End-stage renal disease is a public health problem responsible for millions of deaths worldwide each year. Although transplantation is the preferred treatment for patients in need of renal replacement therapy, long-term allograft survival remains challenging. Advances in high-throughput methods for large-scale molecular data generation and computational analysis are promising to overcome the current limitations posed by conventional diagnostic and disease classifications post-transplantation. Non-coding RNAs (ncRNAs) are RNA molecules that, despite lacking protein-coding potential, are essential in the regulation of epigenetic, transcriptional, and post-translational mechanisms involved in both health and disease. A large body of evidence suggests that ncRNAs can act as biomarkers of renal injury and graft loss after transplantation. Hence, the focus of this review is to discuss the existing molecular signatures of non-coding transcripts and their value to improve diagnosis, predict the risk of rejection, and guide therapeutic choices post-transplantation. End-stage renal disease (ESRD) is an increasingly prevalent public health problem responsible for millions of deaths worldwide each year ,2. TransNon-coding RNAs (ncRNAs) are RNA molecules that lack protein-coding potential but are essential in the regulation of epigenetic, transcriptional, and post-translational mechanisms involved in homeostasis and disease . The devMiRNAs are small RNA molecules of ~23 nucleotides in length that interact with the 3′ untranslated region (UTR) of their target mRNAs to induce their degradation or repress their translation . NonetheCircRNAs expressed in mammalian cells are non-coding transcripts with a circular structure in which the 3′ and 5′ ends are covalently linked . These nlncRNAs are transcripts of > 200 nucleotides in length, with no protein-coding capacity and often transcribed from intergenic regions ,25. ThesThe purpose of this review is to summarize current evidence regarding the value of ncRNA expression profiles in renal transplantation. All the information gathered in this integrative review was extracted from original and high-quality English language papers indexed in PubMed, based on the search of the MeSH Terms: “non-coding RNA”, “microRNA”, “long non-coding RNA”, “circular RNA”, “renal transplantation”, “molecular signatures”, and “allograft rejection”. Extraordinary progress in technologies designed for high-throughput data generation and analysis has had profound repercussions on biomedical research and precision medicine . UnfortuRenal biopsy is the gold standard in current clinical practice for the diagnosis of post-transplant rejection. Nevertheless, the data is descriptive and provides little information about prognosis . The fieMolecular signatures of ncRNAs can echo epigenetic and post-transcriptional modifications occurring within the kidney ,38,39. TDelayed graft function (DGF) is the clinical manifestation of post-transplant AKI, a common complication that affects short- and long-term transplantation outcomes . Organs Wilflingseder J. et al. initially identified seven miRNAs  upregulated in DGF kidneys . Then, tInterestingly, cell-free miRNAs in graft preservation fluid are predictive of DGF post-transplantation. Roest HP et al. identified an association between high levels of miR-505-3p in the preservation fluid of kidney grafts donated after circulatory death and an increased risk of DGF after transplantation . AnotherExosomes are secreted vesicles present in biological fluids that transfer molecular cargo, including ncRNAs, between cells. Despite current excitement regarding exosomes as up-and-coming diagnostic and prognostic tools in cancer, studies of exosomes and other extracellular vesicles in transplantation are scarce . Wang J.Although it is clear that other types of ncRNAs such as lncRNA and circRNAs are involved in the development of renal ischemic injury in animal models, their role as potential predictors of DGF in transplant recipients is unknown.Traditional diagnosis of allograft pathology post-transplantation relies heavily on the histological assessment of renal biopsies following the Banff classification . The posOne of the first microarray analysis of ncRNAs in renal biopsies led to the identification of twenty differentially expressed miRNAs in AR biopsies . Sui W. An analysis that integrated transcription factors, miRNAs, and lncRNAs resulted in a comprehensive view of signaling pathways in AR . ThroughA few studies have addressed the role of ncRNAs associated with transforming growth factor-beta (TGF-β), a key promoter of fibrosis and renal failure . Acute pFew research groups have associated ncRNA signatures in kidney biopsies with chronic allograft dysfunction (CAD) and antibody-mediated rejection (ABMR). A study by Scian MJ et al. used microarrays to find a miRNA signature of CAD with interstitial fibrosis and tubular atrophy (IF/TA) . Differewww.ncbi.nlm.nih.gov/geo/) is an excellent opportunity to circumvent a critical limitation of ncRNA profiling studies in kidney biopsies carried out to date, which is the small number of patients included in each study. Using this approach, Zou Y et al. performed lncRNA data mining in 1105 human renal allograft biopsies of AR in GEO, and discovered six highly expressed lncRNAs  strongly associated with AR [Integrating information from curated transcriptomic datasets stored in database repositories of high-throughput gene expression data, hybridization arrays, chips, and microarrays such as Gene Expression Omnibus , targets the AKT/mTOR signaling pathway, and is involved in inflammation, cell migration, and proliferation ,91,92,93MiR-21 is a hypoxia-controlled miRNA consistently upregulated in kidney diseases, promotes renal fibrosis via post-transcriptional silencing of metabolic pathways, and is a known mediator of inflammatory responses associated with NF-κB activation and cytokine expression ,95,96. TMiR-155 is considered a master regulator of inflammation and participates in the differentiation and stimulation of cells related to innate and adaptive immune responses ,98. The MiR-142-3p is found in hematopoietic cells and has been implicated in the control of immune functions, particularly regulatory T-cells, by targeting the transcription factor forkhead box P3 and autophagy . MiR-142MiR-223, a miRNA expressed in immune cells, is downregulated in patients with chronic kidney disease and upregulated in PBMCs of transplant recipients with experiencing TCMR ,58. The MiR-210, along with miR-10a and miR-10b, is downregulated in the urine of AR patients . RemarkaRP11-354P17.15-001, a lncRNA induced by inflammatory signaling in tubular epithelial cells, is upregulated in urine samples from patients with acute TCMR. This lncRNA detects acute TCMR with high specificity, has a positive association with a decline in glomerular filtration rate six weeks post-transplant, and its expression normalizes in AR patients with effective anti-rejection therapy .AF264622 and AB209021 are two lncRNAs upregulated in peripheral blood from pediatric and adult renal transplant patients with AR. Their high sensitivity and specificity to detect AR make them a promising alternative in the search for non-invasive biomarkers of AR in both pediatric and adult renal transplant recipients .MGAT3-AS1 is an intronic antisense lncRNA downregulated in mononuclear cells from deceased donor kidney transplant recipients with DGF . Thus, MRegarding hsa_circ_0001334 and hsa_circ_0071475, the urinary expression of these circRNAs was significantly and specifically increased in patients with acute TCMR when compared to stable grafts without signs of rejection . This fiThe generation and validation of dependable and robust ncRNA expression profiles able to improve clinical and pathological factors currently being used to assess disease states and response to treatment is a promising alternative to prolong graft survival in renal transplant recipients. Unfortunately, studies addressing the diagnostic, prognostic, and therapeutic value of ncRNAs in renal transplantation to date are insufficient. Future research must include more massive data-sets and address the need for large-scale RNA-seq studies. Molecular profiling in nephrology and transplantation faces multiple challenges. First, transplantation outcomes are affected by multiple factors, and disease phenotypes post-transplantation are complex. Second, the degree of certainty in the diagnosis of allograft rejection through the subjective assessment of histopathological lesions is inadequate. Some biopsies do not fit within current histological classifications and end up being classified as borderline or indeterminate rejections. Third, biopsies are invasive and can present complications, which makes it hard to have timely detection of disease states post-transplantation. Studying patterns of variation of ncRNA expression post-transplantation could be a step forward into personalized treatments and better diagnostic methods that could help us overcome the actual constraints imposed by existing histologic classes.


