The objective of the CONTINUE study is to gather preliminary data on the potential impact of implementing a “Cost Tool” in routine obstetrics (OB) care. It is hypothesized that by providing prenatal patients with an ability to forecast their care plan, they would be better able to anticipate and plan for the costs associated with their prenatal care.Pilot data from interviews and surveys were collected from 71 prenatal patients across three clinics throughout Chicago, IL.As compared to privately insured prenatal patients, prenatal patients with public insurance reported the most benefit in Cost Tool use. Specifically, that the Cost Tool helped to navigate insurance more effectively , see the "Big Picture" and link it to the family budget , and make the financial tradeoffs needed to get through pregnancy .The CONTINUE study provides preliminary signals of the Cost Tool’s potential to help publicly insured prenatal patients better navigate the costs associated with their care plan.The CONTINUE study contributes valuable preliminary data about the utility of a cost tool in routine OB care, especially as it may benefit low-income prenatal patients navigate prenatal care better. •low-income prenatal patients benefited from using well-designed validated tool.•Low-income prenatal patients welcome less cost conversations with providers.•More research should be conducted to capture the effects of tools in OB care. HowevStudies suggest that more than half of patients want to engage in cost-of-care conversations and for their medical provider to factor costs into their care plans . Yet, feAnnals of Internal Medicine in 2019 focused on cost-of-care conversations and how to improve them. Within this, several provider barriers to effective cost-of-care conversations were identified, which included: insufficient time and expertise, lack of awareness of available resources, lack of knowledge about the costs of specific tests and treatments, difficulty estimating the total costs of a care plan, difficulty estimating nonmedical (indirect) costs associated with care, and discomfort initiating and conducting conversations about costs-of-care [A supplement published by -of-care . A 2017 -of-care . More re-of-care .To support physicians and patients with integrating cost-of-care conversations into routine clinical practice, several healthcare stakeholder organizations, including the American College of Physicians (ACP), American’s Essential Hospitals, and Robert Wood Johnson Foundation, are working to standardize these conversations and promote their usage in routine clinical care. Given the research above, it is generally agreed upon that these conversations need to happen systematically and with all patients, irrespective of condition and perceived financial status. Additionally, recent interventions and research around the efficacy of cost-of-care conversations have concluded that these conversations are better facilitated when supplemented with conversational aids such as sample scripts, tools, handouts, and electronic medical record (EMR) reminders ,17. The 1.1Cost Conversations in Routine OB Care) study piloted and documented the potential impact of implementing the Cost Tool in routine OB care with prenatal patients over a one-year time period in multiple clinics located throughout Chicago, IL. Pregnancy care plans are inherently burdensome and expensive. Typical prenatal care can require up to 42 weeks of visits to OB providers, including labs, monitoring, and other standard-of-care evaluations, all of which have associated direct and indirect – not insurance related – costs. While prenatal care is burdensome to most pregnant people, particularly those with high-risk pregnancies, low-income prenatal patients, regardless of risk status, are more likely to defer, decline, or engage poorly in pregnancy care due to cost [The CONTINUE  identifying patients presenting for their first prenatal care appointment for the current pregnancy episode) during a 14-week pilot. The Cost Tool was available in both English and Spanish. Each 14-week pilot was held sequentially and conducted between September 2020 and July 2021. Directly prior to tool implementation, most OB providers underwent a one-hour in-person training. Training consisted of three components: 1) Tool usage: filling out the tool correctly and distributing it with fidelity, 2) Implementation logistics: identifying where tools will be placed in the clinic to maximize usage  and where in the electronic medical record (EMR) to track tool distribution, and 3) Site readiness: assessing local barriers or preparatory activities to be addressed by the local team. At the end of the training event, providers received an unlimited number of pregnancy support tools for distribution in their clinic. Pregnancy support tools were pre-labeled with unique tracking numbers on each tool, reflecting sequential order and clinic (e.g. ASMC102).Data was collected between January 2021 and December 2021. A mixed-methods approach to data collection was used in the forms of interviews and surveys. This study was approved by Advocate Health Care IRB (#20-264E).2.1The CONTINUE study team targeted clinics with different OB provider types – attending OB, resident OB, midwives, and nurses. Clinic 1 serves mid to higher-income, privately insured, predominantly White, high- and low-risk patients, with four attending OB providers on staff. Clinic 2 serves low-income, publicly insured, predominantly Hispanic, high- and low-risk patients. Clinic 2 is served by 12 resident OB providers, each rotating for four weeks, and three nurse providers on staff. Clinic 3 serves higher-income, privately insured, predominantly White, low-risk patients, with two midwife providers on staff.Patients were given the Cost Tool by their OB provider at their New OB appointment . All New OB patients were eligible for the Cost Tool. To be eligible for follow-up, prenatal patients had to be at least 18 years old, have used the Cost Tool for at least 8 weeks, and be at least 27 weeks pregnant. Additionally, demographics and care-related data were collected during interviews and surveys. th week of pregnancy. Prenatal patient participants self-selected to complete a semi-structured interview or a surrogate electronic survey. The interview was based on human-centered design (HCD) methodologies which were employed during the tool development phase [To capture experiences with the Cost Tool, prenatal patients were offered either an interview or survey after their 27nt phase  and adap2.2The CONTINUE study assessed both who cost-of-care conversations were (or were not) occurring with and what additional financially-related benefits the implementation of the Cost Tool into routine OB care may have. Cost-of-care implementation measures for the CONTINUE study were formulated with prenatal patients and OB providers in a prior study . A total2.3Demographic variables were collected on all prenatal patients, including: Age, categorized, 18-25, 26-35, 36-45; Race, White, Black, Asian, AI/AN, and other; Ethnicity, Hispanic/Latino/Spanish and Non-Hispanic/Latino/Spanish; Insurance status, public and private; Language, English and Spanish; Currently working, yes or no; and Current partner; yes or no. Pregnancy specific variables were also collected, including: Provider type, midwife, nurse, OB, attending; Parity, first or subsequent; Risk, high, low, or unknown; and Clinic, 1, 2 or 3. It is important to note that this study aimed to identify differences in the cost measure by income status; however, to prevent prenatal patients from feeling targeted based on perceived income level, income was not asked in data collection. Instead, insurance status is being used as a proxy for income in this study, with publicly insured prenatal patient participants defined as low-income and privately insured prenatal patient participants defined as higher-income and will be referred to as insurance status (public vs. private) throughout this paper.In total, the cost measure included eight cost-of-care conversation outcome items and five Cost Tool implementation benefit outcome items and was collected using interviews and surveys. Items from the semi-structured interview card sort activity directly corresponded to items from the electronic survey, with each item as a unique statement, and therefore for this manuscript, all cost-related items are treated as quantitative. See 2.4Data management and analysis were performed by the study research team using SAS statistical software . Descriptive statistics are reported as counts (%). Univariate and bivariate analyses were conducted to examine the distributions of each variable, among the overall sample and by insurance type. Reported measures of association include odds ratios (OR) with associated 95% confidence intervals (CI). Because this study hypothesized a greater impact of the pilot Cost Tool on low-income prenatal patient participants and public insurance was used as the proxy for low-income, ORs are interpreted from the perspective of prenatal patients with public insurance. Specifically, in 3Of the 184 prenatal patient participants who were given a Cost Tool during an OB appointment at any of the three involved clinics, 71 (38.6%) completed follow-up interviews or surveys (study participants). Among the 71 study participants, 34 prenatal patients completed interviews and 37 prenatal patients completed surveys. Overall, most patients were 26-35 years old (57.7%), English-speaking (95.8%), Hispanic/Latino/Spanish (56.3%), and received care at Clinic 2 (56.3%). Pregnancy related, most prenatal patients were low risk (54.9%) and had at least one prior child (56.3%).Prenatal patients with public insurance were statistically more likely to be Hispanic/Latino/Spanish , have received care at Clinic 2 , have received the Cost Tool from by a nurse provider , and be in the youngest age group – 18-25 . See 3.1.1Prenatal patients with public insurance were less likely to report having cost conversations, specifically with an OB provider , partner , friend or coworker , someone else at the clinic , insurance provider  or human resources (HR)/benefits specialist at work  as compared with prenatal patients with private insurance , none of3.1.2Implementation of the Cost Tool revealed several statistically significant benefits for prenatal patients with public insurance relative to those with private insurance. Relative to prenatal patients with private insurance, prenatal patients with public insurance were statistically significantly more likely to report the Cost Tool as helping to navigate insurance more effectively , see the "Big Picture" and link it to the family budget , and make the financial tradeoffs needed to get through pregnancy . While not statistically significant, prenatal patients with public insurance were twice as likely to report the Cost Tool as helping to feel their financial situation was being considered  and manage other life responsibilities  as compared with prenatal patients with private insurance.44.1The CONTINUE study is a pilot study to gather preliminary data on the potential impact of implementing a cost tool into routine OB care. This study was particularly concerned with addressing whether a cost tool could facilitate cost-of-care conversations and with whom, and more broadly, if there may be benefits of a cost tool in routine OB care.In respect to whether cost-of-care conversations were occurring in routine OB care with this specific group, low-income prenatal patients, as compared to higher-income prenatal patients were less likely to report having cost-of-care conversations with their OB provider, clinic staff, partner, friend, insurance provider or work associates. On the opposite end, higher-income prenatal patients reported conversations about costs with a broader range of individuals, including OB providers, clinic staff, insurance providers, HR/benefits specialists, friends or