitivity . This atHowever, applications of current SCS approaches outlined in this review are confronting with costs and technological challenges, which impeding our next step on the road to the clinic. By far the most expensive part of SCS is the sequencing itself. With the rapid advancements in sequencing technologies and exploitation of cost-reduction strategies, we believe that the sequencing costs will continue to reduce. Besides, there are several important frameworks and infrastructure are required for clinical use, including: (1) introducing standardized analytic pipelines and quality-controlled workflows when dealing with large amount of SCS data. In particular, batch effects should be carefully examined and corrected to bring reliable clinical results; (2) controlling false positive or negative rates. ScRNA-seq and scDNA-seq data would generate false negative or positive results due to the data sparsity , coveragIn closing, SCS technologies have already revolutionized many aspects of cancer translational research and are prepared to have a greater impact in clinic. As the last decade has seen NGS technologies transform modern oncology, we believe that single-cell methodologies will influence many areas of MM medicine in the same way, and will become a powerful tool that can be implemented for clinical practice. Over the coming years, emerging technologies such as spatial SCS and multi-omics approaches will further expand their utility in myeloma research, and bring benefits for MM patients on personalized medicine and precision prevention. Overall, we expect that the implementation of single-cell technologies in myeloma medicine over the next decade will bring huge improvements in the clinical translation and treatment of MM patients.


Artificial intelligence (AI)-driven laboratory automation—combining robotic labware and autonomous software agents—is a powerful trend in modern biology. We developed Genesis-DB, a database system designed to support AI-driven autonomous laboratories by providing software agents access to large quantities of structured domain information. In addition, we present a new ontology for modeling data and metadata from autonomously performed yeast microchemostat cultivations in the framework of the Genesis robot scientist system. We show an example of how Genesis-DB enables the research life cycle by modeling yeast gene regulation, guiding future hypotheses generation and design of experiments. Genesis-DB supports AI-driven discovery through automated reasoning and its design is portable, generic, and easily extensible to other AI-driven molecular biology laboratory data and beyond.https://github.com/TW-Genesis/genesis-database-system.git. The database use case demo code and data are also available through GitHub (https://github.com/TW-Genesis/genesis-database-demo.git). The ontology can be downloaded here: https://github.com/TW-Genesis/genesis-ontology/releases/download/v0.0.23/genesis.owl. The ontology term descriptions (including mappings to existing ontologies) and maintenance standard operating procedures can be found at: https://github.com/TW-Genesis/genesis-ontology.Genesis-DB code and installation instructions are available at the GitHub repository  Advances in artificial intelligence (AI) and automation are enabling increasingly data-intensive laboratory workflows and closed-loop discovery systems  Machine-interpretable storage of data and metadata compatible with automated reasoning approaches; (2) easy-to-deploy storage for data with custom ontologies; and (3) consistent reproducibility backed by data schema stability across versions. We have created a database system with these attributes, Genesis-DB.Genesis-DB is designed to be used with automated software agents. Many of today’s laboratory databases are primarily designed for human users whose usage differs significantly from the autonomous laboratory systems. For AI-based systems to function seamlessly, data must be encoded in a machine-interpretable format to obviate the need for human intervention. As demonstrated in previous ADAM and Eve studies, Semantic Web technologies provide means for robustly capturing the important aspects of new data, experimental metadata, and background knowledge  and RNA sequencing transcript counts. We then exploited data stored in Genesis-DB with this new ontology to reconstruct a yeast gene regulatory network (GRN), making use of SPARQL, a query language well-suited for upstream automated reasoning applications.Genesis-DB is built around the open-source Apache Jena framework (jena.apache.org). Notably, its containerized nature allows it to be deployed using orchestration platforms such as Kubernetes (kubernetes.io), easing automation of laborious processes such as scaling and monitoring.Stability of stored data over iteration cycles is especially important in the automated laboratory setting. Typically, database curation and maintenance provides stable data access to human users  but does not account for the ways AI-agents may access the data. Even slight changes in the underlying data structure unapparent to human users may break the bond between database and upstream software agents. The ADAM and Eve robot scientists both ultimately relied on internal copies of external databases to circumvent catastrophic system errors as a result of unstructured database updates. Ontology development practices dictate that deprecated classes are defined as obsolete rather than deleted in version updates. By making ontology usage a requirement for Genesis-DB data storage, we require users to enter into this stability-focused system of practices. Additionally, structured recording of experimental protocols and data improves repeatability and reproducibility of the results.Genesis-DB is based on Apache Jena (version 4.6.0) (jena.apache.org), a free and open-source Java framework for building Semantic Web and linked data applications. Most components are inherited from the Jena framework including a Fuseki SPARQL server, TDB2 triple store, and the ARQ SPARQL query engine. We note the possibility of future performance and feature optimization around these different layers based on application-specific