Atrial fibrillation/flutter (AF/AFL) significantly impacts countries with varying income levels. We aimed to present worldwide estimates of its burden from 1990 to 2019 using data from the Global Burden of Disease (GBD) study.We derived cause-specific AF/AFL mortality and disability-adjusted life-year (DALY) estimates from the GBD 2019 study data. We used an age-period-cohort (APC) model to predict annual changes in mortality (net drifts), annual percentage changes from 50-55 to 90-95 years , and period and cohort relative risks (period and cohort effects) between 1990 and 2019 by sex and sociodemographic index (SDI) quintiles. This allowed us to determine the impacts of age, period, and cohort on mortality and DALY trends and the inequities and treatment gaps in AF/AFL management.P < 0.001). Uzbekistan had the largest net drift of mortality  and DALYs  among all countries. High body mass index, high blood pressure, smoking, and alcohol consumption were more prevalent in developed countries; nevertheless, lead exposure was more prominent in developing countries and regions.Based on GBD data, our estimates showed that 59.7 million cases of AF/AFL occurred worldwide in 2019, while the number of AF/AFL deaths rose from 117 000 to 315 000 (61.5% women). All-age mortality and DALYs increased considerably from 1990 to 2019, and there was an increase in age risk and a shift in death and DALYs toward the older (>80) population. Although the global net drift mortality of AF/AFL decreased overall  = -0.20, 0.12 per year), we observed an opposite trend in the low-middle SDI  and low SDI regions . Compared with net drift among men , women had a greater downward trend or smaller upward trend of AF/AFL  in mortality in middle- and low-middle-SDI countries (The burden of AF/AFL in 2019 and its temporal evolution from 1990 to 2019 differed significantly across SDI quintiles, sexes, geographic locations, and countries, necessitating the prioritisation of health policies based on risk-differentiated, cost-effective AF/AFL management. Due to global population aging, atrial fibrillation/flutter (AF/AFL) has become the most prevalent persistent type of arrhythmia worldwide and a leading cause of systemic embolism, particularly ischemic stroke, heart failure, and other cardiovascular illness ,2, resulThe mortality risk for patients with AF/AFL, which can be categorised by period, age, and birth cohort effects, depends on biological age (age effect), but also varies among birth cohorts due to economic and social developmental factors and new diagnostic and therapeutic choices. Thus, an analysis of mortality and DALY trends focused on the effects of these three variables could help with identifying the successes and shortcomings of current treatments and inform future improvements.To the best of our knowledge, this is the first study to use updated GBD 2019 data and age-period-cohort models to explore changes in AF/AFL mortality across 204 countries and territories from 1990 to 2019. It was produced as part of the GBD Collaborator Network and in accordance with GBD Protocols (Contact ID: 0034o00001nHH4NAAW).The GBD 2019 provides the most up-to-date descriptive epidemiological data on a total of 369 diseases and injuries for 204 countries and territories from 1990 to 2019. Each death in the GBD is assigned to a single underlying cause from a mutually and collectively exhaustive list of diseases and injuries. The study team obtained ethics approval from the University of Washington Institutional Review Board Committee, while the protocol and all data are available online upon request from the EPHI-IHME Office [We mapped cause-specific deaths attributed to AF/AFL, diagnosed by electrocardiography as per previous GBD studies ,6, to thWe used the 2019 sociodemographic index (SDI) to categorise each country into one of five quintiles. SDI is an indicator estimated as a composite of income per capita, average years of schooling, and the fertility rate among women under 25 years of age . It is sWe aimed to examine the global trends of AF/AFL mortality and DALYs. To do so, we first assessed temporal trends by all-age mortality  and age-standardised mortality and the relative change in mortality as a percentage between 1990 and 2019. We calculated age-standardised mortality by using global age-standardised population data from the GBD 2019  and examWe then used the age-period-cohort (APC) model to analyse the underlying trends in mortality by age, period, and birth cohort . This mo2 test [P < 0.05 was considered significant. We conducted all analyses in R, version 4.2.2.  [We used GBD 2019 mortality estimates for AF/AFL and the population data of each country/region as data inputs for the APC model. In such cases, the age and period intervals usually must all be equal, i.e. five-year age groups should be used with five-year calendar periods. As GBD estimates are produced in an unequally spaced data format , we arranged the data into a single unit framework by selecting the death and population counts from the mid-year of six five-year periods ((1992) 1990-1994, (1997) 1995-1999… (2017) 2015-2019) to represent the specific period. The input data included nine age groups  and partially overlapping ten-year birth cohorts, as referenced by the mid-year of birth, from 1895 to 1905 (the 1900 cohort) to 1955 to 1965 (the 1960 cohort). The fitted APC model estimated the overall temporal trend in mortality, which is expressed as the annual percentage change in mortality . Technically, the net drift is determined by two components: the trend attributable to calendar time and another attributable to the successive cohorts. The APC model also estimated the temporal trend of mortality within each age group, expressed as the annual percentage age change in age-specific mortality , reflecting trends in the birth cohort effect. A drift of ±1% per year or more is considered a substantial change in mortality  because 2 test . The APC2 test . The relIn the past 30 years, the global population grew by 45% from 5.3 billion  to 7.7 billion , while the number of AF/AFL deaths has increased by 169% from 117 000 (103 000-138 000) to 315 000 (61.5% women) . In 2019, the global death rate for AF/AFL was 4.08  per 100 000 people, representing an increase of 86.0 from 1990 , although the age-standardised mortality rate remained comparable. Meanwhile, all-age mortality rates were generally lower than age-standardised mortality rates in all except for high SDI regions, indicating they more appropriately capture the true burden of AF/AFL for high-income countries. The percentage change in all-age mortality had an inverted U-shape across different SDIs, with the greatest increase in middle-SDI  and low-middle-SDI regions  and the smallest in low-SDI  and high-SDI regions . However, the APC model estimated a moderate decreasing net drift of AF/AFL mortality of -0.16%  per year globally, attributable to high-middle-SDI  and high SDI regions . We found an upward trend in the net drift of AF/AFL mortality in middle-  to low-middle-SDI regions , likewise in the form of an inverted U-shape. Similarly, countries and areas with a high- or high-middle-SDI had higher all-age DALYs and age-standardised DALYs in 2019, with similar inverted U-shaped trends for the percentage change in DALYs and all-age DALYs. However, net drifts of DALYs decreased or changed slightly in high- and high-middle-SDI nations and regions, but they increased in middle- and low-SDI countries. The disparity between the net drift and the all-age/age-standardised drift may be attributable to variations in population composition and the multiple repercussions of the level of economic development   and Pakistan (n = 2712) ;− Low-middle SDI countries: India (n = 29 155)  and Vietnam (n = 3124) ;− Middle SDI countries: China (n = 51 748)  and Indonesia (n = 4992) ;− High-middle SDI countries: Lebanon (n = 196)  and Italy (n = 10 569) ;− High SDI countries/regions: Singapore (n = 135) , Republic of Korea (n = 2022) , and Taiwan (Province of China) (n = 1399) .Similar trends were reported for DALYs. India, the USA, Germany and the Russian Federation accounted for 51.9% of all AF/AFL DALYs worldwide, while Uzbekistan showed the largest increase in AF/AFL-related all-age DALYs, with a net drift of DALYs of 2.16%  per year (Table S3 in the P < 0.001). In the DALY analysis, we only found this trend in middle-SDI countries/regions (P < 0.001).The trends of AF/AFL mortality and DALYs varied greatly among different age groups, especially when comparing countries/regions with high and low SDIs  age group and an increase in risk by age, but different local drift, period effect, and birth cohort effects. As a well-developed East Asian country, Japan exhibited a downward trend across all age groups, with local drifts of less than 0% and a district period effect and cohort effect of decreasing scale. Conversely, for the USA, a typical industrialised North American nation, we observed a U-shaped increase across all age groups, particularly in the elderly and young populations, and upward trends for period and cohort effects. Italy, a country with a high-middle-SDI, had APC effects comparable to those of Japan, while Ukraine, a country with a high SDI, was similar to the USA, excluding the age distribution, as fewer individuals aged ≥90 years died from AF/AFL. China and Brazil are representative middle-SDI countries with a similar APC effect and a shift in AF/AFL deaths to the elderly population. China, the most populous middle-SDI nation, exhibited a downward mortality trend with a local drift of less than 0%, which was primarily attributable to the female population. Deaths attributable to AF/AFL in Brazil, however, exhibited an upward trend, with the local drift generally exceeding 0% and increasing with age. Among low-middle and low-SDI countries, Nigeria had a greater number of AF/AFL deaths in the elderly population (>90) and a downward trend of mortality, in contrast to India, Bangladesh, and Pakistan, which all had an upward trend of AF/AFL deaths across all age groups, as well as greater period and birth cohort effects. We saw similar APC effects between mortality and DALYs across different SDI countries  age group. From 1990 to 2019, Uzbekistan had the largest net drift of mortality and DALYs among all countries. High BMI, high blood pressure, smoking, alcohol consumption, and lead exposure were more prevalent in developed countries and regions.Between 1990 and 2019, the global population increased by 45%, while the total number of AF/AFL deaths increased by 169%. The local drift analysis we performed showed that the increase in AF/AFL mortality was primarily attributable to the all-age upward trend in low-SDI nations and the older population in high- and high-middle-SDI countries. As aging has become a major social issue in developed countries , atrial The shift in AF/AFL mortality and DALYs to the older group was one of our key findings. According to the APC model analysis, it was most prominent in high- and middle-SDI nations and areas, which is rarely reported in other studies ,19. TherThere were also large disparities in AF/AFL deaths or DALYs within the same SDI levels. For example, Japan’s AF/AFL death and DALY rates were more similar to those of Italy due to its rapidly aging population, diet