coworkers, and partners, as compared to prenatal patients with public insurance. While conversations with insurance providers and HR/benefits specialists can be linked with work status and challenges associated with having private insurance, more personal reasons that may explain differences in conversations with close individuals, like partners and family, should be explored further, especially given no differences in reported presence of partners by insurance type. Most notably, higher- and low-income prenatal patients did not align when it came to welcoming cost-of-care conversations in their routine OB care with higher-income prenatal patients welcoming them and low-income prenatal patients not. This may be due to the stigma associated with being low-income, which research shows low-income patients are more likely to have worse treatment and worse health outcomes because of it ,27.As far as reported financial benefits, low-income prenatal patients were more likely to see cost-related benefits as reported by Cost Tool use. Perhaps unsurprisingly, higher-income prenatal patients did not find cost related benefits in the tool, despite welcoming it in OB practice, signaling the Cost Tool may potentially be more beneficial to low-income prenatal patients but could be distributed to anyone, which would be ideal in a clinical setting so as not to target patients due to perceived financial status. The limited sample size made it a challenge to draw widespread conclusions about the financial benefits of a cost tool, but our current data strongly suggests that having an added support in the form of a low-burden tool may be beneficial, even if low-income prenatal patients are not comfortable directly speaking about cost-of-care with their OB provider/s.4.1.1The CONTINUE study is a pilot sought to gather data on the preliminary benefits of introducing a cost tool in routine care in a varied prenatal patient and OB provider population. Given this was a pilot study, the study size – number of patients, providers, and clinics – had to remain manageable which limited some of results and the ability to achieve statistical significance. Although the results are trending favorably, a larger sample size would render a stronger conclusion. Additionally, given that this is an implementation pilot project, sites and prenatal patients were not randomized which may introduce a selection bias.4.2The CONTINUE study is innovative in that it was able to take a diverse population and gather preliminary data on a tool from multiple clinics with varied OB provider types. It was also able to take semi structured interviews and survey data to combine into key benefit items for quantitative analysis . Given t4.3Based on preliminary findings from the CONTINUE study, there are benefits to cost tools for prenatal patients beyond the potential to facilitate cost-of-care conversations. Prenatal patients with public insurance reported cost-related tool benefits such as helping to navigate costs surrounding burdensome OB care plans, making financial tradeoffs, and linking costs associated with pregnancy to the family budget, all of which are essential for care adherence. Given this, the Cost Tool has value to all prenatal patients, even if publicly and privately insured prenatal patients are not deriving the same benefit from tool use. This study called into question that perhaps the goal of promoting cost-of-care conversations is not the right goal for low-income women, but instead the goal should be giving low-income women the foresight to allow them to take the actions they prefer and need, whether a cost-of-care conversation happens.An important distinction needs to be made between the presence of cost-of-care conversations and the tangible cost-related benefits it promotes. While low-income prenatal patients reported less cost-of-care conversations overall, they also reported cost-related benefits that helped them navigate the financial burden of their OB care plan. This is particularly important in this population, given low-income women are more likely to postpone and forego care . More no10.13039/100000867Robert Wood Johnson Foundation (grant # 77290). The funding body had no input on the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. The authors declare that they have no competing interests.This study was funded by the The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The COVID-19 pandemic has led to exceptional stress in pregnant women. The aim of the present study was to investigate associations of maternal stress (pandemic-related and -unrelated), anxiety, and relationship satisfaction experienced during the COVID-19 pandemic with prenatal mother-infant attachment.An online study was conducted evaluating pandemic-related stress, pregnancy-specific stress (unrelated to the pandemic), anxiety, partnership satisfaction, and maternal-fetal attachment in German-speaking women during the second COVID-19 lockdown between January and March 2021. In total, 431 pregnant women (349 lived in Germany and 82 in Switzerland) filled in the questionnaires and gave information on demographic and pregnancy-related variables . Bivariate correlations were calculated in order to investigate associations between the different variables and additionally, a hierarchical regression model was conducted in order to evaluate the influence of the independent variables on prenatal attachment.The hierarchical regression analysis revealed that after controlling for age, gestational age, and parity higher pandemic-related stress, namely stress associated with feeling unprepared for birth, higher partnership satisfaction as well as higher positive appraisal (considered as a way of coping with pandemic-related stress) was associated with stronger maternal-fetal attachment, whereas associations of anxiety and other forms of stress were non-significant.The study highlights interesting associations between maternal pandemic-related preparedness stress and positive appraisal of the pregnancy as well as partnership satisfaction and prenatal attachment in women pregnant during the COVID-19 pandemic. The COVID-19 pandemic has had a great impact on the world population, affecting many areas of life since 2020 . AlthougLower maternal-fetal attachment in the prenatal period has been linked to lower mother-infant attachment postnatally –18. PoorIn the current study, we also examined relationship satisfaction as a contributor to prenatal attachment as studies have shown that together with marital status, partnership satisfaction positively influences prenatal and postnatal mother-infant attachment , 26. MatThe present study evaluated levels of pandemic-related and pregnancy-specific (pandemic-unrelated) stress, anxiety, relationship satisfaction, and prenatal mother-infant attachment in German-speaking pregnant women in Germany and Switzerland during the second lockdown (January-March 2021) of the COVID-19 pandemic. The aim of the study was to investigate associations of maternal stress, anxiety, and relationship satisfaction experienced during the COVID-19 pandemic with prenatal mother-infant attachment. We hypothesized that higher stress and anxiety would be associated with lower attachment and with less relationship satisfaction, and that higher relationship satisfaction would predict greater attachment.The present study is part of an ongoing project, the International COVID-19 Pregnancy Experiences (I-COPE) Study, which was initiated at the beginning of the COVID-19 pandemic in March 2020. The I-COPE Study investigates the experiences of pregnant and postpartum women with an emphasis on the extent and impact of COVID-19-related stress in the peripartum period .Participants for the current study were recruited during the second lockdown of the COVID-19 pandemic in Germany and Switzerland between January and March 2021. In order to participate, women needed to currently be pregnant , over 18 years of age, and able to understand the German language sufficiently to complete the online study questionnaire. The main components of the survey  was developed by colleagues from the US . For theMaternal-Fetal Attachment Scale (MFAS) was used to assess prenatal attachment ).www.soscisurvey.de) in Germany and Unipark (www.unipark.de) in Switzerland. Participants were recruited via social media  and flyer distribution through different organizations for pregnant women . After reviewing study information and providing informed consent, participants completed the study questionnaire, which took approximately 15 min. In Germany, participants had the chance to enter a prize drawing to win one of ten 10 Euro Amazon vouchers, whereas in Switzerland, each participant was sent a small gift if they indicated they would want to receive one.The online survey was conducted via the platform Sosci-Survey . Bivariate spearman correlations were first calculated among MFAS, PREPS, PFB, NuPDQ, and GAD scores. Following this, a linear hierarchical regression model was constructed to examine independent associations of study variables with prenatal attachment. In Block 1 of the model, we included demographic and pregnancy-related factors which have been shown to influence prenatal attachment ; Block 2 added the psychological factors that were significantly correlated with MFAS scores.covariates: maternal age (continuous variable), gestational age (continuous variable), and parity (nullipara vs. multipara) as these have been shown to be important predictors of prenatal attachment [Analyses were adjusted for the following tachment , 39.We checked the variables for normality. As most of the variables were not normally distributed, non-parametric spearman correlations were applied. Regarding the linear hierarchical regression model, we checked after running the analysis whether the residuals are normally distributed using histograms, P&P Plots as well as the normality test, which confirmed that the residuals were normally distributed.For the present study, 431 pregnant women participated, including 349 who lived in Germany and 82 in Switzerland. Their mean age was 32 years  and their mean gestational age was 26 weeks . Approximately half  were expecting their first child. Nearly all participants  were married or living with a partner as if married.Table As shown in Table Additional analyses revealed significant positive correlations of attachment with age  and gestational age  and a significant difference on the MFAS by parity (nullipara vs. multipara), U (431) = 17845.5, z = -4.14, p < .001. Nulliparous women reported higher prenatal attachment (Mdn = 50) than did multiparas (Mdn = 45).A hierarchical regression model was constructed predicting the dependent variable MFAS, adjusting for maternal age, gestational age, and parity in Block 1 and then adding PREPS-Prep, PREPS-Inf, PREPS-Pos, and PFB scores as predictors in Block 2. As shown in Table As it was surprising that parity is highly significant in Model 1 and turns out non-significant in Model 2, we then ran the regression analysis again and excluded the variables which were significantly correlated with parity , they can more easily build up an attachment to the unborn child.The study revealed that higher maternal pandemic-related preparedness stress and positive appraisal of the pregnancy as well as higher partnership satisfaction are associated with stronger prenatal attachment in women pregnant during the COVID-19 pandemic. Furthermore, the results highlight associations between anxiety and positive appraisal and partnership satisfaction. Taken together, the study revealed interesting relationships between maternal stress, partnership satisfaction and maternal-fetal attachment. It would be desirable if future studies include depressive symptoms as an important prenatal psychological factor as well as to then build on these results and investigate how these associations develop postpartum and influence developmental factors of the child.