We also tested the associations between FC changes and clinical information using Pearson's correlation analysis. The results demonstrated that ESRD patients, compared with HCs, exhibit reduced FC specifically within the cortical hubs and between the DMN hubs and two subsystems (the dMPFC and MTL subsystems). Moreover, the FC values between the aMPFC and PCC were positively correlated with creatinine and urea levels in the ESRD patients. Our results suggest that the cortical hubs (PCC and aMPFC) are preferentially disrupted and that other subsystems may be progressively damaged to a certain degree as the disease develops.Neuroimaging evidence implies that cognitive impairment in patients with end-stage renal disease (ESRD) is related to the disruption of the default-mode network (DMN). The DMN can be divided into three functionally independent subsystems, which include the cortical hub subsystem [consisting of the posterior cingulate cortex (PCC) and the anterior medial prefrontal cortex (aMPFC)], the dorsal medial prefrontal cortex (dMPFC) subsystem, and the medial temporal lobe (MTL) subsystem. However, it is unknown how the functional connectivity (FC) in DMN subsystems is differentially impaired in ESRD. This prospective study was carried out at the Affiliated Hospital of Qingdao University, China, between August 2018 and July 2020. Thirty-two ESRD patients and forty-five healthy controls (HCs) were recruited for this study and received resting-state functional magnetic resonance imaging (rs-fMRI) scanning, and FCs on predefined regions of interest (ROIs) were individually calculated in three DMN subsystems using both ROI- and seed-based FC analyses to examine FC alterations within and between DMN subsystems. The two-sample  Hemodiase (CKD) . Small-vIn fact, the connectivity between the brain may be interrupted in accordance with this type of brain injury. Previous diffusion tensor imaging (DTI)  and voxeRecent studies have shown that the DMN functional alterations induced by ESRD are not limited to regional homogeneity (ReHo)  and ampla priori ROIs to a large extent that may potentially affect the accuracy of the reproducibility measures, the advantage is the ability to directly answer questions about connectivity. Therefore, seed-based FC analysis was also performed to comprehensively verify and interpret the findings from ROI-based analysis.To fill this knowledge gap, predefined 11 ROIs according to the research of Andrews-Hanna et al.  were useThe goals of the current study were as follows: (a) We sought to examine the abnormalities in interactions within and between DMN subsystems to provide further evidence of an aberrant DMN and to determine the impaired pattern of DMN in ESRD patients. (b) We attempted to determine whether there were associations between these FC changes and the clinical variables in patients with ESRD.−1 1.73 m−2, and who underwent regular hemodialysis were recruited from the nephrology and renal transplantation department at our hospital between August 2018 and July 2020. Concurrently, 45 healthy, age-, and gender-matched volunteers were recruited from the local community. To avoid possible coupling effects, all subjects in the present study were right-handed and younger than 60 years old. The demographic and clinical data of each ESRD patient were acquired from the electronic medical records in our hospital. All ESRD patients completed laboratory examination within 24 h before MR imaging, which included serum creatinine level, urea level, hemoglobin level, hematocrit level, cholesterol level, serum potassium, serum sodium, and serum calcium.The study was approved by the Medical Research Ethics Committee of the Affiliated Hospital of Qingdao University, China, and written informed consent was obtained from all subjects before the study. For this hospital-based prospective case–control study, 45 ESRD patients who were diagnosed with renal failure, defined by a GFR <15 ml minThe shared exclusion criteria for patients and control subjects were as follows: (a) history of severe head injury or obvious brain lesions on T2-fluid-attenuated inversion recovery (FLAIR) images; (b) neurodegenerative diseases ; (c) acute cerebrovascular disease or peripheral arterial occlusion; (d) chronic liver failure or heart failure; (e) history of psychiatric disorders in any control subject or history of major psychiatric disorders in any subject; (f) severe metabolic diseases ; (g) substance abuse, including drugs, alcohol, or cigarettes; (h) pregnancy or lactation at the time of the study; and (i) contraindications to MRI and excessive head movement during the scan. Five ESRD patients were excluded due to lacunar infarct lesions. Eight patients were excluded during functional MR image preprocessing. The final study population included 32 patients with ESRD and 45 healthy controls (HCs). Details regarding the clinical and demographic data of the remaining subjects are shown in All MRI images were collected using a GE 3T MRI scanner  equipped with a standard head coil. Participants were asked to remain awake, relaxed, keep their eyes closed, and not to do any specific thinking during functional data collection. Conventional imaging sequences, which included T1-weighted images and T2-FLAIR images, were acquired for each subject to detect clinically asymptomatic lesions.Using an echo-planar imaging (EPI) sequence, the rs-fMRI data were obtained with the following parameters: repetition time (TR)/echo time (TE) = 3,000 ms/40 ms, flip angle = 90°, 25 slices, thickness/gap = 5/0 mm, matrix size = 96 × 96, and field of view = 24 × 24 cm, 128 time points. Each scan lasted ~6 min.Three-dimensional brain high-resolution T1-weighted structural images were acquired using a 3D magnetization-prepared rapid-acquisition gradient-echo (3D-MPRAGE sequence). The parameters are as follows: 176 sagittal slices, TR = 5.6 ms, TE = 1.7 ms, matrix = 256 × 256, (FOV) = 25.6 × 25.6 cm, and thickness/gap = 1.2/0 mm. This session lasted for ~5 min.http://www.restfmri.net) with the following steps: (a) Image format conversion (DICOM to NIFTI) and then removal of the first 10 time points to stabilize the longitudinal magnetization and to accustom the subjects to the rs-fMRI scan noise. One healthy subject was excluded due to format conversion errors. (b) Slice timing was performed to avoid the time phase difference between different slices. (c) The subjects who had excessive head motion were excluded, and the thresholds were set to mean framewise displacement (FD) per Jenkinson . (d) The individual T1-weighted structural images were coregistered to functional images; segmented into gray matter, white matter, and cerebrospinal fluid (3). (e) Covariates, including head motion, white matter signal, and cerebrospinal fluid signal, were regressed out from the time series of each voxel. We used the Friston 24-parameter model  to regress out head motion effects (f < 0.08 Hz) were performed to reduce low-frequency drift and high-frequency cardiac or respiratory noise. (g) The images were smoothed with an isotropic Gaussian kernel with a full width at half-maximum of 4 mm. Then, FC was calculated based on the preprocessed fMRI data.The rs-fMRI data were preprocessed by the Data Processing Assistant for Resting-State fMRI (DPARSF) software   LinIn our study, both ROI- and seed-based FC analyses were performed to investigate the abnormal FC within the DMN.z values using DPARSF software. Specifically, for each ROI, the average time series was calculated for each subject and then correlated with the time series of the other 10 ROIs. An 11 × 11 FC matrix was obtained for each subject. Next, a network-based statistics (NBS) method  were computed for each link using a generic procedure to control the familywise error rate (FWE)  were controlled for covariates in the between-group analyses.To investigate the altered function and interaction of DMN subsystems, we performed a ROI-based FC analysis in a pairwise manner. Eleven ROIs of the DMN were approximated as spheres, each with a 5-mm radius see , accordi) method  was used) method . Indepente (FWE) . A valuer-to-z transformation to transform the correlation coefficients into z values to improve the normality of their distribution. Two-sample t-tests were performed on the PCC/aMPFC/dMPFC/vMPFC-seeded FC maps of the two groups individually to identify regions with significant group differences  with age, gender, education, and head motion parameters (FD according to Jenkinson) as covariates.To comprehensively verify and supplement the findings from ROI-based analysis, four spherical ROIs (radius = 5 mm), selected on the basis of previous research , and cent-test and χ2 tests in SPSS 22.0 software . Statistical significance was set to p < 0.05.The demographic and clinical data differences between the two groups were compared using the two-sample r-to-z transformation) of these abnormal regions using DPABSF software. Then, we conducted a Pearson's correlation analysis between altered FC and clinical variables  in the ESRD patients.In the FC analysis, the regions showing significantly different FC between the ESRD and HCs were mapped to cortex surface and visualized with the BrainNet Viewer package . To invep > 0.05).The demographic and clinical information of all patients and healthy subjects are shown in The ROI-based FC strength of the ESRD and HC controls is shown in Compared with HCs, ESRD patients exhibited significantly decreased PCC-seeded FC with the bilateral aMPFC and Pcu. For the aMPFC seed, only the bilateral PCC showed significantly decreased FC in patients with ESRD compared with HCs. For the dMPFC seed, the bilateral aMPFC showed significantly decreased FC in patients with ESRD compared with HCs . Howeverr = 0.426, p = 0.015) and urea level   .To date, this study is the first to focus on the neural activity of DMN subsystems in ESRD patients, although a previous work has investigated other aspects of ESRD. We report two major findings. First, the extensive functional disconnection within the DMN in ESRD patients was mainly between the DMN hubs and two subsystems. Second, the dMPFC and MTL subsystems in the DMN were also disrupted to a certain degree.Our ROI-based FC analysis shows a widespread functional disconnection between the DMN hubs and those two subsystems . In addition, seed-based FC analysis shows significantly decreased FCs between the PCC and Pcu, the PCC and aMPFC, and the aMPFC and dMPFC in patients with ESRD compared with HCs, which were consistent with the results of ROI-based analysis. In line with our findings, Ni et al.  found thz-values of FC between the aMPFC and PCC. This is a surprising finding that completely contradicts previous research  in the DMN were preferentially disrupted; this is a specific pattern distinct from what is observed in other diseases; for example, in Alzheimer's disease (AD), disruption has been found mainly in the MTL subsystem . This inresearch , 35. To research . HoweverIn addition to the predominantly disrupted cortical hubs in ESRD patients, we also found reduced FC in the dMPFC subsystem (dMPFC-TPJ) and MTL subsystem (pIPL-Rsp and pIPL-PHC), which may suggest further development of cognitive impairment in ESRD. The dMPFC subsystem is robustly activated for tasks that require mental state inference . There iThe MTL subsystem is preferentially activated when involved in episodic memory and thinking ; thus, sSome limitations of the current study should be noted. First, patients with end-stage renal disease have severe metabolic imbalance, which is likely to have a substantial impact on cerebral vascular regulation. Rs-fMRI connectivity is not only driven by neurovascular but also merely vascular mechanisms. Although the current study tries to avoid the confounding effect, we did not have the ability to avoid the effect of these kinds of mechanisms, such as atherosclerosis. We selected hemodialysis patients to minimize the influence of different dialysis methods. In addition, the effects of physiological effects such as respiration and heart rate, especially the respiration-related “connectivity network” on functional connectivity, were not considered in this study. Second, 11 ROIs were selected from a previous study  based onIn conclusion, different subsystems of the DMN have inconsistent degrees of impairment in ESRD. The cortical hubs (PCC and aMPFC) are preferentially disrupted, and other subsystems may develop progressive impairment to a certain degree as the disease develops. Our findings provide novel insights into the underlying pathological mechanism of cognitive impairment in ESRD patients.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Medical Research Ethics Committee of the Affiliated Hospital of Qingdao University, China. The patients/participants provided their written informed consent to participate in this study.CM, Y-dR, and J-cF contributed to the conception and design of the study. CM, FT, M-gM, and H-wS collected the subjects, and Z-hL and CM contributed to the analysis of the resting-state fMRI data. CM wrote the first draft of the manuscript. Y-dR and J-cF performed critical revision of the manuscript for intellectual content. All authors contributed to manuscript revision and read and approved the submitted version.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.