requirements. All the components in Genesis-DB are containerized using Docker, enabling portable deployment in most environments.In order to demonstrate the ability of Genesis-DB to flexibly accept custom ontologies, we developed a new ontology incorporating some relevant aspects of the Genesis robot scientist setup. This ontology describes usage of automated microchemostats including the sample, experimental, and protocol metadata and RNA sequencing transcript counts. A visual overview of the domain model can be found in the demonstration GitHub repository. The data model follows the popular Ontology for Biomedical Investigations (OBI) guidelines  reconstruction of a GRN for Data from a yeast chemostat cultivation study of stress responses , suggestThis cycle of data- and metadata-driven systems biology model improvement involved two software agents working on top of Genesis-DB. One is the informatic agent running hLICORN to create co-regulatory networks based on data available in Genesis-DB. The second is the metadata and hypothesis agent using Genesis-DB to explore experimental condition space and order new rounds of experiments. Both agents may interact to read from and write to Genesis-DB using SPARQL.In this article, we presented Genesis-DB: a database suitable for AI-driven automated laboratories that incorporates lessons learned from more than two decades of experience. We demonstrate the usage of this system by creating a novel ontology for automated microchemostat yeast cultivation and running a simulated automated laboratory cycle of multiple of rounds of experimental data collection, analysis, and model improvement.The example provided here involves simple implementations of software “agents” as scripts run by the human user without an automated orchestration system. For example, the informatic and hypothesis agents here are, respectively, human-written data processing and visualization scripts. Interaction with Genesis-DB is programmatic; such software interaction may be triggered by a user, or by a higher level orchestration system. The degree of software autonomy and agent logic will vary with specific use-case. For the Genesis robot scientist project, Genesis-DB is intended to function in an autonomous laboratory where its primary function is to store experimental data and metadata in a manner that suits the needs of a robot scientist environment. In this case, upstream software agents are expected to interact with external data sources to derive conclusions such as those in the example suggesting increased activity in thermal stress conditions for the genes YDR171W, YLR259C, and YPL240C. We note that the programmatic interface of Genesis-DB enables different modes of application depending on the balance between software autonomy and human usage, which will differ for each laboratory and their applications.SPARQL-driven data access provides a powerful framework for automated applications of formal logical reasoning . SPARQL


Zolpidem is a sedative drug that has been shown to induce a paradoxical effect, restoring brain function in wide range of neurological disorders. The underlying functional mechanism of the effect of zolpidem in the brain in clinical improvement is still poorly understood. Thus, we aimed to investigate rest brain function to study zolpidem-induced symptom improvement in a patient who developed postoperative pediatric cerebellar mutism syndrome, a postoperative complication characterized by delayed onset transient mutism/reduced speech that can occur after medulloblastoma resection. The patient experienced clinical recovery after a single dose of zolpidem. Brain function was investigated using arterial spin labeling MRI and resting-state functional MRI. Imaging was performed at three time-points: preoperative, postoperative during symptoms, and after zolpidem intake when the symptoms regressed. Whole brain rest cerebral blood flow (CBF) and resting state functional connectivity using Pearson coefficient correlations between pairs of regions of interest were investigated two-by-two at the different time points. A comparison between postoperative and preoperative images showed a significant decrease in rest CBF in the left supplementary motor area, Broca’s area, and the left striatum and a decrease in functional connectivity within the dentato-thalamo-cortical and cortico-striato-pallido-thalamo-cortical loops. Post-zolpidem images showed increased CBF in the left striatum and increased functional connectivity within the disrupted loops relative to postoperative images. Thus, we observed functional changes within the broader speech network and thalamo-subcortical interactions associated with the paradoxical effect of zolpidem in promoting clinical recovery. This should encourage further functional investigations in the brain to better understand the mechanism of zolpidem in neurological recovery. It is characterized by transient mutism or a severe reduction in speech that occurs on average within 48 h after surgery, associated with emotional lability and frequently accompanied by cerebellar motor syndrome . RecoverIn the context of an ongoing prospective neuroimaging study investigating the neural basis of pCMS, we report here a rest functional brain imaging case study of a seven year-old child who developed pCMS characterized by the severe loss of spontaneous speech, the loss of motivation, and irritability. A single administration dose of zolpidem promoted clinical recovery within 24 h. The patient underwent full clinical evaluation before and after the surgery, as well as after zolpidem intake. As per protocol, multimodal magnetic resonance imaging (MRI) was performed at three time points: preoperative, immediate postoperative images, during which the patient presented pCMS symptoms and post-zolpidem intake, when pCMS symptoms regressed. We investigated zolpidem-induced changes in brain perfusion using arterial spin labeling (ASL)-MRI by measuring cerebral blood flow (CBF) at rest at each clinical stage. In addition, we investigated resting state functional connectivity (rs-FC) within the dentato-thalamo-cortical loop given the involvement of this loop in pCMS . We furt2.A right-handed