T-CLEARE incorporates community responses to an open survey designed to capture details not commonly found in the scientific literature, including modifications to published protocols required for specific use cases and instances when tissue-clearing protocols did not perform well (negative results). The goal of T-CLEARE is to provide a forum for the community to share evaluations and modifications of tissue-clearing protocols for various tissue types and potentially identify best-in-class methods for a given application.Selecting and implementing a tissue-clearing protocol is challenging. Established more than 100 years ago, tissue clearing is still a rapidly evolving field of research. There are currently many published protocols to choose from, and each performs better or worse across a range of key evaluation factors . Additionally, tissue-clearing protocols are often optimized for specific experimental contexts, and applying an existing protocol to a new problem can require a lengthy period of adaptation by trial and error. Although the primary literature and review articles provide a useful starting point for optimization, there is growing recognition that many articles do not provide sufficient detail to replicate or reproduce experimental results. To help address this issue, we have developed a novel, freely available repository of tissue-clearing protocols named T-CLEARE (Tissue CLEAring protocol REpository;  Tissue clearing refers to methods that increase the physical transparency of biological samples. Through a series of chemical or physical steps, tissue-clearing methods homogenize the refractive index of a sample by removing, replacing, or modifying light-scattering components . This process increases light transmission and optical imaging depth, making it possible to capture volumetric images of large samples without sectioning the material into thin slices. In recent years, tissue clearing has made it possible to generate high-resolution, three-dimensional (3D) images of entire brains, peripheral organs, bones, and embryos from model organisms –18, and Selecting and implementing a tissue-clearing protocol can be challenging. Several excellent reviews highlight that no single tissue-clearing protocol (or subset of protocols) is broadly applicable across different experiments. Instead, there are many published tissue-clearing techniques, and each has its strengths and weaknesses  –40. Thushttps://doryworkspace.org/doryviz). T-CLEARE is intended to complement publications and protocol repositories and help the community compare and evaluate protocols when designing a tissue-clearing strategy. T-CLEARE is based on the results of a survey that asked researchers to identify tissue-clearing protocols they have used. Respondents were also asked to provide details not usually found in publications or protocol repositories, including protocol effectiveness and ease of use, modifications needed to optimize a protocol for specific circumstances, pre- and postprocessing steps not specific to published protocols, and negative results . T-CLEARE represents each tissue-clearing protocol reported by the community as a flow chart of five steps: fixation, pretreatment/decolorization, labeling, delipidation, and refractive index matching. Each flow chart is included in a tree diagram and organized according to whether it was very successful, successful, or not successful. Users can filter protocols based on whether it was successful, the tissue and organism studied, and the details of five different tissue-clearing steps.This article describes the development and implementation of T-CLEARE  between November 2019 and January 2020. The goal of the WG was to establish standards to promote data sharing within the research community. The WG prioritized two approaches for developing standards: (The tissue-clearing survey was developed by the 10-member BRAIN Initiative 3D Microscopy Working Group (WG) https://dWG members reviewed the literature and reached out to colleagues to identify the most widely used tissue-clearing techniques and key experimental parameters that impact selection of a protocol and tissue-clearing success. Based on this input, the subgroup developed a table of commonly used tissue-clearing protocols as a framework for gathering and comparing methods between laboratories. The table included protocol-specific details for five generalized steps commonly used in tissue clearing , 42. Thehttps://doryworkspace.org/tissue_clearing_feedback) for feedback and comment by the larger research community between November 2020 and January 2021. Potential respondents were identified by searching the NIH RePORTER .The results of the tissue-clearing survey were downloaded from the DORy website in CSV format and imported into Microsoft ExcelEach unique tissue-clearing protocol was diagramed as a flow chart using Lucidchart software . Each flkey): PFA 4% overnight). The JSON structure also contained some attributes to define the visualization part of the chart such as protocol step images, orientation of the nodes, or animation.Each flow chart was converted to a JavaScript Object Notation (JSON) tree data structure where the five different protocol steps were mapped to an arrays of key-value pairs . The tissue being cleared is the child of the refractive index matching protocol step .https://fperucic.github.io/treant-js/) open-source visualization library. The code included the jquery.min.js library to access and manipulate HTML elements. A custom JS library (dory-custom.js) was written to support the filters. CSS was used for styling. The T-CLEARE presentation layer was integrated into the Drupal-8 based DORy website (https://doryworkspace.org/doryviz) by packaging the JS and CSS files along with the JSON tree structure into a custom Drupal 8 module. T-CLEARE was tested with Chrome Version 101.0.4951.64 and is compatible with any browser .The T-CLEARE presentation layer was implemented using pure JavaScript (JS) and the Treant.js (https://github.com/Defining-Our-Research-Methodology-DORy/TissueClearing). The lightweight T-CLEARE application can be run in any browser as a standalone client or integrated and deployed in other platforms.A standalone implementation of T-CLEARE is available from our GitHub repository (https://doryworkspace.org/doryviz). When a user first opens T-CLEARE, the tree diagram displays four boxes. The “Protocols” box includes all flow diagrams for the reported tissue-clearing protocols. The next level to the right includes three boxes that organize the flow diagrams according to whether the protocols were “Very Successful,” “Successful,” or “Not Successful.” Clicking these three boxes will display the associated tissue-clearing protocol flow diagrams. The color of the box in the flow diagrams indicates whether the protocol step is associated with a hyperhydrating- (blue), tissue transformation- (aqua), or organic solvent-based class of tissue-clearing technique. Gray boxes indicate that the survey respondent used an “Other, specify” box to enter details for a protocol step. The fixation steps are yellow because these methods  are shared among the classes of techniques.T-CLEARE displays a tree diagram including each tissue-clearing protocol from the survey , details for each of the five major steps of the protocol) and organism and tissue type . These filters can help users tease how successful a method or group of methods, is for a given tissue. For example, users can select “successful” protocols that follow hyperhydrating principles for fixation, pretreatment, labeling, and refractive index matching in “mouse brain.”Several limitations of the tissue-clearing survey results include a relatively small number of responses, the qualitative nature of the survey questions, overrepresentation of experiments in mouse brain see , and a lhttps://doryworkspace.org/tissue_clearing_feedback) for the community to report results of additional tissue-clearing experiments. There could also be future email campaigns asking for feedback on tissue clearing and other types of protocols . Future versions of T-CLEARE could automate the flow of the data from the survey to the user interface. Although the current lightweight JS/JSON implementation of T-CLEARE is modular  and scalable , analyzing the survey results, curating the protocols flow diagrams, and creating images displayed in the nodes are manual steps. Future versions could include a MySQL database to capture and store the survey responses and algorithms that dynamically process new responses, generate the JSON arrays and images, and add them to the tree. Updates to the T-CLEARE user interface could include additional filters  and detailed comments from respondents. These comments, which provide details about protocol modifications, optimization, references, and why an experiment may have failed, are difficult to classify and are currently only available in the raw Excel data file. Future T-CLEARE features could link to full text versions of tissue-clearing protocols and resulting images in data repositories. The community is also encouraged to provide comments and suggestions using the feedback tools on the T-CLEARE and GitHUB repository pages.There are several ways to increase the utility of T-CLEARE. The most obvious is to gather additional input from the scientific community. To this end, the tissue-clearing survey will remain open and accessible from the DORy website (In summary, T-CLEARE is a novel, web-based repository of tissue-clearing protocols to help the community share, find, and evaluate available tissue-clearing protocols in real time. As more information is added, we hope that T-CLEARE can help the community coalesce around reporting standards and standard tissue-clearing protocols. These community standards will help ensure consistent data collection and reporting, improve data interpretation, and facilitate data sharing among the scientific community.