Peroxisomes participate in essential cellular metabolic processes, such as oxidation of fatty acids (FAs) and maintenance of reactive oxygen species (ROS) homeostasis. Peroxisomes must communicate with surrounding organelles to exchange information and metabolites. The formation of membrane contact sites (MCSs), where protein-protein or protein-lipid complexes tether the opposing membranes of two organelles, represents an essential means of organelle crosstalk. Peroxisomal MCS (PO-MCS) studies are emerging but are still in the early stages. In this review, we summarize the identified PO-MCSs with the ER, mitochondria, lipid droplets, and lysosomes in mammalian cells and discuss their tethering mechanisms and physiological roles. We also highlight several features of PO-MCSs that may help future studies. Peroxisomes are essential single-membrane-bound organelles present in virtually all eukaryotic cells . PeroxisPeroxisome deficiency causes severe human diseases, emphasizing the crucial role of peroxisomes. The diseases fall into two main categories: single peroxisomal enzyme deficiencies and peroxisome biogenesis disorders (PBDs) . PBDs arOrganelles are cellular compartments that perform specific enzymatic reactions. However, organelles cannot exert their activities alone and must exchange information and metabolites with others to coordinate cellular functions. Several mechanisms have been proposed for this crosstalk, including vesicular trafficking and signal transduction pathways . AccumulFor many years, electron microscopy (EM) studies in fungi, plants, and mammals revealed that peroxisomal membranes are juxtaposed to many other organelles, such as the ER, lipid droplets (LDs), plasma membrane (PM), mitochondria, and chloroplasts . The simIn human cells, the biosynthesis of unsaturated FAs, sterols, ether phospholipids, and bile acids involves both the ER and peroxisomes and requires intimate crosstalk. Metabolic defects in these organelles lead to severe human diseases . The ER Acyl-CoA binding domain containing 5 (ACBD5) is a peroxisomal tail-anchored membrane protein, and its deficiency can cause a defect in peroxisomal very-long-chain FA metabolism . ACBD5 aIn these studies, super-resolution microscopy and EM visualization revealed that the two organelles were in proximity to each other. Cooverexpression of ACBD5 and VAPA/B or their knockdowns increases and decreases MCS formation, respectively, suggesting that tethering relies on the ACBD5-VAPA/B interaction. As shown for other VAPA/B interacting proteins, ACBD5 interacts with the MSP domain of VAPA/B through the FFAT motif. ACBD4, a second ACBD family protein, also interacts with VAPB for PO-ER associations .Peroxisomes can proliferate through the growth and division model, which involves membrane elongation, constriction, and fission . Since pThe phospholipid contents of peroxisome membranes are rich in phosphatidylcholine (PC) and phosphatidylethanolamine (PE), similar to the contents of the ER . The perBoth groups found that disrupting the ACBD5-VAPA/B tethered MCS increases the movement of peroxisomes, suggesting that the MCS negatively regulates peroxisome motility through ER anchoring. A motility-restricting role is also indicated for the yeast PO-ER-MCS, which can retain a fraction of peroxisomes by anchoring with the ER in mother cells when peroxisomes passage into the daughter cells . In addiOther PO-ER-MCSs have also been identified. The MCS tethered by the peroxisomal PIP2 and ER-resident extended synaptotagmins (E-Syts) may facilitate the transport of cholesterol from the peroxisome to the downstream ER organelle . ATF6α iPeroxisomes and mitochondria must communicate with each other to meet the metabolic needs of cells. The best examples are illustrated by the β-oxidation of FAs and metabolism of ROS (discussed below). These processes share some crucial division proteins , de novoIn the 1970s, a close spatial peroxisome-mitochondrion (PO-Mito) association was observed in the myocardium of rodents and primates by a peroxidative catalase activity-based alkaline DAB staining method . OverexpBoth peroxisomes and mitochondria possess separate β-oxidation pathways in mammalian cells, which are different from those in yeast and plants, whose peroxisomes are the sole organelles for β-oxidation of FAs. The enzymatic steps of β-oxidation of FAs in these two organelles are similar but differ in the catalyzed substrates. For example, peroxisomes preferentially catalyze the β-oxidation of very-long-chain FAs, while the mitochondrial β-oxidation system catalyzes medium and long-chain FAs. The chain-shortened FAs, as well as the acetyl-CoA generated through peroxisomal β-oxidation, need to be directed to mitochondria for further oxidation and ATP production. Different mechanisms have been proposed for the transfer of these metabolites, including the carnitine system, membrane pores, and vesicular transport . A high 2+ transfer stimulates ROS translocation from mitochondria to the MCS. The local H2O2 enrichment at the MCS further augments the ER-Mito Ca2+ flux, likely through H2O2-mediated oxidation of specific thiol groups of the pump receptor IP3  family. The longer M1 variant (M1 Spastin) encodes an N-terminal hydrophobic hairpin motif, which targets M1 Spastin to LDs . Chang eCaenorhabditis elegans, and mice. The study reveals the physiological significance of the PO-LD-MCS in maintaining energy homeostasis in response to nutritional status. As aberrant lipolysis is associated with severe metabolic diseases, such as obesity and diabetes, this study suggests PO-LD-MCSs as a potential therapeutic target for these diseases.Another study revealed the role of PO-LD-MCS in regulating lipolysis, the hydrolysis of lipid metabolites stored in LDs . During As discussed above, the MCS can facilitate the transport of lipids from LDs to peroxisomes for their breakdown or function as a station enriched with lipases to hydrolyze the lipids in LDs. Detection of peroxisome-derived metabolites  in LDs suggests that they may be transferred from peroxisomes to LDs through the MCS . The bidLysosomes are degradative and metabolic organelles. Many essential metabolic processes, such as those for cholesterol, occur in this organelle. Cholesterol is a crucial component for maintaining the fluidity, permeability, and organization of mammalian membranes. Cholesterol is unevenly distributed in cellular membrane structures, with the highest contents  in the PM . The low2 lipid and lysosomal synaptotagmin VII (Syt7) protein tether the MCS for cholesterol trafficking from lysosome to peroxisome  and disordered (ERd) lipid domains. Interestingly, they find that the PO-ER-MCS is located at the ERo/ERd interphase, involving association with a mitochondrion. A yeast study also found that peroxisomes contact the ER and mitochondria at the three-way junction through Pex11 interacting with Mdm34, a component of ERMES (ER-mitochondria encounter structure) (A study investigated the assembly of ER-MCSs with a variety of organelles through lipid-based phase separation . By emplructure) . As the 2 lipid at peroxisomal membranes tethers peroxisomes to both lysosomes and the ER. Regulation of these common PO tethers, such as VAPA/B and PIP2, may provide mechanistic hints for PO-MCS coordination.Membrane contact site coordination can be achieved through the regulation of common tethering molecules . For exaAspergillus nidulans. Given the crucial role of microtubules in organizing a variety of organelle contacts and the reciprocal relationships between organelle motility and contact (The movement of peroxisomes in mammalian cells preferentially depends on the microtubular network and allows peroxisomes to be uniformly dispersed for metabolism . PO-LD-M contact , it is tIn summary, the vital importance of peroxisomes is underscored not only by the essential metabolism within this organelle but also by the intimate crosstalk with other organelles. MCS formation is an efficient means by which peroxisomes communicate with other organelles. Some of the tethering mechanisms and physiological functions have been elucidated or suggested. These studies have increased our understanding of not only peroxisomes but also other organelles, including their biogenesis/turnover and metabolic functions. However, these studies are still in the early phase, and much that is unknown remains to be addressed. Future PO-MCS studies would shed novel insights into human diseases and determine their therapeutic targets.CC, JL, and XQ wrote the draft of the manuscript. WW drew the figure and organized and proofread the manuscript. All authors contributed to the article and approved the submitted version.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.