regimens, and climate. SDI is an indicator assessed as a composite of income per capita, average years of schooling, and the fertility rate among women aged <25 years, and is more associated with economic level. The clinical outcome of atrial fibrillation is impacted by numerous factors, only one of which is the SDI, so a customised evaluation approach is needed to assess and classify the global disease burden.Previous studies have analysed the attributable risk factors for AF/AFL deaths and DALYs based on GBD data ,19. In tThis study has some limitations. First, death rates for paroxysmal and chronic atrial fibrillation varied substantially, but no classification was provided by the data. We also lacked sufficient data on anticoagulation, anti-arrhythmia medication therapy, and radiofrequency for detailed analyses. Third, the risk score classification plays a crucial role in predicting clinical outcomes for atrial fibrillation, which was unavailable in the GBD data, as were the life expectancy data for each country, which may have helped better determine the effects of life expectancy on the disease burden. Nevertheless, large data analytics across countries, SDIs, and age groups can still show the worldwide patterns of AF/AFL mortality and sex differences and guide future health policy interventions.We found that the burden of AF/AFL in 2019 and its temporal evolution from 1990 to 2019 varied significantly by SDI quintile, sex, geographic region, and country. Even though global net drift mortality and the DALYs of AF/AFL decreased, there was an upward trend in the net drift in the elderly population in high-SDI nations compared to the overall population in low- and low-middle-SDI countries. Special attention should be given to hypertension, obesity, smoking, and alcohol consumption in high- and high-middle-SDI countries, while lead exposure should be prioritised in developing nations. The increasing overall awareness and diagnostic opportunities are a major force in detecting AF/AFL, and readiness and treatment opportunities are also critical in the achievement of national goals. Health authorities and policymakers must consider improving the allocation of resources, increasing access to health care resources, controlling variable risk factors, and urgently improving efforts to curb the growth of the disease burden.


We aim to explore whether the bacterial co-infection with COVID-19 will raise the in-hospital mortality.COVID-19 patients’ information were collected for analysis in our retrospective study. Neutrophil count and procalcitonin (PCT) were used to estimate whether there was a suspected bacterial co-infection.P < 0.001) between SBI and NBI groups in overall population. And in each subgroup based on pneumonia inflammation index (PII), it also showed higher in-hospital mortality of COVID-19 patients with bacterial co-infection. With logistic regression models, it showed that bacterial co-infection was associated with significantly higher in-hospital mortality in overall population  and mild subgroup . The rate of bacterial co-infection in overall population was 51%. At the same time, it showed a significantly higher rate of bacterial co-infection in critical subgroup than severe subgroup , and than that in moderate subgroup  based on clinical classification. It showed a significantly higher rates of bacterial co-infection in severe subgroup than moderate subgroup  based on PII. The result showed that the risk factor associated with significantly higher in-hospital mortality was PII  with logistic regression models.The main baselines between the suspected bacterial infection (SBI) and no evidence of bacterial infection (NBI) groups were no significant differences. In SBI group, patients required more therapies than NBI group. There was significantly higher in-hospital mortality (26% vs.9%, Bacterial co-infection estimated by Neutrophil count and procalcitonin significantly raises in-hospital mortality of COVID-19 patients in overall population in our study. Its impact is more significant in mild and moderate PII subgroups. PII based on CT imaging combined with neutrophil count and PCT is beneficial for accurate differentiation of bacterial co-infection of COVID-19. In recent three years, people all over the world have been affected by the outbreak of COVID-19 . Similar9/L), (2) PCT was higher than 0.5 ng/mL. Meanwhile, the information of gender, age, comorbidities, C-reactive protein (CRP), blood gas analysis and chest CT imaging were collected within 48 h after admission. More information about treatments and outcomes were collected too. Before collecting complete information, we established inclusion and exclusion criteria. Inclusion criteria: a) all the patients was diagnosed by a positive SARS-CoV-2 Real Time-Polymerase Chain Reaction (RT-PCR) for a confirmed diagnosis of COVID-19, b) CT imaging findings met the standard of viral pneumonia. Exclusion criteria: a) age < 18 years, b) patients during pregnancy and lactation, c) no chest CT imaging or no pneumonia was found by chest CT imaging. At present, COVID-19 patients were classified into four grades as follows: mild, moderate, severe and critical  and no evidence of bacterial co-infection (NBI). The patients were classified as the SBI group if the any one of (1) and (2) were met: (1) Neutrophil count was abnormal  thep-values<0.05. We used the odds ratios (ORs) and 95% confidence interval (CIs) to estimate the association between bacterial co-infection and in-hospital mortality, and the association between bacterial co-infection and its risk factors with multivariable adjusted logistic regression models.The statistical analysis was performed with SPSS 23.0. Measurement data conforming to normal distribution were represented by means±standard deviations (mean ± SD), and the difference between groups was compared by t test of two independent samples. The measurement data that did not conform to the normal distribution were expressed by medians and range (median ± IQR), and the difference between groups was compared by Mann–Whitney U test of two independent samples. The counting data was expressed as a percentage and the chi-square test was used to compare the differences between groups. It was considered statistically significant if p = 0.329), gender , frequency of chronic pulmonary disease , chronic liver disease , platelet count . In SBI group, frequency of diabetes , cardiovascular diseases , chronic kidney disease  were higher than NBI group. It showed a significantly higher in neutrophil count , CRP , PCT , D-dimer , and significantly lower in oxygenation index , lymphocyte count  between SBI and NBI groups. In SBI group, patients required more therapies than NBI group, such as systemic corticosteroids , budesonide , supplemental oxygen , NIV , IMV , Azvudine  and Paxlovid .A total of 1,018 patients with a diagnosis of COVID-19 pneumonia were evaluated. The baselines of the SBI and NBI groups were shown in p < 0.001) between SBI and NBI groups in overall population (p = 0.069) and critical subgroup . But in-hospital mortality was significantly higher in mild subgroup  and moderate subgroup .There was significantly higher in-hospital mortality , mild subgroup  and moderate subgroup  with univariate analysis, but no significant association in severe subgroup  and critical subgroup . With multivariable adjusted logistic regression models, it showed that bacterial co-infection was associated with significantly higher in-hospital mortality in overall population  and mild subgroup , but no significant association in moderate subgroup , severe subgroup  and critical subgroup .Further more, we analyzed the association of bacterial co-infection and in-hospital mortality of COVID-19 patients with logistic regression models . The resp = 0.003), and than that in moderate subgroup , but no significant difference between moderate and severe subgroups .The rate of bacterial co-infection in overall population was 51%. At the same time, we analyzed the rates of bacterial co-infection of COVID-19 patients in different subgroups . Based op = 0.075), also between moderate and mild subgroups . But it showed a significantly higher rates of bacterial co-infection in severe subgroup than moderate subgroup .Based on PII , there wp < 0.001). While all of older age , gender , with diabetes , cardiovascular diseases , chronic pulmonary disease , chronic kidney disease , and chronic liver disease  were not significantly associated with higher in-hospital mortality.Using multivariable adjusted logistic regression models , the resMany studies have focused on bacterial co-infection of COVID-19, but the reported rates varied greatly between different studies . Some stFurther more, we analyzed the in-hospital mortality of COVID-19 in different PII subgroups with bacterial co-infection or not. The results showed that the in-hospital mortality of the four subgroups based on PII were as follows: critical subgroup (63% vs. 57%), severe subgroup (44% vs. 26%), moderate subgroup (23% vs. 13%), mild subgroup (17% vs. 4%) with bacterial co-infection or not. This result indicated that bacterial co-infection significantly raised in-hospital mortality in mild and moderate subgroups classified by PII, while in severe and critical subgroups, bacterial co-infection did not significantly affect in-hospital mortality of COVID-19. It also found that bacterial co-infection was an independent risk factor for in-hospital mortality in the overall population and mild subgroup with multivariable adjusted logistic regression models. Therefore, it was beneficial for predicting the correlation between bacterial co-infection and in-hospital mortality of COVID-19 patients classified by PII which based on CT imaging within 48 h of admission. Similar to our results, Peng S et al. pointed out that the PII correlated well with the clinical classifcation, and PII could be used to monitor the outcome of COVID-19 pneumonia .Our study only analyzed the impact of community bacterial co-infection on in-hospital mortality, but payed no attention to the hospital acquired bacterial co-infection. Furthermore, we did not analyze the antimicrobial treatment during hospitalization, because doctors tended to use antibiotics even without evidence of bacterial infection.In conclusion, bacterial co-infection estimated by Neutrophil count and procalcitonin significantly raises in-hospital mortality of COVID-19 patients in overall population in our study. Its impact is more significant in mild and moderate PII subgroups. PII is an independent risk factor of bacterial co-infection of COVID-19. CT imaging combined with neutrophil count and PCT is beneficial for accurate differentiation of bacterial co-infection of COVID-19.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 the Research Ethics Commission of the Second Affiliated Hospital of Chongqing Medical University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SL and KZ designed the study and analyzed the data. All authors contributed to the article and approved the submitted version.This work was supported by the General Program of Chongqing Natural Science Foundation (CSTB2022NSCQ-MSX0901) and Kuanren Talents Program of the Second Affiliated Hospital of Chongqing Medical University (kryc-yq-2204).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.