The emergence of immune checkpoint inhibitors (ICIs) has significantly prolonged the survival time of cancer patients. However, it may also lead to various immune-related adverse events (irAEs), including Guillain–Barré syndrome (GBS), a rare type of irAE. Most GBS patients can recover spontaneously due to the self-limited nature of the disease, but severe cases can result in respiratory failure or even death. Here we report a rare case of GBS occurring in a 58-year-old male patient with non-small cell lung cancer (NSCLC) who developed muscle weakness and numbness of the extremities during chemotherapy combined with KN046, a PD-L1/CTLA-4 bispecific antibody. Despite receiving methylprednisolone and γ-globulin, the patient’s symptoms did not improve. However, there was significant improvement after treatment with mycophenolate mofetil (MM) capsules, which is not a routine regimen for GBS. To the best of our knowledge, this is the first reported case of ICIs-induced GBS that responded well to mycophenolate mofetil instead of methylprednisolone or γ-globulin. Thus, it provides a new treatment option for patients with ICIs-induced GBS. Immune checkpoint inhibitors (ICIs)-based immunotherapy has revolutionized the therapeutic landscape of malignant tumors in recent years. Antibodies directed against programmed cell death protein-1 (PD-1), anti-PD-1 ligand (PD-L1), and antibody targeting cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) are the representatives of ICIs. ICIs-based immunotherapy has not only extended the survival time but also significantly improved the living quality of patients with certain cancers, such as melanoma, lung cancer, liver cancer, and breast cancer .Guillain–Barré syndrome (GBS) is an autoimmune peripheral neuropathy characterized by demyelinating lesions of peripheral nerves and nerve roots and inflammatory cell infiltration of small vessels. The most common clinical manifestation of GBS patients is acute symmetrical flaccid limb paralysis. A recent meta-analysis found that although immune-related neurological adverse events (NAEs) are relatively rare compared to chemotherapy, they often result in high mortality and disability . GuillaiALPHAMAB ONCOLOGY has independently developed a PD-L1/CTLA-4 bispecific antibody called KN046 which is composed of a CTLA-4 with a PD-L1 single-domain antibody. KN046 aims to achieve a dual targeting effect by simultaneously targeting the tumor microenvironment, which is known to be enriched in PD-L1, and by eliminating regulatory T-cells (Tregs) that inhibit tumor immunity. This innovative approach could potentially result in better treatment outcomes for patients with cancer.Here we report a rare case of GBS occurring in a 58-year-old male patient with non-small cell lung cancer (NSCLC) who developed muscle weakness and numbness of the extremities during treatment with chemotherapy combined with KN046. Based on the results of an electromyogram (EMG) and cerebrospinal fluid (CSF) analysis, he was diagnosed with ICIs-induced GBS. Traditional treatment of GBS including methylprednisolone and immunoglobulin (IVIG), was used to relieve his symptoms. However, these treatments were initially ineffective until mycophenolate mofetil (MM) capsules were prescribed, which resulted in a significant improvement in his symptoms. Our study discusses the diagnosis and treatment characteristics of GBS and provides a non-routine but feasible treatment option for ICIs-induced GBS patients.A 58-year-old male patient who presented with recurrent thoracalgia was admitted to our department. A CT scan of his lungs identified a lump in his left lobe, and a biopsy through fiberoptic bronchoscopy confirmed lung squamous cell carcinoma. The PD-L1 tumor proportion score (TPS) was 5%. After a series of examinations, including single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI) of the brain, the diagnosis of primary lung squamous cell carcinoma  was confirmed. The patient had no previous history of other chronic diseases or family cancer history, and was a smoker for 30 years with an average of one pack per day. After screening, the patient was enrolled in a multicenter, randomized, double-blind, placebo-controlled phase III clinical trial to assess the efficacy and safety of KN046 combined with platinum-based chemotherapy compared to placebo and platinum-based chemotherapy in patients with advanced squamous non-small cell lung cancer. The clinical trial registration number is CTR20201294, and the patient’s random number is 376. In August 2021, the patient began the first cycle of treatment, which included an intravenous infusion of paclitaxel 261 mg and carboplatin 490 mg, with an intravenous infusion of KN046 or placebo 240 mg. On the third day after medication, the patient developed mild pain in his lower limbs, for which ibuprofen was prescribed to alleviate the discomfort. Subsequently, the patient was discharged.Twenty-one days later, the patient was readmitted to the hospital in a wheelchair due to symptoms of fatigue, muscle weakness, and limb pain that had developed over the course of three days. Physical examination revealed grade 1 muscle strength in upper and lower limbs, accompanied by mild bilateral ptosis. Various markers including procalcitonin, erythrocyte sedimentation rate, C-reactive protein, and myoglobin showed varying degrees of increase. The cerebrospinal fluid (CSF) analysis showed a clear appearance, with no cells and mildly elevated glucose , and elevated protein level . The electromyogram (EMG) revealed slowed nerve conduction velocity and abnormal amplitude in multiple parts of the patient’s upper and lower limbs. Given the acute onset and progression of the disease, and the CSF analysis result showed a typical “albumino-cytologic dissociation” phenomenon, the patient was diagnosed with ICIs-induced GBS by the neurologist. Anti-tumor treatment was ceased and a serious adverse event (SAE) was reported. The patient was excluded from the study and unblinded; it showed that he had been assigned to the KN046 drug group.Initially, the patient was treated with intravenous methylprednisolone of 500 mg and immunoglobulin (IVIG) of 20 g (0.4 g/kg) per day, in accordance with the Guidelines for the management of immune checkpoint inhibitor-associated toxicity 2021 by the Chinese Society of Clinical Oncology (CSCO). Mecobalamin and pregabalin were used together to nourish the nerves and improve the symptoms of weakness and numbness of limbs. However, there was no improvement in the patient’s myasthenia after three days of treatment. Then the patient was given mycophenolate mofetil (MM) capsules 500 mg twice a day. After taking the MM capsules for three days, the patient showed significant improvement in muscle strength, progressing from grade 1 to grade 3, and bilateral ptosis gradually recovered. Methylprednisolone was reduced gradually as the patient’s symptoms improved. After 19 days of treatment, the patient’s myodynamia recovered when he was discharged from the hospital, and the muscle strength of his upper limbs and lower limbs recovered to grade 5 and 4, respectively. The patient was able to walk out of the hospital on his own. The treatment procedure is shown in The use of immune checkpoint inhibitors (ICIs) is highly effective in restoring and enhancing the cytotoxic T cells’ anti-tumor activity. However, overactivation of T lymphocytes can occur systemically and may lead to not only an anti-tumor immune response but also autoimmunity, resulting in various irAEs . A studyGBS is currently classified as an immune-mediated polyradiculoneuropathy, with most patients presenting neurological symptoms after an infective illness . It has We presented a case of GBS which occurred in a 58-year-old male patient with lung cancer, who experienced muscle weakness and numbness in his extremities after the first cycle of treatment with chemotherapy combined with KN046. This patient was diagnosed with ICIs-induced GBS. Notably, antitumor chemotherapy regimens, such as platinum-based agents, taxanes, vinca alkaloids, and thalidomide analogs, can also cause direct neurotoxicity and chemotherapy-induced peripheral neuropathy (CIPN) . These mAccording to the CSCO 2021 guideline on ICIs-associated toxicity, corticosteroids and IVIG are traditional treatments for GBS. The combination of these treatments can improve clinical symptoms of GBS patients by 73% . Plasma GBS is a complex neurological disease, and it takes a long time for patients to relieve from neurological symptoms. Therefore, more effective, affordable, and safer treatments for GBS are urgently needed. Our case report provides valuable insights into effective treatment options for ICIs-induced GBS.In conclusion, we report a rare case of ICIs-induced GBS who didn’t derive benefit from traditional methylprednisolone and IVIG but recovered soon after the adoption of mycophenolate mofetil. It has significant reference to similar ICIs-induced GBS.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.This study was reviewed and approved by the ethics committee of the Second Xiangya Hospital, Central South University. The patient provided his written informed consent to publish in this case report.MD: Writing-original draft. CD: Writing-review and editing. XL, SJ, YG: Validation. DF, YZ, JH: Investigation. CL: Conceptualization and methodology. All authors contributed to the article and approved the submitted version.


Tuberculosis(TB) is among the leading causes of infectious death worldwide. Contact investigation is an evidence-based, World Health Organisation-endorsed intervention for timely TB diagnosis, treatment, and prevention but has not been widely and effectively implemented.We are conducting a stepped-wedge, cluster-randomised, hybrid Type III implementation-effectiveness trial comparing a user-centred to a standard strategy for implementing TB contact investigation in 12 healthcare facilities in Uganda. The user-centred strategy consists of several client-focused components including (1) a TB-education booklet, (2) a contact-identification algorithm, (3) an instructional sputum-collection video, and (4) a community-health-rider service to transport clients, CHWs, and sputum samples, along with several healthcare-worker-focused components, including (1) collaborative improvement meetings, (2) regular audit-and-feedback reports, and (3) a digital group-chat application designed to develop a community of practice. Sites will cross-over from the standard to the user-centred strategy in six, eight-week transition steps following a randomly determined site-pairing scheme and timeline. The primary implementation outcome is the proportion of symptomatic close contacts completing TB evaluation within 60 days of TB treatment initiation by the index person with TB. The primary clinical effectiveness outcomes are the proportion of contacts diagnosed with and initiating active TB disease treatment and the proportion initiating TB preventative therapy within 60 days. We will assess outcomes from routine source documents using intention-to-treat analyses. We will also conduct nested mixed-methods studies of implementation fidelity and context and perform cost-effectiveness and impact modelling. The Makerere School of Public Health IRB(#554), the Uganda National Council for Science and Technology(#HS1720ES), and