MonashWatch is a telehealth public hospital outreach pilot service as a component of the Government of Victoria’s statewide redesign initiative called HealthLinks: Chronic Care. Rather than only paying for hospitalizations, projected funding is released earlier to hospitals to allow them to reduce hospitalization costs. MonashWatch introduced a web-based app, Patient Journey Record System, to assess the risk of the journeys of a cohort of patients identified as frequent admitters. Telecare guides call patients using the Patient Journey Record System to flag potential deterioration. Health coaches  triage risk and adapt care for individuals.The aim was a pragmatic controlled evaluation of the impact of MonashWatch on the primary outcome of bed days for acute nonsurgical admissions in the intention-to-treat group versus the usual care group. The secondary outcome was hospital admission rates. The net promoter score was used to gauge satisfaction.Patients were recruited into an intention-to-treat group, which included active telehealth and declined/lost/died groups, versus a systematically sampled (4:1) usual care group. A rolling sample of 250-300 active telehealth patients was maintained from December 23, 2016 to June 23, 2019. The outcome—mean bed days in intervention versus control—was adjusted using analysis of covariance for age, gender, admission type, and effective days active in MonashWatch. Time-series analysis tested for trends in change patterns.P=.05), with a small number of very frequent admitters in the intention-to-treat group. Age, MonashWatch effective days active, and treatment group independently predicted bed days. The analysis of covariance demonstrated a reduction in bed days of 1.14 (P<.001) in the intention-to-treat group compared with that in the usual care group, with 1236 bed days estimated savings. Both groups demonstrated regression-to-the-mean. The downward trend in improved bed days was significantly greater (P<.001) in the intention-to-treat group (Sen slope –406) than in the usual care group (Sen slope –104). The net promoter score was 95% in the active telehealth group compared with typical hospital scores of 77%.MonashWatch recruited 1373 suitable patients who were allocated into the groups: usual care (n=293) and intention-to-treat . Admission frequency of intention-to-treat compared to that of the usual care group did not significantly improve (P<.001), although admission frequency was unchanged with more short stay admissions in the intention-to-treat group. Nonrandomized control selection was a limitation. Nonetheless, MonashWatch was successful in the context of the HealthLinks: Chronic Care capitation initiative and is expanding.Clinically and statistically meaningful reductions in acute hospital bed days in the intention-to-treat group when compared to that of the usual care group were demonstrated ( Potentially preventable hospitalizations or potentially avoidable admission costs are of significant interest, not only to governments and hospitals, but to individuals, their families, the community, and general practice . A pragmHealthLinks: Chronic Care (HLCC) is a voluntary, funding-neutral reform that aims to support the Australian State of Victoria’s public health services in adopting outcome-based, rather than activity-based, funding . An algoThe MonashWatch telehealth and coaching model used design principles to establish a collaborative patient-journey approach responding to broad social determinants beyond disease management and the boundaries of hospital, primary, home, and social care.telecare guides track risk and identify issues in biopsychosocial and environmental domains using frequent telephone calls and the Patient Journey Record System, which uses a client-server architecture with a browser-based user interface. A rule-based algorithm provides a real-time risk assessment of calls based on data entry and telecare guide opinion. Health coaches triage calls and support participants to optimize their health journeys.Laypersons called This paper reports a pragmatic summative evaluation of the MonashWatch service. We compared bed days for an intention-to-treat group versus a usual care control group for 30 months from the MonashWatch service commencement. The intention-to-treat group included a MonashWatch active telehealth group consisting of those who used the telehealth service.The Australia-wide universal free public health system has both federal and state/territorial governance. Parallel private health systems exist. Medicare is the Australian federal government’s scheme to give universal public access to health care (funded by taxation—the Medicare levy) through (1) direct clinical service funding to general practitioners and specialists in all states and territories and (2) indirect financing, with the states and territories administering public hospital and most community services.Most services, including social services and welfare, aged care, education, and employment, have split funding and administration across federal and state/territory systems.There have been multiple initiatives to address avoidable admission costs across the jurisdictions for more than 20 years. The Australian Institute of Health and Welfare (AIHW) annually reports on 18 International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes of chronic, acute, and vaccination-preventable admissions for national performance monitoring by local area . SignifiVictoria is the second most populous state of Australia with a population of 6.25 million. The Victorian Department of Health and Human Services (DHHS) funds and administers 85 public health service organizations. It has had activity-based funding (fee-for-service) for all acute admissions with accelerating demand growth in hospital separations per 1000 individuals. Victoria has deployed hospital readmission prevention programs since 1996, which have improved satisfaction with care but have had little impact on cost containment [The HLCC initiative began in 2016, identifying patients at-risk of ≥3 repeat hospitalizations and their admission costs in the subsequent 12 months . The DHHMonash Health is the most extensive public hospital and community care system in Victoria. Its 15,000 staff  work at more than 40 sites, providing more than 3 million occasions of service, admitting more than 238,000 hospital patients, and handling more than 206,000 emergency presentations per year. HLCC data indicated that in 2017 and 2018, Monash Health had more than 3000 patients with >4 acute medical admissions and more than 12,000 with >3 acute medical admissions . It was an early adopter of the HLCC service initiative MonashWatch in 2016.Rather than adding a new layer, the MonashWatch model was intended to be a catalyst within a working health system, to begin a transition of acute services to outcome-based funding.Patient journeys involve physiological, psychological, social, and environmental issues. Disturbances in any or combinations of domains including housing, food security, support with daily living, access issues, as well as biology, medication issues, or clinical deterioration may lead to tipping points into acute admissions ,9. ThereClinicians—nursing or allied health—enable others in the goals and health journeys which they chose to follow . CoachinFollowing HLCC algorithm identification and allocation, the intention-to-treat group were invited to initially consent and agree to a home visit for enrollment, formal consent, baseline assessment, and induction. Telecare guides, then made conversational phone calls to enrolled people to track their health and needs, in accordance with personal preference and previous Patient Journey Record System flags.Regular audiotaped calls between 1 to 5 times per week (median 1), depending on risk level, were conducted by telecare guides. They used the Patient Journey Record System semistructured monitoring app, which began with open-ended narratives and included directed questions  in a braThe health coaches were all recruited from within the Monash Health community and acute services to develop the new service. Telecare guides were recruited from the local or adjacent community. Care pathways to existing services were mapped and tested before the service commenced. The pathways were to the general practitioners, hospitals’ emergency, inpatient and outpatients, hospital readmission prevention programs, and other community health, social, and welfare services including housing, legal, financial, employment, education, and voluntary organizations.MonashWatch participants were selected in a highly disadvantaged catchment area adjacent to the Dandenong hospital. Keeping the MonashWatch team local to patients was a concept borrowed from Buurtzorg: the Dutch neighborhood care model . TargeteThe HLCC web-based algorithm incorporated a wide range of conditions in adults >18 years old . The HLCAIHW potentially preventable hospitalizations diagnostic codes only accounted for 18% of HLCC admissions. Only approximately 20% of HLCC-identified hospitalizations in Monash Health, and other Victorian health services had ever accessed hospital readmission prevention programs or other hospital admission prevention services.The DHHS provides continuously updated HLCC-eligible cohort lists to hospital groups and funds care improvement initiatives based on projected reductions in admission costs. Once the patient was deemed eligible, when they had their next acute admission, they could be enrolled. Enrollment commenced with a gradual ramp-up from December 2016 and continued beyond the evaluation cutoff point. Pragmatic screening by health coaches excluded those who were not suited to a self-rated phone-based health model . Patients were considered candidates to be entered into the MonashWatch evaluation pool before allocation, based on a ratio of 4:1. There was minimal chance of bias because the health coaches and team performing the assignment had no idea who would benefit in advance in this pilot service, and the allocation was conducted using hospital unit numbers from a list without patient details.The primary outcome metric was bed days  derived from the Victorian Admitted Episode Data from the Victorian Emergency Minimum Dataset  between A secondary outcome metric was rate of emergency nonsurgical admissions. This was initially considered as the primary outcome; however, capitation costs being the biggest driver of the HLCC program led to bed days being more critical. Net promoter score was also a secondary outcome.P<.05 was used. Analysis of bed days was conducted using least square ANCOVA, in accordance with acceptable practice [Analysis of covariance (ANCOVA) is a statistical technique that adjusts for covariates in determining the outcomes of an intervention. Least square means are an acceptable method to calculate the means adjusted for covariates . In ANCOpractice . Mean bepractice .Quality assurance of the data analysis was performed in several ways. One author conducted the ANCOVA using XLSTAT software . Two other authors independently analyzed the same dataset, after rechecking the download from Victorian Admitted Episode Data/Victorian Emergency Minimum Dataset , using REthics approval for low-risk clinical research was