Following a Research Topic on matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) application for susceptibility testing of microorganisms  software tools.Campylobacter coli and C. jejuni, Feucherolles et al. describe a ML prediction approach as an AMR screening tool for seven antimicrobial resistances. The aim of diagnostic tests is achieving both high sensitivity and specificity. This study shows the potential of this approach, but also the unsolved hurdles to reach the necessary balance between sensitivity and specificity. Here, high sensitivity was chosen as the most important parameter to adjust the threshold score during the tuning part, which led to specificity problems regarding some of the antibiotics tested. The authors concluded that threshold adjustment is vital while elaborating ML pipeline for routine use based on MALDI-TOF mass spectra. Wang H-Y. et al. used ML approaches to construct a prediction model for rapid detection of ciprofloxacin-resistant Klebsiella pneumoniae strains based on identified significant biomarkers. However, as with similar ML approaches, they realized that those models cannot be generalized to other microbial species and antibiotics. This limitation has been addressed by Zhang et al. on serial antibiotic resistances prediction. They generated a multi-label prediction model for clindamycin and oxacillin susceptibilities in Staphylococcus aureus based on MALDI-TOF MS data. In this context, multi-label learning targets the challenge where each case is represented by a single instance while simultaneously related with a set of labels  for that a benchmarking study has recently shown that it is able to outperform traditional machine learning methods  was introduced.Nowadays, there is an increased effort to take advantage of artificial intelligence (AI) algorithms to analyze the patterns of MALDI-TOF MS peaks for microbial identification and AST . Jeannot et al. evaluated the MALDIxin test for the detection of colistin-resistant Pseudomonas aeruginosa clinical strains. All colistin-susceptible and most of the resistant strains were detected in <1 h; the remaining resistant strains were detected after 4-h colistin pre-exposure. However, this procedure needs a spectrometer equipped with a respective switching modality and it creates more effort, e.g., by additional calibration steps, because the positive-ion mode is used for routine diagnostic purposes in clinical microbiology. For this reason, Foglietta et al. developed a MALDI-TOF MS test in positive-ion mode for rapid detection of colistin-resistant K. pneumoniae after a 3-h incubation reaching total agreement with the phenotypic reference method.The polymyxin colistin, a polycationic peptide antimicrobial, is still considered as last line of defense against carbapenemase-producers. Determination of resistance by MS-based assessment of the negatively charged lipopolysaccharide component lipid A as cellular target of the polymyxins is favored by switching the MALDI-TOF-MS device into the negative-ion mode  workflow to detect enterobacterial carbapenemases with a screening method based on peptide groups .Olson et al. used MALDI-TOF MS to genotype Moraxella bovis strains based on two biomarker models to classify strains according to genotype with an overall accuracy of 85.8–100%.In summary, the main conclusion that can be drawn from this Research Topic is that the development of non-identification MALDI-TOF MS applications is worth continuing. The overriding advantage is its special potential to obtain a lot of information from one single protein spectrum analysis, i.e., species identification, AST results, data of the genetic diversity and, possibly, further information e.g., on virulence factors.KB and AL managed the Research Topic MALDI-TOF MS in Microbiological Diagnostics: Future Applications Beyond Identification as topic editors. KB and AL wrote the manuscript and both authors reviewed and edited the manuscript.


To perform a detailed description of executive functioning following moderate-to-severe childhood traumatic brain injury (TBI), and to study demographic and severity factors influencing outcome.n = 43), was compared to normative data using a newly developed neuropsychological test battery (Child Executive Functions Battery—CEF-B) and the BRIEF.A convenience sample of children/adolescents aged 7–16 years, referred to a rehabilitation department after a TBI (Performance in the TBI group was significantly impaired in most of the CEF-B subtests, with moderate to large effect sizes. Regarding everyday life, patients were significantly impaired in most BRIEF clinical scales, either in parent or in teacher reports. Univariate correlations in the TBI group did not yield significant correlations between the CEF-B and socio-economic status, TBI severity, age at injury, or time since injury.Executive functioning is severely altered following moderate-to-severe childhood TBI and is best assessed using a combination of developmentally appropriate neuropsychological tests and behavioral ratings to provide a comprehensive understanding of children’s executive functions. Traumatic brain injury (TBI) is the leading cause of pediatric death and lifelong acquired disability, representing a serious public health issue . Recent Among cognitive functions affected by severe TBI, the executive functions (EFs) are often significantly affected . These fMost studies recognize that EFs are considered a multidimensional rather than a unidimensional construct . Among tExecutive functions develop throughout infancy, childhood, and adolescence, following different developmental trajectories, in parallel with maturation of prefrontal regions and cortical–subcortical pathways . These iMost studies report EF deficits in TBI of various severity levels, especially moderate and severe TBI . OverallFollowing pediatric moderate-to-severe TBI, few predictors have been identified that can reliably identify individuals at risk for long-term cognitive difficulties . ChildreDespite the recognition of executive deficits in children with moderate–severe TBI, the differentiation between specific executive component deficits and overall EFs deficits remains unclear regarding performance-based tests. In fact, the theoretical and methodological approach to assess EFs in children with TBI is often limited. Few studies simultaneously assessed at least the three basic EFs through performance-based tests  all components of EFs would be impaired (in both CEF-B measures and BRIEF scores); (2) performance-based tests and rating measures would be partially congruent to discriminate executive deficits in children diagnosed with TBI; (3) younger age at injury, longer time since injury, greater injury severity, and lower parental SES would be associated with more severe EF deficits.A convenience sample of children with moderate-to-severe TBI was included, according to the following inclusion criteria: children and adolescents (1) who sustained TBI before the age of 17 years, and who were subsequently referred to a pediatric rehabilitation department for assessment and/or follow up; (2) aged 7–16 years at assessment; (3) parents able to understand and read French; and (4) parents signed informed consent. Exclusion criteria were the presence of (1) a history of diagnosed developmental, neurological, or psychiatric disorders, (2) uncorrected sensory disorder  and (3) ongoing psychoactive treatment. Patients were included as in- or out-patients in four sites between November 2010 and December 2015: the rehabilitation departments or outreach teams in Saint-Maurice Hospitals (Saint-Maurice), Clemenceau (Strasbourg), Capucins (Angers), or SMAEC (Lyon), France. All participants were French and had French as their mother tongue.moderate if the initial/lowest GSC score was 9–12  and/or brain lesions were seen on acute imaging; and severe if the initial/lowest GSC score was 3–8, and/or neurological condition leading to intubation, neuro-sedation, and mechanical ventilation in the intensive care unit. We used the number of years of education of both parents as a proxy for SES. Intellectual ability was assessed using the age-appropriate Wechsler Intelligence Scales .Age at injury, time since injury and information related to injury severity were retrieved from the medical files. Several measures of injury severity were used: Glasgow Coma Scale (GCS) score , length WISC IV; . In thisExecutive functions were assessed using both performance-based tests and rating scales. Regarding performance-based tests, CEF-B  was usedAlertness score (percentile 90–94), (2) Impairment score (percentile 95–98), and (3) Severe impairment score (percentile 99). Following this conversion, in the third step we calculated an impairment score per task, which corresponds to the average of the outcome measures scores  in order to consider different aspects of each task  Normalization of the data, (2) Categorization of the percentiles, (3) Calculation of the impairment index by task, and (4) Calculation of the impairment index by component , and the metacognitive index . The global executive composite (GEC) index provides an overall measure of executive functioning. Raw scores for all scales were converted into T-scores and percentiles based on French normative data , but also among