the Yale Institutional Review Board(#2000023199) approved the study and waived informed consent for the main trial implementation-effectiveness outcomes. We will submit results for publication in peer-reviewed journals and disseminate findings to local policymakers and representatives of affected communities.This pragmatic, quasi-experimental implementation trial will inform efforts to find and prevent undiagnosed persons with TB in high-burden settings using contact investigation. It will also help assess the suitability of human-centred design and communities of practice for tailoring implementation strategies and sustaining evidence-based interventions in low-and-middle-income countries.The trial was registered on 16 November 2022, after the trial launch on 7 March 2022.The online version contains supplementary material available at 10.1186/s12889-023-16510-0. Over 4 million people with active tuberculosis (TB) disease worldwide went undiagnosed in 2021 . SystemaSeveral comparative effectiveness trials have contributed to these efforts. An individually randomised, controlled trial in Brazil found that intensified TB screening among household contacts  decreased TB incidence by 15% over five years relative to usual care without contact investigation . The ZAMHowever, in a comparative meta-analysis of 15 contact investigation implementation projects in programmatic settings in high-burden countries, most involving community health workers (CHWs) and performance incentives, the yield of newly diagnosed persons with TB among all contacts varied widely, from 0.1 to 6.2% . Lower sOne novel approach for developing implementation strategies is human-centred design , also knBecause sustaining complex interventions like contact investigation is a challenge in high-burden, resource-constrained settings , we inclTuli Wamu Nawe (a Luganda phrase meaning “We are Together with You”); and (b) healthcare-worker-centred tools designed to foster the formation of a CHW community of practice. The goal is to improve and sustain standard TB contact investigation delivery following Uganda National TB and Leprosy Programme guidelines. Our primary hypothesis is that the user-centred strategy will result in more close contacts completing TB evaluation and being diagnosed and treated for TB than the standard strategy. We further hypothesise that the user-centred strategy will (1) be more feasible, acceptable, and appropriate for clients and CHWs than the standard strategy, (2) increase self-efficacy and perceived social support among CHWs, and (3) be cost-effective and capable of reducing national TB incidence over a 10-year horizon relative to the standard strategy. We are currently conducting a stepped-wedge, cluster-randomised trial with nested mixed-methods studies to evaluate whether a user-centred strategy targeting clients and implementers can improve and sustain delivery of TB contact investigation in Uganda. Our study has three aims: (1) to determine the implementation, effectiveness, and public health impact of TB contact investigation delivered via a user-centred compared to a standard implementation strategy; (2) to identify processes and contextual factors that influence the implementation, effectiveness, and public health impact of the user-centred implementation strategy; and (3) to compare the costs and epidemiological impact of the user-centred and standard implementation strategies. The user-centred strategy has two parts: (a) four client-centred facilitation tools delivered under the brand name  We are conducting a complete (closed) stepped-wedge, cluster-randomised Type III hybrid implementation-effectiveness trial to determine if a user-centred delivery strategy can improve the proportion of close contacts of people with TB completing TB evaluation . The triUganda is one of thirty WHO-designated high HIV-TB burden countries, with an estimated annual TB incidence of 199 per 100,000 persons and treatment coverage of only 82% . In 2019To select sites for trial inclusion, we reviewed National TB Programme data for all TB units to identify healthcare facilities (1) reporting ≥ 12 new persons with TB per month and (2) located outside but within 180 km of Kampala District. Research staff conducted site visits to verify eligibility by auditing on-site TB treatment registers and to determine the willingness of facility leaders to participate in the trial. We excluded facilities whose administrators declined to participate.To select individuals for inclusion as persons with TB, we are recruiting (1) adults or children recorded as having TB disease in the on-site national TB treatment register, following national contact investigation guidelines , if theyTo select individuals for inclusion as close contacts, we are recruiting adults or children reporting ≥ 12 cumulative hours with the person with TB inside an enclosed space within the previous three months, as per national contact investigation guidelines . We are For the Aim 2 fidelity and context studies, we are directly observing collaborative improvement meetings and conducting demographic and social-behavioural surveys, in-depth interviews, and focus-group discussions with all CHWs delivering the standard and user-centred implementation strategies. Research staff are also purposively sampling 20 persons with TB and 50 close contacts by age, gender, and HIV status for in-depth interviews during the trial intervention periods. For the Aim 3 time-and-motion and costing studies at selected study sites, we are including CHWs and healthcare workers who are 1) ≥ 18 years of age, 2) employed by the study site, and 3) involved in conducting or supervising TB contact investigation at the healthcare facility.According to Uganda national guidelines , healthcThe standard implementation strategy for contact investigation in Uganda is for national TB programme instructors to deliver on-site training on TB contact investigation procedures to TB unit staff, including CHWs, followed by supportive supervision from the National TB Programme district supervisor and on-site focal person during implementation. To prepare for the trial, we ensured that each site had 3–4 CHWs to serve all persons starting TB treatment at that site and provided a monthly salary and travel allowance for site visits at standard local rates. We collaborated with the National TB Programme to deliver the standard training on the national TB contact investigation guidelines to all CHWs and TB unit staff. We also trained all CHWs to accurately record all contact investigation data in the programmatic registers and in electronic case-record forms  using trial-issued electronic tablets. The electronic data collection system includes decision support to prompt CHWs to deliver all contact investigation services . ResearcThe user-centred strategy for implementing contact investigation adds four client-facing and three healthcare-worker-facing components to the standard implementation strategy components of training, supportive supervision, and electronic data collection. We describe these seven components of the user-centred strategy below, including how and why each was selected.Previous studies show that a lack of TB knowledge, anticipated and enacted stigma, cost and travel obstacles, and dissatisfaction with public health services are the main barriers that prevent people with TB and their close contacts from fully participating in contact investigation , 34. To  The final client-facing components of the user-centred strategy consist of four implementation facilitation tools delivered as the branded “Tuli Wamu Nawe” package. These tools include (1) a TB education booklet, 2) a contact identification algorithm, (3) an instructional video on sputum collection, and (4) a community health rider (CHR) service staffed by commercial motorcycle taxi drivers who transport clients, CHWs, and sputum samples at no cost to users. Finally, to help clients recognise and trust different members of the contact investigation team, CHWs and CHRs carry identification cards and uniforms . These are imprinted with a small Tuli Wamu Nawe graphic logo depicting two Marabou storks, a beloved local bird species in Uganda, flying in tandem in front of a sunrise  before diagnosis. During the HCD process, designers observed and heard from CHWs that contact enumeration was a particular challenge. The algorithm aims to identify more close contacts per household and do so earlier in the contact investigation process to facilitate efficient planning of community visits and to improve the public health yield, a particular need given the high costs of contact investigation .Formatted for display to clients on provider tablets or phones, the sputum collection video provides standardised instructions and encouragement to help contacts overcome the anticipated stigma associated with sputum expectoration  and learCommunity Health Riders (CHRs) are commercial motorcycle-taxi drivers paid to transport CHWs, persons with TB, and close contacts to and from the community at no charge. Developed during the human-centred design process, the CHR concept adapts and expands the “hub-rider” model used to transport TB specimens between healthcare facilities to overcome the barriers CHWs face in finding and reaching households and linking contacts to clinics , 34. HeaThe three healthcare-worker-facing components of the user-centred contact investigation strategy were selected as activities previously shown helpful in fostering a CHW community of practice for implementing contact investigation . These cCollaborative improvement meetings take place weekly, rotating through several formats. These include internal meetings of each site’s CHWs and CHRs, virtual meetings  with external CHWs and CHRs at a paired implementation site, and in-person meetings of CHWs and CHRs with other healthcare workers at their own site. Each type of meeting seeks to review implementation performance, identify challenges, and brainstorm solutions. CHWs may also organise structured didactics on best TB care practices led by TB focal persons and other clinicians.Starting during cross-over, an unblinded data manager prepares weekly individual-level and monthly facility-level reports on CHW and CHR performance at each step of TB contact investigation. These reports are electronically delivered to a secure, password-protected server  on CHW tablets for group review during collaborative improvement meetings. Drawing on evidence from behavioural economics about promoting cooperation in groups , the repAt cross-over, we will connect all CHWs and CHRs at each health facility and their supervisor, the local TB focal person, on a local WhatsApp chat group. The goal is to facilitate coordination of client care, exchange of technical assistance, shared accountability, and social support outside the collaborative improvement meetings. The schedule of procedures for the standard and user-centred strategies is summarised in Table We selected three expert CHWs from non-trial sites to deliver the trainings at the start of each eight-week transition period. CHWs were chosen for their excellent communication skills and prior experience with the user-centred implementation strategy during the live prototyping phase of the human-centred design work. Before the first transition period, research staff