obtained from the Monash Health's Health Research Ethics Committee. The Australian government’s main research and development agency, the Commonwealth Scientific and Industrial Research Organisation, is conducting an external evaluation of the diverse state-wide HLCC initiatives in Victoria, and this also has ethics approval.The HLCC clinical algorithm identified 2502 patients as having a high risk of repeat admissions within the period of December 23, 2016 to June 23, 2019.MonashWatch identified 1373 suitable HLCC patients: usual care (n=293) and intention-to-treat  years, and mean participant age for intention-to-treat was 68.3  years. The number of effective days active for usual care was 756.2 , and the number of effective days active for intention-to-treat was 624.2 .In the usual care group, 293 patients had 639 admissions, and in the intention-to-treat group, 1080 had 934 admissions from the time they joined the MonashWatch program (effective days active) until June 23, 2019 . Usual cP=.05 and P=.056, respectively; see Admissions were highly skewed in the intervention group with several outliers with frequent short admissions to the emergency department for chest pain and abdominal symptoms which may account for the highly skewed profile of the intention-to-treat group. The raw median and mean number of admissions per person were higher in the control group (P=.34), that is, 0.05% (8/1573) of all admissions were coded vaccine preventable. The most frequent AIHW potentially preventable hospitalizations conditions were chronic obstructive pulmonary disease or bronchiectasis ; heart failure or angina , urinary tract infection or cellulitis . Chest pain (of minor complexity) was the most frequent admission description in all groups (P=.03). Diagnoses using AIHW potentially preventable hospitalization ICD codes that were designated as major complexity (high cost and high comorbidity) [P=.02), and intention-to-treat nontelehealth participants had 1.1% (9/852) (P<.001).AIHW potentially preventable hospital admission codes were present in 18.3 % (117/639) of all acute admissions in usual care and 16.4% (153/ 934) of all acute admissions in intention-to-treat (l groups . Two indrbidity)  are indiANCOVA was conducted on bed days with admission age, gender, the presence or absence of a potentially preventable hospitalizations ICD-10 code, and effective days active as quantitative variables and with intervention versus control as qualitative variablesP<.001), effective days active from allocation until June 23, 2019 (P<.001), and whether they were in the intervention (intention-to-treat) or control  group (P<.001). Gender (P=.98) and having a designated AIHW potentially preventable hospitalizations admission ICD code (P=.82) were not significant predictors of bed days.P<.001) bed days saving of 1.14 bed days per 1080 intention-to-treat patients (1236 days) was estimated  bed days while the intention-to-treat least square mean was 3.4  bed days. A statistically significant (stimated .P<.001) in bed days per person per month  compared with usual care . The bed days per person per month time series demonstrated regression to the mean in both intention-to-treat and usual care groups. The intention-to-treat group demonstrated a statistically significant greater (P<.001) downward trend in bed days compared with the usual care group using Mann-Kendall trend test, and the Sen slope was –406 for intention-to-treat and the slope was –104 for usual care.Longitudinal tracking of average bed days per person per month nonsurgical acute admissions was conducted for 12 months before enrollment until the evaluation cutoff date . The ManA high net-promoter rate (satisfaction scores) of 95% was demonstrated, with common findings of about 77% in hospital evaluations .This evaluation demonstrates that the MonashWatch service intervention achieved its objectives by reducing bed days and, by implication, worked within the capitated budget consistently over time.P=.05; mean, P=.056) with a frequent admitter intention-to-treat subgroup. The number of low complexity conditions, including chest pain and gastrointestinal conditions, was higher in the usual care group than it was in the intention-to-treat group. The intention-to-treat group had nonsignificantly more potentially preventable hospitalizations admissions, perhaps suggesting an optimization of hospital bed use, reducing admissions that were not related to clinical need alone. Analysis of covariance, controlling for age, effective days active, gender, and AIHW potentially preventable hospitalizations diagnoses demonstrated that bed days were statistically improved by 1.14 bed days per 1080 intention-to-treat patients (P<.001) and an estimated 1236 bed days. Improved bed days were consistent over the evaluation period. The intention-to-treat group demonstrated a consistent improvement in bed days per person per month (P<.001).The percentage of patients admitted at least once was very similar . Admissions per person were nearly statistically significantly different  who declined. This arduous process may have diluted the uptake rate and thus had an impact on bed days but reflects real-world clinical service evaluations. It would be worth other methods of recruitment in the future to see if there would be increased recruitment with a more significant impact.Pragmatic clinical evaluations in live health systems outside of research study are challenging, particularly in MonashWatch due to long-term unpredictable, complex dynamics in unstable patient journeys . There aThis summative evaluation was conducted in a living health system as the first phase of a government funding initiative to move from activity to value-based funding when Monash Health services were under significant funding constraints. Success was achieved in the real world without going through the traditional research route with a trial before rolling out an implementation. The positive feature of this approach is that (to date) it has not gone the way of many beautifully designed and executed pilots that never achieved implementation. In the first phase, the successful delivery of care was within existing funding. The MonashWatch-type model deployment in other health services in the second and third phases has the opportunity to improve on trial methodology. The addition of more research resources, given the current successful proof of concept, would enable the conduct of a more sophisticated randomized propensity-matched trial.Ongoing study of the data is needed to identify who benefits from which components and how the intervention can be improved for different groups. There is a need to continue to shift current care pathways and health systems to adapt care to the needs of vulnerable MonashWatch-type patients. A whole of systems transformation is needed to respond to the dynamics of unstable health journeys, beyond the current single disease or condition siloed care. Outcome-based funding has the potential to make major inroads into fragmented care. Macrolevel health service funding changes in the Australian Health System such as in northern Spain  would beThe MonashWatch telehealth and coaching intervention using the HLCC innovative funding model was effective in a local catchment area of a hospital in a highly disadvantaged community and achieved its health service funding model objectives. It requires ongoing and broader implementation and evaluation. In the future, evaluation of additional teams is needed to confirm these findings in different populations and settings. Two additional teams are now in place. Ultimately, the progressive scaling up to a multisite intervention will require ongoing tailoring and evaluation with feedback for improvement.


Transcatheter aortic valve replacement (TAVR) was initially introduced to treat patients with aortic valve stenosis (AS) at high-risk for surgical aortic valve replacement (SAVR). Today, there is ample evidence supporting TAVR in high-risk groups. However, in recent years TAVR has been extended to low-to intermediate risk groups and relevant clinical evidence is still emerging, leaving some uncertainties.To obtain information on TAVR versus SAVR in low-to intermediate risk groups, we conducted an overview of systematic reviews following PRISMA guidelines and based on a systematic search of EMBASE, MEDLINE, Cochrane and CRD databases. We focused on systematic reviews assessing mortality and VARC 2 as clinical outcomes.The majority of the 11 systematic reviews included in our study reported no differences in mortality between TAVR and SAVR at short and long-term follow-up times. Two reviews that included the most recent RCTs on low-risk patients reported a decreased mortality risk with TAVR at one-year follow-up. Regarding the secondary endpoints of stroke and MI, the majority of studies presented similar results for TAVR and SAVR. Acute Kidney Injury, Bleeding Complications, Atrial Fibrillation were less frequent with TAVR, with lower risk of Permanent Pacemaker Implantation and Aortic Regurgitation with SAVR.Our overview indicated that TAVR is a promising intervention for low-to-intermediate surgical risk patients; however additional evidence from longer term follow-up is needed to confirm these findings. This overview highlights inconsistencies about reporting and presentation of data, most notably limited clarity on effects of risk of bias on trial results. •We reviewed the evidence for TAVR and SAVR in low-to intermediate risk patients.•Most reviews found no difference in mortality between TAVR and SAVR.•Acute Kidney Injury, Bleeding and Atrial Fibrillation were less frequent with TAVR.•Pacemaker Implantation and Aortic Regurgitation were less frequent with SAVR.