the four CEF-B components. For each patient, a dichotomous rating of congruence between CEF-B and parent/teacher ratings was conducted to determine to what extent performance-based and questionnaire-based measurements were comparable in discriminating executive deficits. For these analyses, only the scores of inhibition, working memory, shifting, plan/organize, and GEC of the BRIEF were considered . In this sense, two categories were considered: (1) Congruent scores: sum of congruent normal percentiles (<90 for both CEF-B and BRIEF) and congruent deficits (percentiles ≥90 for both CEF-B and BRIEF); (2) Incongruent deficits: BRIEF percentile ≥90 and CEF-B percentile <90 or BRIEF percentile <90 and CEF-B percentile ≥90. Based on these categories, we established an overall congruence percentage. The agreement rate was classified using Cohen’s kappa  and executive scores. Statistical analyses were performed using SPSS v.20.0 . For all analyses, the significance level was set at 0.05.Scores of the TBI group on the four components of the CEF-B were compared with normative French data  using a ’s kappa . FinallyFifty-six patients were approached to participate in the study, four did not agree to participate and eight files were lost or too incomplete, leaving 43 patients with sufficient available data. Descriptive statistics regarding demographic and medical/TBI severity data are summarized in Regarding EFs deficits, r = 0.35, p = 0.042) and with the flexibility component . On the other hand, the planning component showed no significant correlations with the other components . The inhibition and WM components also showed no significant correlation (r = 0.15).In order to evaluate correlations among CEF-B components, we performed several correlation analyses between the four impairment scores. The working memory component was significantly correlated with the inhibition component  scores in most of the clinical scales and composite BRIEF indices for teacher version (n = 29). In addition, the percentage of patients in the clinical range (T-score ≥ 65) was relatively high for all clinical scales, ranging from 28 to 54.5%. Regarding the parent version (n = 27), t test results were significant only for some clinical scales and indices. Furthermore, the percentage of patients in the clinical range was substantially lower than those of the teachers, ranging from 0 to 41.7%.t-test and correlation analyses performed between the scores obtained in the CEF-B components and factors known to influence EFs outcomes in the literature . The analyses showed no significant gender differences in all four executive components and overall, most correlations were low and non-significant. Only the WISC-IV matrix reasoning subtest showed significant correlations with working memory and flexibility of the CEF-B. In addition, a significant correlation was also found between the working memory component of the CEF-B and the vocabulary subtest of the WISC-IV.κ = −0.18 to 0.47), and slight to fair for parents . When divergent, EF impairment was more frequently found in the CEF-B components than in the BRIEF parent or teacher rating.Correlations between parent/teacher ratings and CEF-B performances were non-significant for all clinical scales and composite scores . HoweverThe main objective of this study was to examine the clinical value of a new child neuropsychological performance-based tests battery (CEF-B) to explore the multidimensional nature of EFs in a moderate to severe TBI sample and to provide preliminary arguments for validity. In addition, we aimed to compare the executive performance on CEF-B to parental and teacher ratings on the BRIEF questionnaire and to investigate the influence of demographic and TBI severity variables on performance-based tests of EFs.As expected, our findings highlight severe and global EFs deficits following severe childhood TBI, measured both by performance-based tests (CEF-B) and rating measures (BRIEF). Regarding the CEF-B, indices were significantly impaired for all executive components compared to normative data. Among the four components studied, the flexibility component was the most impaired (73.5% of the patients presented deficits), followed by planning (64.5%), inhibition (61.8%), and working memory (48%). In addition, 75% of patients were impaired in at least two EFs components and 29.2% had deficits in all four components. Impairment severity was particularly severe in this sample as most executive disorders scored in the 95 or 99th percentile range compared to normative data. Overall, our findings regarding the CEF-B provide evidence of significant executive deficits following moderate to severe TBI, as frequently reported , as wellRegarding the clinical validity of the CEF-B in childhood TBI, our findings also reveal positive and significant correlations between working memory and inhibition components and working memory and flexibility indices. Correlations between EFs factors were also found in other studies using the CEF-B in typically developing children in Brazil and in France . These rAlthough the findings of CEF-B were statistically significant and relatively homogeneous for all EF components, the rate of working memory deficits was considerably lower than the rate of deficits in the other components. These results could be related to two main issues: (1) the sample of children who underwent the working memory component sub-tests was smaller than for the other EF components  were found for all indices and clinical scales for the teachers’ questionnaire , whereas only five were significant for parent ratings. Regarding parent’s reports, the GEC score was impaired in 42% of the sample, which is similar to impairment rates reported in the literature . SignifiGlobal and severe executive deficits were reported through teachers’ scales. Forty-four percent of the sample exhibited significant deficits on GEC score. Both MI and BRI were impaired, suggesting difficulties in all EF domains. In contrast to parents’ complaints, teachers reported severe impairment in all EF clinical scales. This is certainly also partially explained by the fact that time since injury was relatively short, in a sample of patients who had sustained mostly severe TBI, with a majority of them still hospitalized (as in- or out-patients) given their deficits, that were not compatible (yet) with rehabilitation in the community and return to school without major adaptations or even special education. Thus, specialized school was provided on-site and teachers were specialized teachers, dealing on a routine basis with children who sustained a number of conditions affecting the brain, with good knowledge and understanding of cognitive, executive, and behavioral issues following acquired brain injury. Their observation was probably accurate. This result is similar to those obtained by Regarding associations between results of CEF-B assessment and questionnaire based BRIEF ratings, our study yielded interesting results: correlations between parent/teacher ratings and CEF-B performances were low and non-significant. This is in line with most studies having assessed correlations between direct testing and questionnaire-based reports using the BRIEF . This biased the sample toward more severe cases, unlike a prospective longitudinal study that would have included patients from the intensive care unit. Thus, our results cannot be directly translated to the whole severe TBI population. However, they contribute to the preliminary validation of the use of a newly and rigorously developed test battery to diagnose EF deficits in children who sustained moderate to severe TBI. Finally, it was not possible to measure the impact of the rehabilitation interventions that the patients received since their injury on the measures performed in this study.In conclusion, this study reports a high prevalence of EFs deficits following childhood TBI. Although this is not a new finding, the use of the newly developed CEF-B allowed addressing deficits in a multidimensional way and addressing not only sub-test results, but also domain specific deficits, supported by factorial analyses performed in a very large normative sample. This study also shows that paper and pencil tests, addressing various EF domains, using rigorously developed standardization data, can be relatively good at exhibiting and characterizing EF deficits after severe childhood TBI. The lack of correlation with questionnaire-based measures is not a new finding and supports the recommendations to use both types of measures when assessing impairments following childhood severe TBI. The use of the CEF-B should also be explored in patients with less severe injuries and with other types of acquired or developmental brain conditions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was approved by Savoie University ethics committee. The study was conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.MC, AR, AG, JR-R, DLG, and NF contributed to conception and design of the study. LS, EP, PN, CH, AKP, JR, and RF organized the database. AG and JL-R performed the statistical analysis. LS, MC, and AR wrote the first draft of the manuscript. MC, AR, AG, RF, and J-LR wrote the sections of the manuscript. All authors contributed to the article and approved the submitted version.