led a training of trainers for the expert CHWs requiring 24 contact hours over one month. Each transition period begins with a three-day in-service training in an off-site classroom setting near the healthcare facility led by the regional and district TB supervisors for that site, two research staff, and one expert CHW. All CHWs (3–4 per site), all CHRs , TB unit staff, and at least one representative each from the laboratory, the HIV unit, and the facility administration are required to attend. The curriculum includes process mapping, interactive didactic sessions, engaging printed materials, short videos, and role plays on contact investigation and the user-centred strategy. On days 4–10, the expert CHWs move to the site with the trainees for peer-mentored co-enrolment, including supportive supervision and daily debriefing sessions to streamline processes and agree on key learnings. Research staff are also on-site for support. CHWs and CHRs graduate to independent enrolment after they have been observed going through the entire process of user-centred delivery of contact investigation and have performed satisfactorily.After the initial 10-day training, CHWs and CHRs proceed with independent enrolment while the expert CHWs and research staff move to train the second site for that transition period. After two weeks, the trainers return to debrief with the CHWs and CHRs and introduce the concept of communities of practice. Trainers participate in the subsequent collaborative improvement meetings to address operational challenges, provide mentoring on directing discussion, and observe trainee progress. Mentoring continues in-person and remotely until the end of the transition period or when the training team decides the trainees are ready for independent implementation and all training activities and site visits end.We hosted a public randomisation ceremony in Kampala, Uganda, on 11 February 2022. We used sequential random drawing to randomly allocate the order in which participating healthcare facilities would transition to the user-centred strategy , we will determine the proportion of contacts diagnosed with active TB and initiated on active TB treatment and the proportion of contacts initiating TB preventative therapy (TPT) within 60 days of the index person with TB’s treatment initiation date. Second, to measure public health effectiveness, we will determine the counts of contacts diagnosed with active TB and of those initiating TPT. Third, as measures of public health efficiency and timeliness, we will measure the proportion of all persons diagnosed with TB who are contacts and the time to completion of contact evaluation. We will compare these outcomes during the standard and user-centred implementation periods and determine the between-period differences, testing the null hypothesis that there is no difference between periods. Finally, the hybrid implementation-effectiveness outcomes structure draws on the RE-AIM Evaluation Framework , and add A SPIRIT flow diagram for the trial is provided in Fig. For Aim 2 fidelity and context outcomes, the research team will administer surveys and conduct qualitative interviews and focus group discussions. These will be audio-recorded, professionally transcribed and translated, and securely stored for analysis. Any personal health identifiers disclosed during the interviews will be removed and names replaced by numbered aliases in the final transcripts. We will store all audio files and de-identified transcripts from qualitative data collection on a secure password-protected network and destroy audio files once transcription is complete. For the Aim 3 costing studies, CHWs will collect time and motion data, and research staff will collect other costing data from facility administrators. We will de-identify all data prior to analysis.Power and sample size calculations for the stepped-wedge, cluster-randomised trial assume two levels of clustering; first, persons with TB nested within health facilities and second, contacts nested within persons with TB. We estimated the intraclass correlation coefficient (ICC) for each level. Drawing on pre-trial empirical data collected at the 12 trial health facilities between 1 January 2022 and 6 March 2022, we conservatively project an average of 11 persons with TB per facility per 8-week block period and an average of one symptomatic contact person per index person with TB. We further assume that 20% of symptomatic contacts in the pre-intervention period and 40% in the post-intervention period will achieve the primary trial outcome of completing TB evaluation. Based on pre-trial data, we estimated an ICC of 0.172 at the facility level and an ICC of 0.647 at the level of index persons with TB. Allowing for two facilities to cross over at each step, six cross-over steps, and 924 symptomatic contacts during the study period, we will have a power of 99% to detect a ≥ 20% increase in the primary outcome. We have estimated this sample size and power using PASS 15  and Stata 16  with an extension to account for multiple levels of clustering , 44. BecThe primary analysis will compare the pre- and post-implementation periods, excluding the first eight weeks after transition as a buffer period and the 14 weeks after the announcement of Ebola Virus Disease-related public health restrictions. We will consider the intention-to-treat population only; a per-protocol analysis is not feasible given the site-level nature of the intervention exposure and the lack of granular individual-level fidelity data. Because the primary implementation effectiveness outcome and the secondary clinical effectiveness outcomes are proportions, we will use modified mixed-effects Poisson generalised linear models to determine prevalence risk ratios (PRRs) or proportion ratios (PRs) between the post- and pre-implementation exposure periods. We will use mixed-effects Poisson models for the count outcome of public health effectiveness. For time-to-event outcomes, we will use mixed-effects parametric survival analysis models.If secular trends are present, we will collapse individual-level data at health facility and cluster levels by trial month. We will estimate the difference in the primary outcome by comparing the pre- and post-implementation periods using aggregated data. We will consider a random-effects logit model, or a random-effects generalized estimating equations (GEE) model, allowing cluster-level aggregated data to vary across time by cluster. The multivariable model will include cluster-level covariates. We will test various correlation structures and select the final model using likelihood-ratio tests and information criteria.In the absence of secular trends requiring an aggregated analysis by site and month, additional adjusted analyses will consider outcome differences by age, sex, HIV status, site, and site characteristics, including health centre level, location, and district-level gross-domestic product. We will adjust for trial period as appropriate for stepped-wedge trial analysis. In the presence of secular trends, adjusted analyses will consider age, sex, HIV status, and any other baseline characteristics found to be imbalanced between the pre- and post-implementation periods.The Yale School of Public Health will serve as the study coordinating centre, with Amanda Gupta as the data manager and Noah Kiwanuka and Suzan Nakasendwa as trial statisticians. The Trial Steering Committee includes Mari Armstrong-Hough, Raymond Byaruhanga, Adithya Cattamanchi, David Dowdy, Jessica Haberer, Moorine Sekadde, and Erez Yoeli, and oversees the decisions of the principal investigators, J. Lucian Davis and Achilles Katamba. Given the low-risk behavioural nature of the implementation strategy being evaluated, no data monitoring committee is appointed and no trial audits or interim analyses are planned.Adverse events occurring after enrolment in contact investigation will be reported to the trial investigators within 24h of initial disclosure and reported to the IRBs within two working days. The IRBs will have the authority to determine if the trial needs to be paused or terminated. No protocol amendments are planned once the trial commences. If an amendment is required based on safety or other indication, we will immediately notify the IRBs. Relevant changes to the study protocol will be communicated to all shareholders as needed after IRB approval.This protocol and the consent forms  was initiated on 16 November 2022, inadvertently exceeding the 30-day timeframe advised by the International Committee of Medical Journal Editors due to an oversight by the principal investigator. The authors acknowledge that late registration constitutes a methodological limitation. However, the authors note that late registration is unlikely to result in biased reporting in this circumstance, for several reasons. First, this is a protocol manuscript for a not-yet-completed trial, so the trial analysis cannot be changed. Second, the trial is powered to detect the minimum clinically important difference in the trial outcome across all realistic scenarios of enrolment, reducing any incentive to alter the trial design after the start. Third, because the trial is a complete stepped-wedge, cluster-randomized implementation trial, its sample size is fixed by the duration of the enrolment period and cannot be changed after the trial starts. Last, this is a trial of a social and behavioural intervention, reducing any financial incentive to delay registration.The three pillars of the WHO END TB strategy are Integrated, Patient-Centred Care and Prevention, Bold Strategies and Supportive Systems, and Intensified Research and Innovation. This pragmatic, stepped-wedge cluster-randomised implementation trial leverages all three of these pillars, including novel and interdisciplinary implementation research methods; community-engaged co-design method to tailor delivery strategies that support community members and healthcare workers; and integrated person-centred TB diagnostic, treatment, and prevention services.This ongoing trial has several strengths that enhance its novelty and rigor. First, the tailored, multi-component implementation strategy was developed using human-centred design and targets both client and healthcare-worker barriers to uptake and completion of TB contact investigation . Second,The trial also has some potential limitations. The stepped wedge trial design increases the study’s vulnerability to secular trends, such as enrolment and recruitment interruptions related to a recent Ebola Virus Disease outbreak in Uganda. In addition, this trial is vulnerable to several additional challenges for power estimation and analysis common to stepped-wedge trials conducted in real-world settings, including small and imbalanced cluster-sizes; clustering at multiple levels; and rare outcomes, especially in usual care periods . A key oIn conclusion, the proposed pragmatic, quasi-experimental implementation trial will inform efforts to find and prevent undiagnosed persons with TB in high-burden setting using contact investigation. It will also help assess the suitability of human-centred design and communities of practice for tailoring strategies to implement and sustain evidence-based interventions in Uganda and other low-and-middle-income countries.Additional file 1.Additional file 2.