•Most reviews found no difference for Stroke and Myocardial Infarction. In 2002 the less invasive transcatheter aortic valve implantation/replacement (TAVI/TAVR) was introduced for the first time and since then TAVR surpassed surgery for high-risk patients.The first clinical trials comparing TAVR with SAVR were specifically focusing on patients deemed inoperable or at high risk for surgery  and TAVRSince TAVR represents a less invasive alternative to surgery, there is a worldwide trend toward the extension of TAVR for treatment of AS also in intermediate or low-risk patients. However, investigations on safety and efficacy of TAVR specifically focused on these patient groups are still emerging. Recently, two randomized clinical trials that compare the outcomes of TAVR versus SAVR in low-risk patients (PARTNER 3 and EVOLUT low-risk) have been published ,7. The oIn August 2019, based on the outcomes of the above mentioned trials, FDA has approved an expanded indication of some TAVR devices to patients with severe AS who are at low-risk for death or major complications during surgery . HoweverIn line with the above considerations, the FDA has specifically required manufacturers of TAVR devices, as part of approval process, to continue the annual follow-up of patients up to 10 years post procedure.In order to obtain a view of the current status of cumulative evidence on clinical safety and effectiveness of TAVR versus SAVR interventions in low-to-intermediate surgical risk patients with AS, we evaluated information from systematic reviews.In our overview of systematic reviews we summarise the results of published systematic reviews, with the aim of facilitating access to the full range of information available and to support healthcare decision making ,10. We dTo our knowledge, this is the first overview of reviews on this topic. Hence, the aim of the present study is: (a) to compare evidence from published systematic reviews of randomised clinical trials (RCTs) and observational studies regarding the efficacy and safety of TAVR versus SAVR in low-to-intermediate risk patients, (b) to look into consistency of main outcomes across different reviews and (c) assess methodological quality and the quality of evidence presented in systematic reviews.2We performed an overview of systematic reviews assessing the safety and efficacy of TAVR compared to SAVR in low-to intermediate surgical risk patients with severe aortic valve stenosis.2.1We conducted this overview of systematic reviews with a previously registered and published protocol, PROSPERO 2020 CRD reference: CRD42020151651. Our systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) , includiThe PICO strategy was applied to formulate the main research question. “Outcome” was not included in the search strategy since this information is not always available in the title or abstract of papers. For the patient group we focused on individuals with severe AS that were categorised to be low-to-intermediate risk for surgery defined by EuroSCORE (<20%) and STS-PROM (<10%) . We want2.2We included only peer-reviewed systematic reviews in our overview. Included studies had to report at least on the primary outcome of mortality for TAVR compared to SAVR in low-to intermediate patient risk groups . We excl2.3We conducted a systematic search of the literature including EMBASE, MEDLINE (PubMed), Cochrane CENTRAL and CRD databases with no restrictions to publication year . The searches were performed on 11th of June 2019 and the language was limited to English, Italian, Spanish, French, German and Greek. Additional papers were identified through automated database notifications of new publications according to our search terms until November 2019. The reference lists from all included reviews were checked to identify any other potential reviews to include.2.4Two authors independently performed a screening of citations by title and abstract, with discrepancies resolved by consensus. Disagreements between authors were solved by consensus. Citations identified in the systematic search were uploaded to Mendeley reference manager and duplicates were automatically deleted. The reasons for exclusion of papers are listed in Table 8, supplementary information.2.5Two authors acquired the full-text of included papers and independently assessed their methodological quality using the AMSTAR2 tool . Any disThe quality of evidence for each outcome per systematic review was evaluated using the following domains of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool: risk of bias, precision and consistency . Two rev2.6Two authors independently extracted data on study characteristics and on patients enrolled in the trials included in each systematic review. The following outcome data was extracted: mortality as the primary endpoint and secondary endpoints including stroke, acute kidney injury, atrial fibrillation, bleeding, aortic regurgitation, permanent pacemaker and myocardial infarction.3The search strategy identified a total of 1624 articles. After removal of duplicates, 1305 articles were screened for meeting selection criteria. The remaining 31 articles were then evaluated for their methodological quality with the AMSTAR2 tool . Systematic Reviews with a “Critically Low” score were excluded in our overview. We included all reviews with a score of “Low” quality or higher in order to provide a full picture of the available evidence, aiming to explore possible differences in findings according to AMSTAR2 scores. Eleven systematic reviews were included in the analysis ,  through the JRC Work Programme for 2019-2020, running under Horizon 2020, the current EU Framework Programme for research and innovation funding.This work was supported by the None.Roisin Mc Morrow: Conceptualization, Methodology, Writing - original draft, Formal analysis. Christine Kriza: Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Formal analysis. Patricia Urbán: Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Visualization, Formal analysis. Valeria Amenta: Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Formal analysis. Juan Antonio Blasco Amaro: Conceptualization, Writing - review & editing. Dimitrios Panidis: Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Formal analysis. Hubert Chassaigne: Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Supervision, Formal analysis. Claudius Benedict Griesinger: Conceptualization, Methodology, Writing - original draft, Supervision, Formal analysis.


Paillard; Watanabe et al.). This unique feature of efficiency and high workload with low voluntary effort may explain the steadily growing attractiveness of WB-EMS for health, fitness, and performance professionals. The present Research Topic on WB-EMS thus aimed to stimulate incentivize dedicated research in all these disciplines.Originally created and commercially launched in Germany in 2009, whole-body electromyostimulation (WB-EMS) is a promising training technology with rapid and widespread dissemination particularly in Europe and the Far East. Even though there are more than 2,000 commercial WB-EMS providers with about 250,000 clients in Germany alone, research on WB-EMS is still limited. Symptomatically, there is not even a mandatory definition of WB-EMS. Thus, we would suggest defining WB-EMS as “simultaneous application of electric stimuli via at least six current channels or participation of all major muscle groups, with a current impulse effective to trigger muscular adaptations.” This concurrent stimulation of large muscle areas, each with dedicated impulse intensity, delivers the “time effectiveness” of WB-EMS, a key feature of this training method. However, apart from its “efficiency,” EMS technology applied locally or globally enables a supramaximal workload without high voluntary effort  focus on basic EMS research, predominately to derive optimized WB-EMS protocols. While the German research group  focused on dedicated strain parameters, Watanabe et al. and Paillard addressed the interaction of WB-EMS and voluntary contraction in humans. Apart from other important findings highly relevant for practical application, one key message can be derived from both basic research and the performance studies listed below: Evidence suggests that simultaneously applied WB-EMS did not increase the effects of maximum voluntary contractions. Thus, when exercising with WB-EMS, impulse parameters and not high voluntary effort are the decisive effectors.Since completion of the present Research Topic, 15 of 24 submitted articles have been accepted. Simplified, five contributions , sports students , amateur ice-hockey players , and professional soccer players . Apart from functional outcomes e.g., sprint and jump performance, shoot speed, strength, and power  amenable to resistance-type WB-EMS, Amaro-Gahete et al. and Amaro-Gahete et al. reported WB-EMS induced improvements in running performance after volume reductions in recreational runners. This finding on endurance capacity was not confirmed by Filipovic, Bizjak et al., however, who found no relevant WB-EMS effects on VO2max and various blood parameters related to oxygen supply in professional soccer players.With seven studies, the majority of projects address the fitness and performance domain. In summary, the trials included recreational runners , the “WB-EMS and health” domain was considerably underrepresented in our Research Topic. While Teschler and Mooren reviewed negative side-effects of WB-EMS, a topic that will be addressed in more depth later, two research groups from Erlangen, Germany  addressed interactions of WB-EMS and dietary supplements. While Schink et al. determined the effect of combined WB-EMS and dietary support on body composition, physical function, quality of life, and blood parameters in patients with hematologic malignancies, Willert et al. evaluated effects of WB-EMS and protein supplementation on energy-restriction-induced loss of muscle mass during intended weight reduction.Reviewing the present literature on WB-EMS, with only three contributions that addressed health related issues , in essence most of the studies indicated that WB-EMS can be indeed be considered an effective training technology for improving health- and performance-related parameters. Transferred into clinical practice, WB-EMS might thus be an option for people with low time resources and inability or unwillingness to exercise conventionally. This also includes athletes looking for time-efficient exercise protocols to impact secondary training aims related to strength and power.Although it is far from clear which composition of exercise and/or impulse parameters might be optimum or even appropriate for a given outcome (2 of muscular area simultaneously entails a high risk of triggering unintended effects (Teschler and Mooren)—at least when inappropriately applied  frequent feedback from the participant about perceived exertion for each area of stimulation, (2) permanent visual monitoring of the participant and eye contact to check participant strain, avoid overload, and to react immediately to the first signs of cardiorespiratory or metabolic side effect, and (3) verbal and haptic movement corrections and rapid assistance in cases of emergency, particularly cutting off power supply of the device, leads us to strongly advise a 1:1 instructor-participant ratio; although a 1:2 ratio is also considered tolerable for non-medical WB-EMS application with less critical participants.We feel that this Research Topic provides additional evidence for the health, fitness and performance aspects WB-EMS application. We are aware that a plethora of research questions with respect to the most optimum WB-EMS protocol for given outcomes and varying target populations remained to be addressed. However, we conclude that some key aspects of WB-EMS should be addressed with particular emphasis in the nearest future. From a sport scientific point of view, intensity regulation by objective strain parameters based on advanced biomarkers might further increase the safety and effectiveness of WB-EMS. In parallel, the evaluation of progression models is essential for ensuring the sustainability of WB-EMS effects. To date, only few studies exceed a period of 6 months, thus longer trials have to monitor WB-EMS effectiveness and safety. Considering the time effectiveness, joint friendliness, low voluntary effort and customization of WB-EMS; from a health perspective, further research should particularly focus on diseases  with limited potential or perspective for conventional exercise. The permissive, additive or synergistic effect of other low-threshold interventions  combined with WB-EMS should also be addressed more forcefully. However, apart from health issues, the feasibility and effectiveness in settings with low time and spatial resources but high physical demands  will be challenging.