Several trials and meta-analyses found a benefit of adjunct corticosteroids for community-acquired pneumonia with respect to short-term outcome, but there is uncertainty about longer-term health effects. Herein, we evaluated clinical outcomes at long term in patients participating in the STEP trial (Corticosteroid Treatment for Community-Acquired Pneumonia).This predefined secondary analysis investigated 180-day outcomes in 785 adult patients hospitalized with community-acquired pneumonia included in STEP, a randomised, placebo-controlled, double-blind trial. The primary endpoint was time to death from any cause at 180 days verified by telephone interview. Additional secondary endpoints included pneumonia-related death, readmission, recurrent pneumonia, secondary infections, new hypertension, and new insulin dependence.p = 0.601). Compared to placebo, corticosteroid-treated patients had significantly higher risks for recurrent pneumonia , secondary infections  and new insulin dependence . There was no difference regarding pneumonia-related death, readmission and new hypertension.From the originally included 785 patients, 727 were available for intention-to-treat analysis at day 180. There was no difference between groups with respect to time to death from any cause (HR for corticosteroid use 1.15, 95% CI 0.68 to 1.95, In patients with community-acquired pneumonia, corticosteroid use was associated with an increased risk for recurrent pneumonia, secondary infections and new insulin dependence at 180 days. Currently, it is uncertain whether these long-term adverse effects outweigh the short-term effects of corticosteroids in moderate CAP.This trial was registered with ClinicalTrials. gov, number NCT00973154 before the recruitment of the first patient. First posted: September 9, 2009. Last update posted: April 21, 2015.The online version contains supplementary material available at 10.1186/s12890-023-02794-w. Lower respiratory tract infections such as pneumonia are the most deadly infectious disease worldwide and the world’s fourth common cause of death, according to WHO publication in December 2020 . In spitThe Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) guidelines published in 2019 recommended supplementary treatment with corticosteroids in treatment of septic shock in CAP . The invThese findings support short-term corticosteroid administration in order to prevent pulmonary dysfunction induced by hyperinflammation, for both, viral COVID-19-pneumonitis and in bacterial community acquired pneumonia, even in moderate cases hospitalized outside the ICU .However, whether corticosteroids have a lasting effect on outcome beyond 30 days needs further exploration.We herein analysed the 180 day - outcome of patients included into the STEP-trial , which iThis is a pre-planned secondary analysis of a multicentre, double-blind, randomised, placebo-controlled trial, which investigated adjunct prednisone for patients with CAP on the primary outcome of time to death from any cause. The study protocol of the initial STEP-trial has been published elsewhere . In brieEligible patients were randomly assigned (1:1 ratio) to receive either 50 mg of prednisone or placebo daily for 7 days. Randomisation was done with variable block sizes of four to six and patients were stratified at the time of study entry by study centre. Allocation was concealed with a prespecified computer-generated randomisation list, which was centrally kept at the pharmacy of the main study centre. Patients were randomly assigned to receive a prepared set of study medication that contained seven tablets of 50 mg prednisone or placebo. The placebo drug was purchased from a local prednisone manufacturer , which produces both prednisone and its corresponding placebo. The drugs were prepared before the initiation of the study and packed into identical containers by the Pharmacology Department, University Hospital, Basel, according to the randomisation list. Patients, treating physicians, investigators, and data assessors were blinded to treatment allocation until day 30 .After informed consent was obtained, baseline blood samples were drawn and nasal swabs for virus multiplex PCR were done. All other microbiological assessments were at the discretion of the treating physicians. Patients started antibiotic therapy as soon as community acquired pneumonia was confirmed. Treating physicians chose the empirical regimen according to the ERS/ ESCMID guidelines adapted for Switzerland , 17. MosThe objective of this analysis was to investigate differences in outcome until 180 days after adjunct prednisone or placebo in CAP. Specifically, we analysed the two treatment groups for differences in the following primary and secondary endpoints. Furthermore, subgroup analysis for predefined endpoints was performed.The primary endpoint was defined as time to death from any cause.Secondary endpoints included CAP-related death, readmission, recurrent pneumonia, secondary infections, new hypertension at day 180 and new insulin dependence at day 180.Types of secondary infections were categorized as dermatological, urogenital, pulmonary, intestinal, and endocardium/ foreign body infections, as well as a group of combined urogenital and pulmonary infections. The last group was formed due to the frequent issue of the two infections often occurring simultaneously.In the original trial protocol, the primary outcome was time to clinical stability. Secondary endpoints in the original protocol were all-cause mortality, time to effective hospital discharge, and side effects of corticosteroid treatments, among others .The statistical analysis was prespecified, and investigators who analysed the data were masked to treatment allocation . The priAs a sensitivity analysis, the same analyses were performed in the per-protocol population.Results are given as adjusted odds ratio (OR) and with 95% CI. In primary and secondary outcomes, hazard ratio and odds ratio were adjusted for PSI and age.The prespecified subgroup analyses  .After blinded post-randomisation exclusion of 18 patients not meeting eligibility criteria, 392 patients were allocated to the prednisone group and 392 patients to the placebo group. The intention-to-treat analysis further excluded 57 patients . Therefore, 361 patients were available for the intention-to-treat analysis at 180 days in the prednisone arm and 366 patients in the placebo arm.Baseline characteristics between the two arms were balanced . Similarly, CAP-related death was not different between treatment groups . This was also true for hospital readmission  and new hypertension at day 180 . However, recurrent pneumonia , secondary infections , and new insulin dependence at day 180  occurred more often in the prednisone group compared to the control group.There was no difference between prednisone and placebo groups regarding the time to death from any cause over the 180 day follow-up . (see Tables However, a significant subgroup effect was found in regard to recurrent pneumonia in the subgroup of patients with negative blood cultures, and in the subgroup of patients without bacterial proof, but not in the subgroup with viral proof.The sensitivity analysis in the per-protocol population showed similar results (see Additional file In this 180-day analysis of a large randomized controlled trial in patients hospitalized with CAP, we found similar risks for mortality and most other secondary endpoints, but higher incidences of secondary infections, recurrent pneumonias and new insulin dependence in patients randomized to the active corticosteroid group.While corticosteroids have shown beneficial effects at short term in the population of patients with CAP including shorter time to stabilization and lower mortality –7, 12, lThere is limited availability of evidence on outcome after CAP beyond day 30 , 26. MosWhereas the absolute number of new insulin dependence at day 180 was low, it was significantly higher in the prednisone group. Various individual risk factors for the development of corticosteroid-induced diabetes have been identified . Before We performed subgroup analyses with the aim to identify specific subgroups which would be more susceptible to adverse events, but we could not assert any effect modification by median age, initial median CRP, previous history of COPD, or severity of community-acquired pneumonia. We did find that patients without bacteremia and without proof of bacterial infection had a higher incidence of recurrence of pneumonia when receiving corticosteroids, but there was no effect modification by viral etiology of pneumonia. One might speculate that this could be a subset of patients which did, in fact, not have infectious pneumonia but rather a pneumonitis, which was overseen as generally considered uncommon in the pre-COVID-19-era.In another subanalysis with 30-day data, a phenotype with high cytokines benefited most from adjunct corticosteroids, as published elsewhere , 34.The meta-analysis by Stern et al. showed a mortality benefit only in patients with severe CAP . As our In our trial, secondary infections during hospital stay and at 30 days were not increased in the prednisone group. The reduction in length of stay at day 30 may have outbalanced the increased risk for secondary infections conferred by the corticosteroids.In summary, when considering adjunct corticosteroids for CAP, it is necessary to weigh the anticipated benefits like faster time to clinical stability, shorter length of stay and shorter duration of intravenous antibiotic treatment against potential adverse effects like in-hospital hyperglycemia, secondary infections beyond day 30 and recurrence of CAP beyond day 30.The major limitation of this analysis is the question whether short-term corticosteroids are still causative for the effects found at day 180. The trial was not powered for these secondary endpoints; therefore, the results should be considered hypothesis generating.In addition, despite standardized questions in the endpoints, there is a risk of information bias due to the assessment of data as patient interviews.It must be acknowledged that COVID-19 pneumonitis and CAP are different diseases and thus comparison is limited, in spite of similarities in subsequent hyperinflammation and pulmonary affection.The main strengths of the trial are the large number of patients and the randomized placebo-controlled design, preventing many confounders. Moreover, this is the first randomized controlled trial of corticosteroids in CAP investigating long-term outcomes until 180 days.In patients with community-acquired pneumonia, corticosteroid use was associated with an increased risk for recurrent pneumonia, secondary infections, and new insulin dependence in the following 180 days. Currently, it is uncertain whether these long-term adverse effects outweigh the short-term effects of corticosteroids in moderate CAP.Additional file 1: Supplemental Table S1. Baseline characteristics of per-protocol population. Supplemental Table S2. Overview of primary and secondary endpoints per-protocol. Supplemental Table S3. Subgroup analyses per-protocol for the primary endpoint mortality. Supplemental Table S4. Subgroup analyses per-protocol for the secondary endpoint recurrence. Supplemental Table S5. Subgroup analyses per-protocol for the secondary endpoint secondary infection. Supplemental Table S6. Overview of disease activity scores of intention-to-treat population. Supplemental Figure F1. Trial flow chart per-protocol. Supplemental Figure F2. Kaplan-Meier-curve of time to death per-protocol.