To examine the feasibility, acceptability, and preliminary efficacy of a positive affect skills intervention for middle-aged and older adults with fibromyalgia syndrome (FMS).n = 49) or (b) emotion reporting/control (n = 46). LARKSPUR included 5 weeks of skill training that targeted 8 skills to help foster positive affect, including (a) noticing positive events, (b) savoring positive events, (c) identifying personal strengths, (d) behavioral activation to set and work toward attainable goals, (e) mindfulness, (f) positive reappraisal, (g) gratitude, and (h) acts of kindness. Outcome data were collected via online surveys at baseline, postintervention, and 1-month follow-up.Ninety-five participants with FMS aged 50 and older  were randomized to 1 of 2 conditions: (a) Lessons in Affect Regulation to Keep Stress and Pain UndeR control  = 1.49; control: M = 8.59, SD = 1.97). Improvements were greater in LARKSPUR participants compared with control participants on measures of positive affect , negative affect , and pain catastrophizing . Improvements in positive affect  and negative affect  were maintained at 1-month follow-up. Dose–response analyses indicated that intervention engagement significantly predicted pre-to-post and post–to-follow-up reductions in pain catastrophizing.Completion rates (88%) and satisfaction ratings  were high (LARKSPUR: The current preliminary findings add to existing literature and highlight the specific potential of internet-delivered positive affect skills programs for adults with FMS.NCT04869345. Translational Significance: This study demonstrates the feasibility, acceptability, and preliminary efficacy of an internet-based intervention program to support positive affect skills training among middle-aged and older adults living with fibromyalgia syndrome (FMS). Findings indicate that for individuals with FMS, augmenting positive affect may be crucial for optimizing the effects of interventions in real-world settings. These findings are of interest to primary health care providers who serve vulnerable older adult populations, whose physical impairment and chronic pain may make access to traditional face-to-face clinical care difficult.Fibromyalgia syndrome (FMS) is a chronic pain disorder characterized by widespread musculoskeletal pain, fatigue, impaired sleep, and cognitive dysfunction . DepressIncreasing evidence suggests that positive affective states  play a unique role in promoting adaptive functioning in the face of chronic pain . PositivAlthough evidence to date supports the use of PPIs in the treatment of chronic pain , implemeTo date, RCTs of internet-delivered pain management programs have focused on individuals with a diverse range of pain-related disorders, with few interventions examining subgroups of individuals with specific pain conditions, such as FMS, and none targeting enhancement of PA see . FosteriTo address these gaps in the literature, the primary objective of this study was to report findings from a novel pilot intervention, Lessons in Affect Regulation to Keep Stress and Pain UndeR control (LARKSPUR). This intervention was designed to increase PA and reduce pain and fatigue in adults with chronic pain. This study reports the main analysis examining the feasibility, acceptability, and preliminary efficacy of the LARKSPUR clinical trial in adults with FMS, a chronic pain population with known physical impairments and deficits in positive emotional responses . Dose–reThe LARKSPUR pilot  has been described elsewhere . BrieflyIndividuals randomized to the LARKSPUR group received skills training to increase PA. The online intervention was self-guided and targeted eight PA skills over five weekly learning modules. The eight skills included (a) noticing positive events ; (b) savThe control program included daily emotion reporting during the 5-week intervention period. The daily emotion reports consisted of ratings of positive and negative emotions during the past 24 hr and were similar to those used in previous studies of positive psychology interventions . The purParticipants in both arms were assessed at baseline, postintervention, and follow-up. In addition, immediately before (baseline) and after the intervention (postintervention), and at 1-month follow-up, participants completed a 7-day burst of online daily positive and negative emotions. Participants were compensated for their time and incentivized to remain in the study with gift cards: $75 for baseline, postintervention, and follow-up assessments; $42 for the diary assessments ($2 each for 21 days); and $25 for postintervention feedback. The study procedures were reviewed and approved by the Institutional Review Board (IRB) at Weill Cornell Medicine.The PA-skills intervention on which LARKSPUR is based was developed by J. Moskowitz (R34AT009685) and has been widely tested by her team in multiple studies with more than 1,000 participants (ages 16–78) coping with various life stressors—from diagnosis with a serious illness to normative daily stress , 2017. TData were collected from 95 participants, ranging in age from 50 to 80 years old. The majority were female (94%) and identified as White (80%). Participants were recruited from July 2021 to June 2022 through referrals from NYS practicing physicians, posted flyers throughout the New York Presbyterian Healthcare System, New York City-based senior centers, community centers, and online platforms . Recruitment links were also posted on clinicaltrials.gov, and emailed to potential participants via ResearchMatch, a national health volunteer research registry created by several U.S.-based academic institutions and supported by the U.S. National Institutes of Health.definitely not to 10 = definitely yes.The primary outcomes included feasibility and acceptability. Feasibility was assessed through recruitment, retention, engagement, and adherence. Engagement with the intervention was assessed for the LARKSPUR group using the number of completed daily home practices during the intervention window, the number of weeks to complete all daily home practices at least once, and intervention skill completion. In addition, adherence was assessed by examining the number of daily check-ins completed for both the LARKSPUR and control groups. Acceptability was assessed at postintervention. Participants were asked to provide feedback on perceived helpfulness, usability, and overall satisfaction with the program. Participants were also asked to rate how much they would recommend the program to someone else with chronic pain using an 11-point Likert scale, ranging from 0 = At baseline, immediately postintervention, and 1 month after intervention completion, participants were asked to complete measures of pain characteristics  and physical functioning .Pain intensity and pain interference were measured by the PROMIS-SI and PROMIS-PI scales. The PROMIS-SI included 3 items that asked participants to rate pain intensity over “the past 7 days” and “right now” using a 0 = no pain to 4 = very severe rating scale  .le (PCS) . The PCSPhysical functioning was assessed using the PROMIS-PF  (never to 4 = most of the time.e (mDES) . The 20-Because the primary aim of this pilot study was to establish the feasibility and acceptability of the methods and procedures to be used in a larger, fully powered trial of LARKSPUR, the sample size was chosen based on feasibility indicators rather than formal power calculations for tests of between-group differences . Additiop values: highest posterior density intervals (HPDs) and posterior probabilities of direction (pd). Bayesian HPDs, like CIs, describe uncertainty around effect estimates. HPDs, however, have an intuitive interpretation (pd) for each effect or parameter was computed using the bayestestR software package  and pre-to-post intervention effects that were at least small (Cohen d > 0.15) were considered feasible to assess the effects of the intervention in a larger trial.Given this is a pilot study, we used Bayesian estimation rather than traditional frequentist methods because Bayesian statistics are better suited for modeling longitudinal data with relatively small sample sizes . Bayesiaretation . Specifiretation . For exa package . The pd p values . Unlike vals see , we usedFailure to account for measurement error across assessment points can result in imprecise and biased parameter estimates and intervention effects e.g., . In the brms software package (d) for the within-group changes and between-group differences in change with corresponding posterior intervals. For completeness, we also present between-group differences within each assessment point as effect sizes with corresponding posterior intervals.Preliminary efficacy outcomes were assessed using intention-to-treat analyses for all participants providing data at baseline and at least one of the postintervention or follow-up assessments. Data were modeled using longitudinal mixed-effects models  and esti package . Treatmeft) defined as the sum of (a) the latent score at the previous occasion (ft−1) and (b) the latent difference .Past research demonstrates that the frequency with which participants engage in intervention exercises significantly predicts better pain outcomes e.g., . To teste points . We focuThe LCSM provides multiple advantages for analyzing longitudinal data in randomized trials see . First, lavaan software package  or the control  included 43 control participants  and 43 LARSPUR participants , as shown in Of 142 individuals screened for participation, 95 were eligible and enrolled in the study. All 95 participants completed the baseline questionnaires and were randomized to LARKSPUR intervention (IQR = 0.16). Intervention skill completion was near perfect , and the median number of completed daily home practice exercises was 173 (IQR = 122), or nearly five exercises per day, indicating high intervention engagement. Overall adherence (as measured by completion of daily check-ins) was moderate; the median number of daily check-ins was 25  within the 35-day intervention period. At the postintervention assessment, LARKSPUR participants rated the intervention favorably on an 11-point Likert scale (0 = definitely no to 10 = definitely yes). Participants were very likely to recommend LARKSPUR to a friend  and very likely to recommend LARKSPUR to someone with chronic pain .Feasibility  and acceptability are summarized in d) of the preliminary efficacy measures at each assessment point. Planned contrasts suggested that the LARKSPUR group improved significantly from baseline to postintervention on PA, pd = 100% and NA, pd = 97.34%. Furthermore, improvements in PA (pd = 100%) and NA (pd = 99.98%) were maintained at the 1-month follow-up assessment for the intervention group. In the control group, a significant decrease in PA was found at postintervention (pd = 97.34%) that was maintained at 1-month follow-up (pd = 97.34%). Notably, LARKSPUR led to larger improvements in PA (pd = 100%) and NA (pd = 98.48%) than control, and these improvements were maintained at 1-month follow-up . pd = 100%), PROMIS-SI (pd = 99.21%), and PROMIS-PI (pd = 98.22%) for the intervention group. Improvements were maintained at 1-month follow-up for PCS (pd = 100%) and PROMIS-SI (pd = 94.48%) but not for PROMIS-PI (pd = 88.71%). Pre-to-post reductions in the control group were also found on the PCS (pd = 100%) and PROMIS-SI (pd = 93.84%) but not on PROMIS-PI (pd = 81.87%). As shown in pd = 99.08%). However, improvements in pain catastrophizing were not maintained at the 1-month follow-up. No significant time-by-condition effects were found at postintervention or 1-month follow-up for pain intensity and pain interference.Mixed-effects analyses revealed significant pre-to-post reductions in the PCS (pd = 99.91%) and PROMIS-F (pd = 99.75%), and these improvements were maintained at 1-month follow-up . Improvements from pre-to postintervention were also observed among control participants on these measures , which were also maintained at 1-month follow-up . For physical functioning (PROMIS-PF) and fatigue measures (PROMIS-F), no significant time-by-condition effects were found at postintervention or 1-month follow-up.LARKSPUR participants improved significantly from baseline to postintervention on PROMIS-PF  and post-to-follow-up  changes. Specifically, PCS scores decreased from baseline to postintervention  increase in engagement) and these changes were maintained at 1-month follow-up. For PA and NA, engagement did not predict pre-to-post  or post to follow-up  changes, although slope coefficients for both measures were in the expected direction.We examined intervention “dose” or engagement using the number of daily home practices completed. Results from LCSM indicated that engagement within the LARKSPUR intervention significantly predicted improvements in PCS, but did not predict improvements in PA or NA. For PCS, results suggested that engagement significantly predicted pre-to-post  a focus on FMS, a chronic pain population with known deficits in PA; (b) a self-paced intervention delivered online; (c) use of an active, attention-matched control condition rather than a wait-list control; (d) high participant retention and engagement; (e) low loss to follow-up; (f) use of measures with strong known psychometric properties; (g) inclusion of a measurement-burst design to assess dynamic changes in PA; (h) Bayesian methods to assist in the interpretation of significance thresholds in pilot trials, and finally (i) use of LCSM to evaluate dose-response effects of intervention engagement.The current study provides initial, strong evidence supporting the feasibility of using an online PA-skills intervention with individuals with FMS. The study design and procedures were successful in enrolling, engaging, and retaining participants in the trial. Satisfaction with the program was high, and nearly all participants in the intervention arm reported feeling confident in recommending the program to friends or people with chronic pain. The high levels of engagement and satisfaction, combined with the lack of adverse reactions and low loss to follow-up, provide evidence of the acceptability of LARKSPUR as a relatively low-intensity online PA intervention for people with FMS.Overall, although adherence (as measured by completion of daily check-ins) was moderate, engagement  was good. Feedback from participants revealed the need for assistance overcoming barriers to completing the intervention, such as difficulties practicing multiple skills within a week and difficulties completing the intervention when fatigue and pain levels were high. These comments suggest that additional attention should be given to strategies for optimizing program delivery . Overall, the findings are consistent with the prior literature, which has demonstrated the value of PA-skills training in populations coping with chronic or severe health conditions e.g., , and extResults were promising with respect to the effects of LARKSPUR on preliminary efficacy outcomes. Within-person changes from baseline to postintervention indicate treatment benefits across all outcomes assessed. Moreover, improvements in PA, NA, pain catastrophizing, pain intensity, physical functioning, and fatigue were maintained at the 1-month follow-up for the intervention group. These results are particularly encouraging in that they indicate the potential of a nonpharmacologic intervention to improve symptom management in a patient population with moderate-to-severe pain. Participants in the control group also reported pre-to-post improvements in pain catastrophizing, fatigue, and physical functioning and pre-to-follow-up improvements in pain catastrophizing. Although within-group benefits were found across outcomes, between-group differences favoring the LARKSPUR group were found only on pre-to-post PA, NA, and pain catastrophizing measures. We did not assess outcomes during the intervention window to reduce participant burden, and it is possible that this pragmatic design choice resulted in reduced estimates of efficacy. Studies that use intensive longitudinal designs  to capture variations in pain and physical functioning  during td > 0.15), the findings from the current pilot trial indicate that all outcome measures except for those assessing NA would be appropriate and feasible. The LARKSPUR intervention may simply not be effective in reducing NA (Cohen d = −0.04). This is consistent with findings that among people newly diagnosed with HIV, a PA intervention resulted in no significant reductions in NA (d = −0.28 to −0.50) and physical functioning (d = 0.29 and −0.36) in this study were comparable to those reported in a recent meta-analysis of internet-delivered interventions for chronic pain (d = 0.15) in this study. One potential reason for this small effect is that the control condition, which involved emotion reporting, may have had an active ingredient that improved PA  to explore the extent to which outcomes could be attributed to PA enhancement versus NA minimization . We did The results of this 6-week pilot study support the feasibility, acceptability, and preliminary efficacy of an internet-delivered PA-skills intervention in individuals with FMS. Sustained improvements in daily emotional functioning were demonstrated, whereas effects on pain and physical functioning were more limited. The study further demonstrated the feasibility of engaging and retaining people with FMS through an online-delivered intervention. A larger, fully powered RCT is warranted to advance understanding of underlying theoretical mechanisms, effects on longer-term outcomes, and benefits across clinical and demographic subgroups.