seven-year-old boy, presented with signs and symptoms of increased intracranial pressure for several months and, gait disturbance and dysmetria for 1 month. Clinical examination revealed a cerebellar syndrome with multi-directional nystagmus and difficulties in walking with enlargement of the sustentation polygon. No behavioral or speech impairments were noted. An MRI showed a large posterior fossa mass invading the vermis, the lower part of the floor of the fourth ventricle, left cerebellar peduncles, and inducing obstructive hydrocephalus. Thus, endoscopic third ventriculostomy was performed to liberate the cerebrospinal fluid pathways and decrease intracranial pressure. The postoperative course was uneventful. The patient underwent a total resection of the mass through a telovelar approach several days later and histopathological examination revealed a medulloblastoma. The clinical status of this patient was independently assessed by a neurosurgeon (K.B) in the context of the clinical follow-up and a researcher (J.B) in the context of an ongoing prospective study investigating the neural basis of pCMS. Of note, as there is no standardized quantification scale for pCMS symptoms, the described symptomatology of the patient was based on our previously classification  based on3.We first present the results comparing the whole brain rest CBF and rs-FC analyses between two-by-two time points: preoperative compared to immediate postoperative images; preoperative compared to post-zolpidem intake images; and immediate postoperative compared to post-zolpidem intake images. In addition, we also present results of rs-FC comparing the mean correlation coefficients of the patient for the preoperative and post-zolpidem intake images to the healthy control group (n = 5).3.1.t = 7.48; df = 6 = 4.84; p = 0.018) and Broca’s area  as well as in one cluster including both the left putamen and in the left caudate constituting together the left striatum  in the immediate postoperative images. We also observed a significant increase in rest CBF in the left striatum  in the post-zolpidem intake images compared to immediate postoperative CBF images. Finally, there was no significant difference in post-zolpidem intake compared to preoperative CBF images. The corresponding brain regions associated with maximum peak coordinates in the SPM analysis are shown in A voxel-wise whole brain comparison of preoperative and immediate postoperative CBF images showed a significant decrease in rest CBF in the left supplementary motor area (SMA) ; left t(VA) and left SMA ; left SMA and Broca’s area ; left t(VA) and Broca’s area ; and Broca’s area and left striatum . In addition, the correlation coefficients between the left striatum and the left GPi  as well as the left GPi and left t(VA)  were significantly higher in the immediate postoperative images relative to preoperative (see The correlation coefficients were significantly lower in the immediate postoperative images than preoperative images in the following pairs of ROIs: right DN and left t(VL) ; left t(VA) and left SMA ; left SMA and Broca’s area ; left t(VA) and Broca’s area ; and Broca’s area and left striatum  relative to the immediate postoperative images   increased, indicating probable “pathological functional hyperconnectivity.” Although the observed disruption of the cortico-striato-pallido-thalamo-cortical loop may result in subcortical functional hyperconnectivity and may appear to be unexpected, this effect has been previously described in several neurological disorders, such as traumatic brain injury , multiplAn empirical model describing possible targets of the paradoxical effect of zolpidem in cases of certain brain injuries resulting in consciousness disorders, the “mesocircuit model, has been previously proposed . This moThis study had several limitations. Indeed, although it is remarkable to observe such effects on a single patient, these findings are based on a one-patient case study and should therefore be interpreted with caution. Further studies, in particular based on randomized controlled clinical trials on large cohorts are needed to corroborate these results and generalize our understanding of the paradoxical mechanism of action of zolpidem. Moreover, given zolpidem’s pharmacodynamics, immediate and closely spaced assessments could help to further understand this phenomenon.In conclusion, we believe that our case study presenting brain imaging results helps to extend our understanding concerning the brain mechanism underlying the long-term effect of zolpidem in clinical improvement and highlights the importance of further brain functional studies. Finally, future multicenter and multinational clinical trials, including a large dataset, are still needed to further investigate the paradoxical effect of zolpidem in various clinical contexts  and provide further insight into the mechanisms involved in the effect of zolpidem in neurological recovery.The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by French Public Hospital: Ethic Commitee “Sud-Est II.” Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)’ legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.JB, KB, and NB performed data collection. JB and LF performed the image preprocessing. JB, AS, HL, AV-L, and NB performed the statistical analyses. KB, VD-R, RL, C-JR, and DG assisted in the data acquisition. JB, KB, TB, LG, CD, JG, SP, SB, MB, RG, MZ, and NB provided the clinical relevance context. JB, KB, AS, TB, LF, LG, CD, JG, HL, SC, SP, SB, MB, RG, MZ, and NB interpreted the results. KB, AS, TB, LF, LG, CD, JG, HL, SC, SP, SB, AV-L, VD-R, RL, C-JR, RG, MZ, and NB revised the paper. JB and AS generated the figures and tables. JB, KB, AS, MZ, and NB wrote the paper. All authors contributed to the article and approved the submitted version.https://www.lisaforever.org/), Canceropole “Ile de France” (https://www.canceropole-idf.fr/), Institut National du Cancer (InCa), Fondation de l’avenir (https://www.fondationdelavenir.org/), and Fondation ARC pour la recherché sur le cancer (https://www.fondation-arc.org/).This work was supported in part by Lisa Forever association (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.