Today, cancer treatment is one of the fundamental problems facing clinicians and researchers worldwide. Efforts to find an excellent way to treat this illness continue, and new therapeutic strategies are developed quickly. Adoptive cell therapy (ACT) is a practical approach that has been emerged to improve clinical outcomes in cancer patients. In the ACT, one of the best ways to arm the immune cells against tumors is by employing chimeric antigen receptors (CARs) via genetic engineering. CAR equips cells to target specific antigens on tumor cells and selectively eradicate them. Researchers have achieved promising preclinical and clinical outcomes with different cells by using CARs. One of the potent immune cells that seems to be a good candidate for CAR-immune cell therapy is the Natural Killer-T (NKT) cell. NKT cells have multiple features that make them potent cells against tumors and would be a powerful replacement for T cells and natural killer (NK) cells. NKT cells are cytotoxic immune cells with various capabilities and no notable side effects on normal cells. The current study aimed to comprehensively provide the latest advances in CAR-NKT cell therapy for cancers. Recently, chimeric antigen receptor (CAR)-armored cell therapy has focused on the T cell . This ceNKT cells have a vital role in the upregulation of the immune system and suppression of the tumor microenvironment (TME) in the course of disease . In addiThe current study aimed to comprehensively discuss the various aspects of CAR-NKT cell therapy and its recent advances in cancer treatment. The different advantages of this treatment, the comparison with other CAR-armored immune cells, and the related preclinical and clinical findings of cancer CAR-NKT cell therapy have been discussed in detail. Also, the limitations, challenges, and solutions for increasing the safety and effectiveness of CAR-NKT cell treatment have been addressed to arrive at the conclusion that CAR-NKT cells whether can be effective in cancer treatment.+, CD4+, and double-negative (CD4− CD8− or DN) cells  technologies, are the other contributory approaches that have been developed to improve the anti-tumor function of CAR immune cells . CRISPR-Another approach is suicide gene modification which is combined with CAR-based treatment and prevents insertional oncogenesis risks . Most viT-cell Redirect Towards Universal Cytokine Killing (TRUCK) is an engineered T cell with a transgenic payload that allows cell-producing proteins and other cell compartments by activating CAR . TRUCK wNKT cells have an antigen recognition system independent of MHC-I, while the main focus in T cells is based on T-cell receptors (TCRs) . EngineeInducible CARs have been recently added to the types of CARs. Inducible CARs have activation capacity after administering the drug to the body. This method has been tried in CAR-T cell immunotherapy, which subsequbtly increased IFN-γ production, cytotoxic function, and survival in mouse models . Furtherin vitro with the α-GalCer substance before reinfusion to change the impairment of NKT cell function in TME [Activating NKT cells with α-GalCer may be suitable but have different problems. Autologous NKT cells are suggested to proliferate n in TME . For redn in TME . This men in TME . It alson in TME  without n in TME , primarin in TME . Besidesn in TME . This prn in TME .2-microglobulin and creates soluble CD1d (sCD1d). Then, an ScFv fragment connects to sCD1d against the tumor marker. This structure is loaded with α-GalCer before administration [+ tumor cells in vitro [The specificity of NKT cells can be increased by using α-GalCer/CD1d anti-tumor fusion proteins. One of the important factors that helps NKT cells affect tumor cells firmly is the existence of CD1d receptors on the tumor cells . So, to stration . Recentlstration , 170. Inin vitro . So, incin vitro . When NKin vitro .New research showed that photothermal therapy improved the anti-tumor function of NKT cells. This strategy uses several ways to create the conditions for the better function of NKT- and CAR-NKT-cells. Examples of these ways include increasing the blood flow in the tumor site and more secretion of cytokines and chemokines that lead to recruiting the immune cells to the tumor site, making an inflammatory condition, elevating tumor infiltration NKT-cells, and causing a higher secretion of IL-1 and IL-12 cytokines . ProductOne of the main obstacles to developing NKT cell-based immunotherapy is isolating adequate NKT cells from the PBMCs of cancer patients. Therby, suitable sources can help advance this treatment. One of the valuable strategies is using induced pluripotent stem cells (iPSCs) derived from patients . Stem ceType II NKT cells have a contributory function in tumors that escape from the immune system, which increases tumor survival. So, the restraint of these cells can be a helpful strategy for cancer immunotherapy. One of the approaches for preventing type II NKT cells is to apply lipids that change or block the responses of these cells. The NKT cells have several sulfatide antigens with different cell signaling functions. Recently, a unique sulfatide antigen isoform of type II NKT cells, namely C24:2, has been introduced and has shown significant inhibitory effects on the progression of lung cancer metastasis. In contrast, other types of sulfatide isoforms, such as C24:1 and C24:0, increased the development of tumor metastasis in mouse models of lung cancer . CpG ODNin vitro [in vivo. However, this increase was not seen in NK- and CD8 T-cell-based immunotherapies [in vivo and in vitro [in vivo and in vitro [Some chemotherapy drugs showed an immune-stimulating function, enhanced immune cell infiltration into TME, and increased effects of ongoing immunotherapy . Utiliziin vitro . Besidesherapies . Those cherapies . Among therapies . The effherapies , augmentherapies , enhancein vitro . Clinicain vitro . In a phin vitro . As a rein vitro. Furthermore, the NKT cells showed better results along with RT than CD8+ T cells [Radiotherapy (RT) combined with cell-based immunotherapy has a beneficial effect on cancers. For example, the combination of RT with CAR-T cell therapy revealed encouraging outcomes in different cancers like B-NHL, lung cancer, and prostate cancer –194. Rec T cells . Inconsi T cells . This isOncolytic viruses infect and lyse the tumor cells exquisitely . The shr+ T cell anergy [One of the helpful immunotherapy methods is exploiting the immune checkpoint inhibitors . Combinil anergy . To thisl anergy –211. Thil anergy . RecruitAnother proper immunotherapy strategy for combining with CAR-NKT cell therapy is using immunostimulatory agents such as monoclonal antibodies (mAbs) and cytokines . The mAbOne of the other solutions to improving cancer treatment is the enhancement function of NKT cells in TME and better recognition of Th1-based lipid antigens . For exaDue to the complexity, smarts, and various escape routes of tumors from the immune system, studies should focus on developing and recruiting intelligence-based treatments like immune-based therapies. The outstanding cytotoxic and regulatory characteristics of CAR-NKT cells with functional capabilities are considered a potent newfound cell-based therapy against cancers. This treatment is entirely novel, and reaching the definitive treatment has a long way to go. CAR-NKT cells possess the most properties of both T- and NK-cells, making them powerful and appropriate cell-based therapeutic choices against cancers. In addition, the CAR-NKT cells have different anti-cancer abilities, such as rapid recognition of the tumor cells, a higher rate of infiltration into TME, promising cytotoxicity, and regulatory function on immune cells. By focusing on past experiences in CAR T- and CAR NK-cell therapy, engineering the intelligent and effective CAR-NKT cell structure and combining it with other therapeutic strategies may open new windows in cancer treatment. The preclinical studies demonstrated noticeable and promising findings of CAR-NKT cell therapy in various cancers, and scientists hoped they would achieve a successful treatment. However, unfortunately, the limited number of clinical trial studies developed or in progress and the lack of access to more definitive results have made the questionable and controversial decision regarding this potent treatment strategy. Utilizing the new contributory solutions such as engineering armored and programmable CARs, progress in gene transfer strategies, and improving the immune system situation in various ways can help achieve potent CAR-NKT cell therapy. The interaction between the immune system and genetics can create new and intelligent treatments that we can one day use to treat cancers. CAR-NKT cell therapy needs more studies and a bright future in cancer treatment, and there have been many experiences for us to continue.