Xanthomonas, a Gram-negative bacterium, belonging to the class Gammaproteobacteria, can infect more than 400 different plants including a wide variety of important crops such as rice, wheat, citrus, tomato, pepper, cabbage, banana, and bean  and X. oryzae pv. oryzicola (Xoc) are the causal agents of bacterial blight and bacterial leaf streak of rice, respectively, which are two severe diseases affecting rice production and quality in tropical and subtropical regions. Moreover, X. campestris pathovars cause diseases in a range of crops. The articles in the Research Topic on the pathogenic mechanisms and biocontrol of Xanthomonas on plants explore the diversity, virulence factors, and potential management of Xanthomonas. The results provide a broader insight into Xanthomonas pathogenicity in relation to host specificity and spread, and the alternative protection strategies of plants.and bean . Some de species . For exaXanthomonas diversity has been largely investigated through genome sequencing and characterized using advances in omics tools , which is one of the major diseases affecting rice production. Song et al. employ whole-genome sequencing to explore the diversity and evolution of Xoo in the main rice-growing areas of China over the past 30 years. They reveal six lineages including CX-1 to CX-6, in which CX-5 and CX-6 were the most prevalent across all studied areas. Recent sporadic disease outbreaks have been primarily caused by Xoo isolates derived from lineages CX-5 and CX-6. The rapid virulence evolution of Xoo against rice is analyzed using large-scale virulence tests and is correlated to the genetic background of Xoo, rice resistance genes, and the planting environment of rice. The population genomic study together with a large-scale virulence evaluation of Xoo may help build durable resistance and management strategies against this pathogen.cs tools . Xoo cauDrehkopf et al. demonstrate the existence of the T4S systems in the tomato and pepper pathogen X. euvesicatoria, which is the only known plant pathogen with a VirB/VirD4- and an Icm/Dot-like T4S system. The VirB/VirD4 T4S system acts as a conjugation system for plasmid transfer between X. euvesicatoria strains and shares substrate specificity with the Icm/Dot system which serves as an additional protein delivery system. VirB/VirD4 T4SS in X. citri provides strains with the ability to kill other Gram-negative bacteria in a contact-dependent manner  systems are multiprotein complexes that deliver DNA, effectors, and protein–DNA complex to the extracellular milieu or into the eukaryotic and prokaryotic target cells . Drehkopt manner , but theXanthomonas increasingly depend on the application of microbial biocontrol agents, or microbiome engineering. The diffusible signal factor (DSF) family is an important type of quorum sensing (QS) signal found in diverse Gram-negative bacteria and mediates intraspecies, interspecies, and inter-kingdom communication (X. campestris elicits innate immunity in plants and is suppressed by the exopolysaccharide xanthan (X. campestris pv. campestris (Xcc) can suppress pathogen-associated molecular pattern-triggered immunity (PTI) in Arabidopsis thaliana  of DSF could prime plant immunity against Xcc when interacting with plants and is mediated by the jasmonic acid signaling pathway. The finding provides new insight into the function of DSF and an alternative strategy for the control of black rot in plants.The biocontrol strategies used for nication . It has  xanthan . Howeverthaliana . Zhao etBacillus strains are always effective and reliable alternatives to develop as a microbial pesticide to fight against Xanthomonas , which causes bacterial spots on stone fruits. They also report that direct bioautography is a fast and suitable method for screening anti-Xap components of complex matrices. The study offers a possibility that EOs could be used to control plant disease caused by Xap.Essential oils (EOs) or EO-based products are promising candidates for being used as biocontrol agents due to their broad-spectrum activity against fungi, bacteria, viruses, pests, and weeds, and are environmentally friendly and economically viable . EOs havl canker . Nagy etXanthomonas spp. cover a variety of plant pathogens that utilize a wide range of virulence factors for pathogenicity and fitness in plant hosts. This Research Topic presents the latest research and perspectives on the diversity and pathogenicity of Xanthomonas and its potential biological control agents. This Research Topic will provide researchers with the opportunity to advance perspectives on the pathogenic mechanism and biocontrol of Xanthomonas.YZ: Writing – original draft. PL: Writing – review & editing. S-WH: Writing – review & editing. FL: Funding acquisition, Supervision, Writing – review & editing.


Li et al. construct a nomogram based on the five variables  for predicting 90-day mortality in CTD-ILD with pneumonia patients using machine learning. Recent studies have proposed some mechanisms involved in the occurrence and development of ILD, such as pro-inflammatory and/or pro-fibrotic immune cells and cytokines, impaired endothelial cells, and fibroblast dysfunction  is also the most common manifestation of connective tissue diseases (CTD), including rheumatoid arthritis (RA), systemic sclerosis (SSc), and polymyositis (PM) or dermatomyositis (DM). Decreased lung function and worsening respiratory symptoms are common factors of death in CTD-ILD patients, which are caused by progressive lung fibrosis. Although multiple clinical trials have shown that nintedanib and pirfenidone are safe and effective in the treatment of CTD-ILD, patients with CTD-ILD who receive glucocorticoids or/and immunosuppressants are more likely to suffer from pulmonary infections. function . This ReYu et al. analyze the association between CHI3L1 and the presence of RA-ILD, and they find that serum CHI3L1 levels were significantly higher in RA-ILD patients and had the ability to assist in the diagnosis of ILD in RA patients. Therefore, exploring new markers will facilitate early diagnosis of the disease. Iguratimod (IGU), which has novel anti-inflammatory and immunomodulatory properties, was developed as a new antirheumatic drug and was approved for active RA in China and Japan. IGU inhibits the production of immunoglobulins, autoantibodies, and various inflammatory cytokines , and osteoclastogenesis. Recent studies have shown that IGU also has anti-fibrotic effects  and is better than csDMARDs, with a higher response rate in RA-UIP patients. These results indicate that IGU not only suppresses the disease activity but also subsequently blocks subsequent fibrosis progression.RA is a chronic systemic autoimmune disease that can cause progressive articular and extra-articular damage, and ILD is the most common extra-articular manifestation of RA and its prevalence was reported to be up to 60% during the disease course . Importa effects . In thisQian et al. evaluate the expression of IFN-stimulated genes to determine the IFN-I score and find that the IFN-I score is a valuable tool to monitor disease activity and predict mortality in patients with anti-MDA5+ DM., Tofacitinib has consistently been used in the treatment of anti-MDA5+ DM-ILD by inhibiting the IFN-I signaling pathway  . Because pathway . However pathway . In addiCollectively, the original research in this Research Topic covers a series of important aspects in the field of disease markers for and clinical management of CTD-ILD which may provide new insights into its diagnosis and treatment.LD: Writing – original draft, Writing – review & editing. YY: Writing – original draft, Writing – review & editing. XZ: Writing – original draft, Writing – review & editing.