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is seen as a valuable innovation in family planning, but little is known about trends in DMPA-SC use or characteristics of users. Using data from Burkina Faso, the Democratic Republic of Congo (DRC) and Uganda, we measured trends in DMPA-SC and identified characteristics associated with DMPA-SC use.We used repeated cross-sectional representative data collected between 2016 and 2019. First, we plotted trends in DMPA-SC use for all women and married women. Next, we presented the sociodemographic and family-planning-related characteristics of DMPA-SC users. Finally, we conducted weighted multivariate logistic regression analysis to examine how DMPA-SC users were different from women (1) using all other modern methods combined and (2) not using any modern method.DMPA-SC use increased monotonically in all three countries. Many DMPA-SC users were first-time users of modern contraception . Never-married women had lower odds than married women of using DMPA-SC (compared to other modern methods) in all three countries . Level of education was positively associated with DMPA-SC use (compared to no use) .DMPA-SC is a rapidly growing method in these settings. Despite the comparable levels of and increases in use for all three countries, the characteristics associated with DMPA-SC use generally differed across countries.This is the first analysis of patterns of DMPA-SC use with representative data for African countries. Our results confirm that DMPA-SC is increasingly popular, although the profile of users varies across settings. Compared to other contraceptive methods, the benefits of DMPA-SC include ease of use, few side effects, fast administration, less pain and greater effectiveness .Studies suggest that DMPA-SC is widely acceptable in sub-Saharan Africa (SSA). Pilot testing in Burkina Faso, Niger, Senegal and Uganda from 2014 to 2016 showed that DMPA-SC can add value to national family planning programs . Some usGiven that the introduction of DMPA-SC is still in the early stages in many countries, little is known about the characteristics of DMPA-SC users. Who are they, and how are they different from users of other modern methods and women not using modern methods? To what extent do the characteristics of DMPA-SC users vary across settings? Some have speculated that DMPA-SC use may be particularly appealing to young women ,5,9 and In this research, we use representative data from Burkina Faso, the Democratic Republic of Congo (DRC) and Uganda to identify characteristics associated with DMPA-SC use and how these characteristics vary across countries. First, we measure trends in DMPA-SC use over time. Next, we provide characteristics of DMPA-SC users in each country, including the percentage who were first-time users of modern contraception. Finally, we identify characteristics associated with DMPA-SC use compared to all other modern methods combined and nonuse of modern contraception.2Data for representative analysis of DMPA-SC users are rare. National health information systems are not usually equipped to track DMPA-SC use because they typically group methods by general type  and do not distinguish between DMPA-SC and DMPA-IM . They alwww.pma2020.org.We used data from the Performance Monitoring and Accountability 2020 Project (PMA2020) . Since 2An innovation of PMA2020 is the use of female resident enumerators (REs) recruited from within or near sampled enumeration areas (EAs) and trained to collect data using smartphone technologies. REs map and list every household within the EA to create a sampling frame from which households are randomly selected. The RE completes a household roster for each selected household, and all females age 15 to 49 are asked to be interviewed . The usThree countries are included in this analysis: Burkina Faso, Uganda and DRC. Data from the first two countries are nationally representative, while data from DRC are representative of the two provinces of Kinshasa and Kongo Central. We selected these three countries because they all have multiple rounds of data in which DMPA-SC use was measured and has increased to non-negligible percentages of use. Other PMA countries were not included in the analysis because they either did not measure DMPA-SC at all or in more than one round , or had a DMPA-SC prevalence of less than 1% among all women . The specific rounds of PMA data used are from 2016, 2017, 2018 and 2019 for Burkina Faso; 2016, 2017 and 2018 for DRC; and 2017 and 2018 for Uganda.Ethical approval for conducting PMA2020 was received from institutional review boards (IRBs) in each country  and Johns Hopkins Bloomberg School of Public Health. All respondents were approached for informed consent before enrollment in the study, and the relevant ethical review boards approved all consent procedures. Because all analyses here were using publicly available data (without any identifying information), IRB approval was not necessary for the analysis in this paper.2.110.13039/100000865Bill & Melinda Gates Foundation. The funding source was not involved in the design or conduct of the research.This article was developed under grant #OPP1079004 awarded to Johns Hopkins Bloomberg School of Public Health by the 2.2Current contraceptive use was measured by PMA2020 through the following question: “Are you or your partner currently doing something or using any method to delay or avoid getting pregnant?” If the woman reported using contraception, she was asked to name the method or methods she was using. We define modern contraceptive methods as hormonal and barrier methods, sterilization, emergency contraception, lactational amenorrhea method and the standard days/cycle beads method. If the woman reported using an injectable, she was asked “Was the injection administered via syringe or small needle?”, and was shown an image of both DMPA-SC and DMPA-IM so she could provide an accurate distinction. We identified the percentage of DMPA-SC users whose first method was DMPA-SC (as opposed to switching to DMPA-SC from another method) through the following question: “Which method did you first use to delay or avoid getting pregnant?”We next focused on characteristics of DMPA-SC users, including sociodemographic measures such as age, number of lifetime births, marital status, level of education, household wealth and urban/rural residence. Household wealth was measured using a constructed index based on ownership of 25 household durable assets, house and roof material, livestock ownership and water source, which was converted into quintiles. We also included measures of family planning programming: whether participants were exposed to a family planning message via radio, television or a magazine in the past 12 months. Finally, we included an additive index of FP method knowledge .2.3We conducted our analysis in several steps, beginning with trends in DMPA-SC use in each country. We plotted the (weighted) percentages of married and all women using DMPA-SC for the rounds of PMA2020 mentioned above in each of the three countries.We next tabulated characteristics of DMPA-SC users in each country. We described DMPA-SC users by age; number of lifetime births; marital status; level of education; household wealth quintile; exposure to FP messages via radio, television and magazine; urban residence ; number of FP methods known and the percentage for whom DMPA-SC use was their first modern method.Finally, we conducted multivariate analysis to examine whether and how users of DMPA-SC were different from women (1) using all other modern methods combined and (2) not using modern methods . To do so, we used logistic regression in which the binary dependent variable was DMPA-SC  compared to the other two categories above . Independent variables included were age , number of births , highest level of educational attainment , marital status , wealth quintile, the FP program exposure measures, number of contraceptive methods known (0–13) and an indicator for PMA2020 survey year. We presented odds ratios and 95% confidence intervals (CIs) for all regression results. The few missing values were considered missing at random. We accounted for the study design features and nonresponse by using survey weights in our analysis. An alternative approach would be to use a multinomial regression models with DMPA-SC use as the reference category (compared to other modern methods and not using any methods), but we use the logistic regressions described above because this produces coefficients for DMPA-SC use specifically, which is of central interest to this study.3Although DMPA-SC was used by only a small percentage of women in our three geographies, use increased monotonically between 2016 and 2019 in DRC, Burkina Faso and Uganda. As shown in Many users of DMPA-SC were first-time users of contraception. In Burkina Faso and Uganda, DMPA-SC was the first contraceptive method for most users . A smaller but not insubstantial 34.6% of DMPA-SC users in DRC were first-time users.In our first set of multivariate results, we compared characteristics of DMPA-SC users with users of all other modern methods combined . One resNext, we compared users of DMPA-SC with women not using any modern method of contraception . Women a4Our results show that DMPA-SC was growing rapidly in Burkina Faso, DRC and Uganda, both among all women and married women. These increases were monotonic and substantial over a relatively short period of time. These trends are consistent with rapid increases in DMPA-SC availability at service delivery points in Burkina Faso .For many users of DMPA-SC, this was their first contraceptive method. Most DMPA-SC users in Burkina Faso and Uganda and more than one third of users in DRC reported as being first-time users of contraception. This number exceeds estimates from the four-country pilot test of DMPA-SC, which reported that 29% of all DMPA-SC doses administered were to new contraceptive users .Many of the characteristics associated with use of DMPA-SC varied across countries. Women living in wealthier households and those who heard an FP advertisement on the radio were more likely to use DMPA-SC in DRC; this was not the case in other countries. The relationship between age and DMPA-SC varied, with women aged 20 to 24 more likely in DRC, compared to 25 to 29 in Uganda, and no relationship between age and use in Burkina Faso. Some of these differences may be explained by family planning programs in each country; DRC has an FP radio campaign targeted at youth aged 18–24 . Our resHowever, some results were consistent across settings. It is important to note that we found no evidence that younger women (aged 15–19) were more likely to use DMPA-SC in any geography; in fact, we found limited evidence of a variation in DMPA-SC use by age overall. Also, never-married women were significantly less likely to use DMPA-SC compared to other modern methods. Level of education was positively associated with DMPA-SC use (compared to nonuse) in Burkina Faso and Uganda.Overall, we find that DMPA-SC is an increasingly popular method, which supports results from pilot tests that demonstrated the appeal of DMPA-SC, particularly among first-time users of contraception . This coThere are some limitations in this research. Although use of DMPA-SC is increasing, it is still at relatively low levels in these countries, which lead to small sample sizes, large CIs and limited ability to detect statistical interactions in some cases. Some measures that might be related to DMPA-SC use are not available in the PMA2020 data, such as access to DMPA-SC, knowledge of DMPA-SC specifically  and urban residence in DRC. Given the multiple ways in which DMPA-SC can be distributed within a community, it would be useful to know how DMPA-SC is administered to the woman: is it self-administered or administered by a trained provider at a fixed facility, or by a community worker? Some research suggests that method continuation may vary by how DMPA was administered , althougOur next steps follow from the above. An important related topic is method switching: does DMPA-SC use come at the cost of DMPA-IM, or are DMPA-SC users switching from other methods, and which ones? We do not thoroughly examine this question here due to space constraints, but our results showed that the majority of DMPA-SC users did not switch from another method in Burkina Faso and Uganda, which are consistent with other research showing few women switching from DMPA-IM to DMPA-SC . This ha