Reconstitution into model membranes, such as liposomes, is a suitable approach to study lipid transporters in vitro and to investigate their key molecular features. In this review, we discuss the current approaches for reconstituting ATP-driven lipid transporters into large liposomes and common techniques used to study lipid transport in proteoliposomes. We also highlight the existing knowledge on the regulatory mechanisms that modulate the activity of lipid transporters, and finally, we address the limitations of the current approaches and future perspectives in this field.Lipid transporters play a crucial role in supporting essential cellular processes such as organelle assembly, vesicular trafficking, and lipid homeostasis by driving lipid transport across membranes. Cryo-electron microscopy has recently resolved the structures of several ATP-dependent lipid transporters, but functional characterization remains a major challenge. Although studies of detergent-purified proteins have advanced our understanding of these transporters,  Cellular membranes are vital structures that maintain cell integrity and perform critical functions such as organelle compartmentalization, signaling, and membrane trafficking. These complex structures are composed of a hydrophobic matrix consisting of a double layer of lipids ,2. Embed4 lipids per second [2+ or proteolytic cleavage [There are three types of lipid transporters: scramblases, flippases, and floppases . Scramblr second , therebycleavage . In contcleavage , phagocycleavage , and hoscleavage .Recent advances in structural biology and computational biology have made it possible to capture the structures of several lipid transporters in multiple functional states (reviewed in ). With tATP-dependent primary lipid transporters are essential membrane proteins that belong to either the P-type ATPase family or the ATP-binding cassette (ABC) transporter family. The P-type ATPase family can be divided into five major evolutionarily related subfamilies (P1-P5), each with distinct transport specificities. Among these subfamilies, P4-ATPases function as lipid flippases and are found exclusively in eukaryotes. The P-type ATPases have a similar structure, consisting of a membrane-spanning (M) domain and three cytosolic domains. These include an autocatalytic phosphorylation (P) domain, a nucleotide binding (N) domain, and an actuator (A) domain, which are responsible for the structural transfer of free energy release, derived from ATP hydrolysis. The amino and carboxyl termini of P-type ATPases face the cytosol, vary in length, and often accommodate regulatory domains or motifs. During substrate transport, P4-ATPases undergo conformational changes and the auto-phosphorylating and dephosphorylating of a conserved aspartate residue within a conserved signature sequence, hence the name ‘P-type’. P4-ATPases typically form heterodimeric complexes with an accessory subunit known as cell division control protein 50 (Cdc50), which are integral membrane proteins glycosylated in their exoplasmic domain. The interaction between Cdc50 proteins and individual P4-ATPases is crucial for endoplasmic reticulum exit and transporter activity .Members of the ABC transporter superfamily include ATP-dependent lipid transporters that function either as flippases, floppases or possibly as lipid importers/exporters. These transporters are found in bacteria, archaea and eukaryotes, and the wide diversity within this family is exemplified by differences in structure, mechanistic features, and substrates transported ,26–28. AThe mechanism by which P4-ATPases and ABC transporters flip-flop lipids is still not fully understood. The classical transport model for P4-ATPases is known as the ‘credit card model’ as an analogy to a credit card being swiped through a reader terminal by only contacting with the magnetic stripe. This model proposes that as phospholipids cross the membrane, only their headgroups gain access to the central cavity, while the hydrophobic hydrocarbon tails remain immersed in the hydrophobic core of the bilayer . Recent Based on recent advances in molecular dynamics simulations and structure determination of eukaryotic and bacterial ABC transporters, new transport models have been proposed that deviate from the canonical alternating access mechanism. Examples include the ‘outward-only’ mechanism with outward-occluded and outward-open conformations, proposed for lipid-linked oligosaccharide flopping by PglK, which does not invoke an inward-facing cavity to interact with the substrate . This baSaccharomyces cerevisiae has become an increasingly popular tool for the functional analysis of candidate lipid flippases. This is due to the ease of handling and the availability of numerous deletion mutants [Although ATP-driven lipid transporters have been extensively studied, much of our current understanding has come from cell-based studies. The first discovery of ATP-dependent lipid flippase activity dates back to the 1980s, based on pioneering work using spin-labeled lipid probes . Subsequ mutants .Cell-based assays to study lipid transport are typically based on short-chained nitrobenzoxadiazol (NBD)-labeled lipids . The method is based on the use of a soluble glucosyltransferase acting in the presence of an excess of nucleotide-bound radiolabeled sugars to convert the truncated substrate upon its appearance in the outer leaflet of the liposome. The change in radioactivity over time provides a quantitative measure of the rate at which PglK flips the truncated substrate , which cannot translocate from the donor liposomes to the proteoliposomes. During the exchange and translocation of the NBD-lipid, a decrease in the energy transfer between the NBD-lipid and the N-Rho-PE occurs, resulting in an increase in NBD fluorescence and enabling continuous measurement of lipid translocation C. This mTo date, only a small number of P4-ATPases and ABC transporters have been successfully reconstituted . Therefore, unidirectional lipid transport in these vesicles, even at small amplitudes, can lead to the accumulation of bilayer stress . This meetergent . To deteetergent . Alternaetergent .sn-2 position, while a long fatty acid chain is at the sn-1 position (As mentioned above, current cell-based and reconstitution assays commonly use lipid probes. These probes have a reporter group attached to a short fatty acid chain at the position . GUVs, rposition A. HoweveFinally, techniques such as measuring the zeta potential using the mechanisms of electrophoresis , nuclearAnother problem encountered in liposome reconstitution is sample heterogeneity, which can bias the quantitative analysis of lipid and protein content as well as protein activity. To overcome this challenge, a promising approach is to characterize the intrasample compositional variation at the single vesicle level. This approach is based on the visualization of single liposomes by microscopy, using fluorescently labeled lipids and reconstituted proteins with corresponding fluorescent labels. By using site-specific quenching of the fluorophores, it is possible to obtain a detailed characterization of the reconstituted proteoliposomes, including parameters such as size, tightness, lamellarity and the number of proteins per liposome as well as their orientation . In addiin vivo.Lipid transporters are inherently difficult to study. On the one hand, this can be attributed to the difficulties in handling the integral membrane proteins and their delicacy in production, purification, and characterization of their assembly with membrane lipids. On the other hand, sophisticated techniques are required to study membrane proteins at the molecular level. Despite these challenges, researchers continue to make progress in understanding the mechanisms underlying transporter function and in developing new techniques for studying these critical cellular components. In this review, we included current published reports on ATP-dependent lipid transporters and their functional analysis using liposomal reconstitution. Such functional assays, coupled with structural analysis and computational studies, including both molecular dynamics and coarse-grained simulations, will be essential in unravelling the inner working of these important transporter classes. In addition, we highlighted recent progress in uncovering key molecular and regulatory mechanisms of these transporters, the role of which remains to be further defined by systematic and detailed studies in model membrane systems and


Effective implementation of evidence-based practices often involves multi-level strategies targeting individual-, organizational-, and system-level determinants of change. Although these multi-level implementation approaches can successfully facilitate EBP uptake, they tend to be complex and resource intensive. Accordingly, there is a need for theory-driven, generalizable approaches that can enhance efficiency, cost-effectiveness, and scalability of existing implementation approaches. We propose the Single-Session Intervention approach as an unexplored path to developing low-cost and scalable implementation strategies, especially those targeting individual-level behavior change. We argue that single-session strategies (S3) for implementation, which can simultaneously target myriad barriers to individual behavior change, may promote clinicians' EBP uptake and sustainment in a manner that is low-resource and scalable. We first overview the evidence-base supporting the Single-Session Intervention approach for patient-level outcomes; situate this approach within the implementation science literature by outlining its intersections with a leading framework, the Theoretical Domains Framework (TDF), as an exemplar; and illustrate how the TDF might directly inform the design and evaluation of single-session strategies for EBP implementation. Overall, single-session strategies (S3) for implementation reflect a promising but yet-to-be-tested means of streamlining and scaling individual-level behavior change efforts in healthcare settings. Future partnered research is needed to gauge the potential of this approach across diverse clinical and community contexts. Per the widely-touted 17-year gap between the identification and application of evidence-based clinical practices, the so-called research-practice gap reflects a canonically “wicked problem” in healthcare . This caWe argue that the Single-Session Intervention approach —typicallvia digital, self-guided programs; and via diverse settings, from classrooms to clinics to smartphones.Single-Session Interventions (SSIs) are “structured programs that intentionally involve just one visit or encounter with a clinic, provider, or program” . To dateN = 2,452) during the COVID-19 pandemic, vs. a supportive-therapy control . The SSI design features highlighted here reflect recommendations for framing SSI content, which may be built-out as briefer or longer interventions, per context-specific needs. At the same time, it is not necessarily required that an SSI