When l-Leu was injected into fertile broiler eggs to examine the cause of reduction of Leu in embryos exposed to HT, in ovo feeding of l-Leu improved thermotolerance in broiler chicks. In ovo injection of l-Leu was also found to inhibit weight loss in market-age broilers exposed to chronic HT, giving rise to the possibility of developing a novel biotechnology aimed at minimizing the economic losses to poultry producers during summer heat stress. These findings and the significance of amino acid metabolism in chicks and market-age broilers under HT are summarized and discussed in this review.Increased average air temperatures and more frequent and prolonged periods of high ambient temperature (HT) associated with global warming will increasingly affect worldwide poultry production. It is thus important to understand how HT impacts poultry physiology and to identify novel approaches to facilitate improved adaptation and thereby maximize poultry growth, health and welfare. Amino acids play a role in many physiological functions, including stress responses, and their relative demand and metabolism are altered tissue-specifically during exposure to HT. For instance, HT decreases plasma citrulline (Cit) in chicks and leucine (Leu) in the embryonic brain and liver. The physiological significance of these changes in amino acids may involve protection of the body from heat stress. Thus, numerous studies have focused on evaluating the effects of dietary administration of amino acids. It was found that oral  The 0.9°C rise in the world's average surface temperature since the late 19th century has been mainly caused by the increase in carbon dioxide and other human-made emissions into the atmosphere . The expin ovo injection of l-Leu afforded thermotolerance in broiler chicks  when compared with the control thermoneutral temperature . Several free amino acids have been found to increase in the blood, brain, and muscle of layer chicks within a short time (15 or 30 min) following exposure to HT at 35°C ; howeverr chicks , 22. Thul-Cit and l-Leu afford thermotolerance. Furthermore, we describe the use of in ovo feeding of l-Leu to attenuate the BW reduction that occurs in market-age broilers under heat stress.In this review, we summarize how heat stress affects amino acid metabolism, with a particular focus on the means by which Animal proteins are commonly consisted of 20 amino acids. In growth-phase chicks, 11 of these  are essential amino acids, while the remaining are non-essential . Heat stIt is still unknown why various amino acids increase in the plasma under short-term heat stress. It is interesting that during short-term heat stress  the free amino acids have been found to be highly concentrated, in complete contrast to the situation during long-term heat stress , which was characterized by a reduction in most of the free amino acids. For instance, there was a reduction in tryptophan, Cit, and ornithine (Orn) in the plasma of layer chicks exposed to long-term heat stress , was fouTM during embryogenesis involves increasing the incubation temperature, leading to neonatal chicks  and chicl-Cit, l-Orn, and l-Arg were administered in the left ventricle of the brain, there was no reduction in body temperature  is produced when synthase  and may synthase , occurrisynthase . Howeverolerance . FurtherIn ovo feeding of l-Leu led to hypothermia in broiler chicks at hatching , non-esterified fatty acids (NEFAs), and ketone bodies were higher in broiler chicks fed l-Leu in ovo under heat stress than in heat-exposed control chicks. One might surmise that broiler chicks would benefit from in ovo feeding of l-Leu because fat generates less heat, and dietary fats have well-known beneficial effects in hot-weather feeding programs  were subjected to acute heat stress (30 ± 1°C for 120 min) or to chronic heat stress . Under acute heat stress, the increased body temperature was found to be suppressed in broilers receiving the in ovo administration of l-Leu, without affecting food intake, plasma TG, NEFA, ketone bodies, glucose, lactic acid, or thyroid hormones. Under chronic heat stress, in ovo administration of l-Leu increased the daily body temperature. Of note, under chronic heat stress, in ovo administration of l-Leu resulted in a higher daily BW gain in comparison with the control group. Furthermore, under acute heat stress, there was a significant increase in several essential amino acids, including Leu and isoleucine, in the liver, and a decrease in their concentration in the plasma, following in ovo administration of l-Leu. These findings indicated that in ovo administration of l-Leu in broilers up to market age produces thermotolerance under conditions of acute heat stress chiefly by altering the amino acid metabolism.As stated above, n et al.  conductein ovo injection of amino acids on the performance of broilers under heat stress, dietary administration of some amino acids was found to be beneficial related to growth and meat quality under heat stress. For instance, El-Naggar et al.  were influenced by l-Leu administration following 120 min of heat exposure in market-age broilers, suggesting that food intake and lipid metabolism may not contribute much to l-Leu–induced thermotolerance (3), are important in modifying the metabolic rate, which influences body-temperature regulation (In ovo administration of l-Leu (34.5 μmol) had no effect on T3 concentrations, even when there was a reduction in body temperature during hatching (l-Leu under conditions of acute heat stress. TM during embryogenesis, which affords thermotolerance, results in a reduction in thyroid hormones at hatching and in posthatch chicks, as well as in chicks exposed to heat stress (l-Leu–mediated thermotolerance could be assumed to be a different mechanism to that of TM. Interestingly, in ovo administration of l-Leu in broilers resulted in an increase in body temperature under chronic heat stress. Under continuous heat stress, higher body temperature might be considered to be an adaptive strategy in the broilers treated with l-Leu, because the increased body temperature has been found to enhance sensible heat loss (In birds, body temperature is considered to be a reliable indicator of thermotolerance acquisition . Previouproteins , 49. In olerance . Thyroidgulation . In ovo hatching . Thus, ahatching , plasma t stress . l-Leu–meat loss . Howevereat loss , moleculin ovo administration of l-Leu has been found to attenuate the reduction in BW induced by heat stress in broilers (in ovo water–administered control and the l-Leu–administered groups tends to be reduced. It is well-known that long-term feed restriction during heat waves in the summer leads to an improvement in heat resistance and thermotolerance, although significantly reducing broiler performance (l-Leu–treated group showed a significantly higher BW compared with the control heat-exposed group, where at 23 days of age the average BW of the l-Leu–administered group was 8.4% higher than that of the control group (In ovo administration of l-Leu has been reported to enhance growth in chicken embryos (l-Leu supplementation (in ovo administration of l-Leu appears to maintain a normal growth under cyclic heat stress (in ovo administration of l-Leu accelerates protein synthesis to maintain growth in broilers under heat stress.Chronic heat stress in broilers has negative effects on feed intake, BW gain, and feed-conversion ratios . Howeverbroilers . In condformance . It coulol group . In ovo  embryos , and in entation , 56. Bect stress , it mighin ovo administration of l-Leu in comparison with control broilers. Acute heat stress alters amino acid metabolism in chicks (l-Leu–treated group than in the control group, which suggests that there were stronger heat-stress responses related to amino acid metabolism in broilers treated with l-Leu. Thus, in ovo administration of l-Leu might improve amino acid metabolism during acute heat stress. Amino acids are derived from catabolized proteins and provide carbon backbones for glucose or fatty acid production (l-Leu administration might enhance energy metabolism in broilers, and high energy is needed to maintain thermoregulation under heat stress (l-Leu treatment under 120-min heat stress (l-Leu–treated broiler chicks in comparison with control chicks (l-Lys oxidation was significantly increased under chronic hypoglycemia for supporting the growth of fetus. The higher concentrations of Lys in the broiler liver fed l-Leu in ovo (in ovo administration of l-Leu could contribute to thermotolerance in broilers, rather than to lipid metabolism as previously predicted in broiler chicks (l-Leu in ovo in comparison with the controls under conditions of chronic heat stress. Al Wakeel et al. (in ovo administration of l-Leu would reduce the negative effects caused by heat stress because GABA is a major inhibitory neurotransmitter, which plays an important role in controlling excitability (Acute heat stress induces catabolic activity in organisms . It is wn chicks  and decrn chicks . During n chicks  reportedoduction ; thus, lt stress . Han et t stress  showed tt stress . In broit stress . With 18l chicks . Limesanl chicks  reportedu in ovo  may be cu in ovo . Methionu in ovo . It has u in ovo . Thus, tr chicks ; 22. Futr chicks , and oxir chicks  reportedl et al.  reportedtability , and it tability .l-Cit and l-Leu because the levels of these two amino acids were affected by heat stress, and treatment with them afforded thermotolerance in chicks and market-age broilers, respectively. Notably, in ovo administration of l-Leu supported a higher BW in market-age broilers in comparison with the control group under conditions of heat stress. Heat stress presents a major problem for poultry production both today and in the future, and our study and others (Heat stress causes changes in amino acid metabolism in chicks and market-age broilers. Research collectively points to d others , 65–69 cAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.