encompass all four design features; they are presented as one of potentially many approaches to constructing single-session programs that spur improvements in relevant outcomes.How do SSIs work? Broadly, they target theory-driven principles and proximal factors that underlie general behavior change—regardless of the distal outcome of interest. For example, Schleider et al.  describeBecause the mechanisms underlying SSI effects reflect generalizable drivers of behavior change, and given SSIs' consistent impacts on myriad outcomes, it stands to reason that SSIs may be helpfully reconceptualized as single-session strategies (S3) for implementation: Targeted, theory-informed activities aimed at promoting the uptake and sustainment of evidence-based clinical practices among clinicians. In other words, by tailoring the content of SSIs to address clinicians rather than patients, these brief, potent activities may be harnessed to motivate clinician EBP uptake and use , highlighting opportunities for the TDF to guide design and evaluation of single-session strategies (S3) to efficiently disseminate efforts to support clinician-level behavior change.Notably, S3s would differ substantially in their goals and structures from existing provider-directed EBP training programs, which generally aim to establish mastery and uptake of complex, multi-pronged interventions  . LikewisThe TDF is a leading implementation determinant framework that incorporates 128 constructs spanning 12 domains, derived from 33 different theories of behavior change . The TDFBased on the SSI literature, it stands to reason that S3 for implementation—built as brief, streamlined programs for clinicians to complete—may be able to target multiple TDF-identified targets for individual behavior change. via psychoeducation about the nature of depression, and how taking values-based actions can boost mood in moments of low motivation or distress. It simultaneously targets social identity by providing users with norms regarding the many teens who experience depression—along with symptom relief after practicing values-based actions. It addresses skills and the nature of the behavior through a personalized “action plan,” wherein users build a plan for engaging in specific, values-aligned activities in response to negative emotions. Further, it enhances memory for SSI content, empowering users to advise a peer in “taking action” to manage their mood . TherefAlongside prioritizing acceptability, co-design with clinicians in different settings will be critical to S3 success, as it has been for evidence-based patient-directed SSIs . Some paOverall, single-session strategies (S3) for implementation represents a promising but yet-to-be-tested approach for streamlining and scaling individual-level behavior change efforts in healthcare settings. Future organization-partnered research may reveal the promise of this approach across diverse healthcare settings, contexts, and EBPs.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.JS and RB conceptualized the manuscript. JS wrote the initial draft. Both authors reviewed, edited, and approved of the final manuscript.JS receives research and grant support from NIH Office of the Director (DP5OD028123), NIMH (R43MH128075), NSF (2141710), HRSA (U3NHP45406-01-00), Upswing Fund for Adolescent Mental Health, the Society for Clinical Child and Adolescent Psychology, and the Klingenstein Third Generation Foundation. RB reported receiving grants from the National Institutes of Health, Patient Centered Outcomes Research Institute, the US Centers for Disease Control and Prevention, and the National Psoriasis Foundation outside of the submitted work. The preparation of this article was supported in part by the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (R25MH080916). JS is an IRI Fellow and RB is IRI Faculty.JS serves on the Scientific Advisory Board for Walden Wise and the Clinical Advisory Board for Koko, is Co-Founder and Co-Director of Single Session Support Solutions. Inc., and receives book royalties from New Harbinger, Oxford University Press, and Little Brown Book Group. RB is principal at Implementation Science & Practice, LLC, she receives royalties from Oxford University Press, consulting fees from United Behavioral Health and OptumLabs, and serves on the advisory boards for Optum Behavioral Health, AIM Youth Mental Health Foundation, and the Klingenstein Third Generation Foundation outside of the submitted work. In addition to the above potential conflicts, the authors would like to note that JS leads a research lab whose mission involves designing, evaluating, and disseminating single-session mental health interventions, including those discussed in the present manuscript.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.


Mycobacterium tuberculosisantimicrobial resistance is a global public health concern. We present a case of a young man from Venezuela who presented to a hospital in New York and was newly diagnosed with pulmonary tuberculosis, human immunodeficiency virus (HIV), and syphilis. His TB isolate was found to be resistant to multiple anti-TB drugs, presenting unusual challenges in treating multidrug-resistant TB with HIV co-infection.Pulmonary tuberculosis (TB) infection is a public health concern in the United States.  Mycobacterium tuberculosis remains the number one bacterial cause of death worldwide [Tuberculosis (TB) caused by orldwide . In 2021orldwide . In 2021orldwide . In the orldwide . While the United States currently has a TB case rate of 2.4/100,000 . TB can be classified by its susceptibility to anti-mycobacterial treatments. Current classifications include drug-susceptible TB (DS-TB), rifampin-resistant (RR-TB), isoniazid, and rifampicin-resistant (MDR-TB), MDR plus resistance to any fluoroquinolone (pre-XDR-TB), and pre-XDR with resistance to any Group A drug (XDR-TB). Group A drugs include levofloxacin, moxifloxacin, bedaquiline, and linezolid .With the ongoing economic crisis in Venezuela, there has been a large migration of these individuals both to neighboring countries and to the United States, which may result in an increased number of cases of patients with TB with varied patterns of resistance as well as TB/HIV co-infection. Since 2015 over 7.1 million Venezuelans have fled the country .In July 2022, a 30-year-old male with no reported medical history, who had recently emigrated from Venezuela presented to a hospital emergency department in New York City (NYC) with complaints of a productive cough, fever, chills, weight loss, and night sweats for two months. He arrived in the United States on January 2022 and lived in a crowded shelter in NYC. He was unemployed and reported no close contact with known TB-infected individuals. On presentation, he reported no chest pain, shortness of breath, or hemoptysis. He does not take any medications, drink alcohol, or use any illicit drugs; he reported having a history of sexual contact with men. He reported smoking three cigarettes a day for 10 years. On presentation to the emergency department, his temperature was 98.7°F (37°C), blood pressure 95/73 mmHg, heart rate 88 beats per minute, respiratory rate 19 breaths per minute, and oxygen saturation of 99% on room air. A physical exam revealed a cachectic young man with left upper lobe expiratory rhonchi. Chest X-ray showed patchy opacities throughout the left lung, perihilar opacities on the right, and cavities in the left upper lobe . He was empirically started on ceftriaxone and azithromycin for the treatment of community-acquired pneumonia. A chest computed tomography (CT) scan without contrast showed left upper lobe cavities with nodular walls and tree-in-bud opacities involving the entire left lung associated with consolidation in the lingula Figure .He was found to have a positive for acid-fast bacilli (AFB) on a smear test, positive for HIV, and reactive for rapid plasma reagin (RPR). Additional pertinent initial lab work is shown in Table .Mycobacterium tuberculosis with gene mutations suggestive of rifampin and INH resistance. The New York City Department of Health (DOH) TB division involved in the case recommended discontinuing rifabutin and adding amikacin, levofloxacin, and cycloserine to the treatment plan. After two weeks of well-tolerated anti-TB treatment, the decision to start HIV anti-retroviral therapy was made; hence bictegravir, emtricitabine, and tenofovir alafenamide were added. Repeat AFB smears remained positive after two weeks of starting the new regimen. TB was isolated from the pretreatment sample. The susceptibility testing showed resistance to rifampin, INH, ethambutol, pyrazinamide, but susceptibility to amikacin, cycloserine, and fluoroquinolones. These results were discussed with DOH TB specialists, who recommended switching current treatment to bedaquiline, pretonamid, and linezolid (BPaL) for six-nine months, as per the updated 2020 WHO recommendations for the treatment of drug-resistant tuberculosis [Ceftriaxone and azithromycin were discontinued, and he was started on rifabutin, isoniazid (INH), ethambutol, pyrazinamide, and pyridoxine (vitamin B6). Penicillin G benzathine was administered for the treatment of presumptive late latent syphilis as he had no prior history of syphilis, no symptoms, and no prior lab results. HIV anti-retroviral therapy (ART) was initially deferred while TB drugs' tolerability was being assessed and to avoid immune reconstitution inflammatory syndrome (IRIS). Repeat AFB smears while on anti-TB therapy remained positive. The molecular DNA testing of sputum showed the presence of rculosis . At the This case highlights the complexity of HIV and pulmonary TB co-infection treatment. The major issues with the treatment of HIV-TB coinfection are drug-drug interactions, risk of immune reconstitution inflammatory syndrome (IRIS), and timing of initiation of ART. In patients who are ART naive antiretroviral therapy should be initiated within two weeks of starting anti-TB medications in patients with CD4 cell counts less than fifty if TB meningitis is not in the differential and within eight weeks for those with higher CD4 cell counts . This paThe strain of TB isolated in this case showed multidrug resistance. Patients with HIV and MDR-TB co-infection have a fourfold higher mortality risk than MDR-TB infection alone . A recenThe importance of evaluating the whole clinical picture when making treatment decisions is evident in this case. The treatment of TB and HIV co-infection is complicated by major drug-drug interactions and, in this case, further complicated his highly resistant strain of TB; however, the fact that this patient was clinically stable when he presented to the hospital gave us the flexibility to start treatment for TB prior to antiretroviral therapy, preventing potential drug-drug interactions. Once the initial bacterial culture sensitivities became available, the optimal anti-TB treatment was evident, and the best antiretroviral therapy regimen was very clear, leading to effective treatment of the TB and HIV co-infection.