In this work, we describe the CRIMSON (CardiovasculaR Integrated Modelling and SimulatiON) software environment. CRIMSON provides a powerful, customizable and user-friendly system for performing three-dimensional and reduced-order computational haemodynamics studies via a pipeline which involves: 1) segmenting vascular structures from medical images; 2) constructing analytic arterial and venous geometric models; 3) performing finite element mesh generation; 4) designing, and 5) applying boundary conditions; 6) running incompressible Navier-Stokes simulations of blood flow with fluid-structure interaction capabilities; and 7) post-processing and visualizing the results, including velocity, pressure and wall shear stress fields. A key aim of CRIMSON is to create a software environment that makes powerful computational haemodynamics tools accessible to a wide audience, including clinicians and students, both within our research laboratories and throughout the community. The overall philosophy is to leverage best-in-class open source standards for medical image processing, parallel flow computation, geometric solid modelling, data assimilation, and mesh generation. It is actively used by researchers in Europe, North and South America, Asia, and Australia. It has been applied to numerous clinical problems; we illustrate applications of CRIMSON to real-world problems using examples ranging from pre-operative surgical planning to medical device design optimization. ad hoc  workflow decisions. CRIMSON’s specialisation deals with these problems, as well as presenting a number of unique features which are unavailable elsewhere.We provide the first full presentation in the literature of CRIMSON, the Cardiovascular Integrated Modelling and Simulation Package. CRIMSON consists of a graphical user interface desktop computer program for creating geometric models of blood vessels from medical imaging scans, specifying parameters such as the stiffness of the artery walls, the resistance of connected vessels which are not visible on the scans, and determining the appropriate parameters for all aspects of the model. CRIMSON additionally consists of the Flowsolver, a high-performance computing package which simulates the flow of blood through the models created in the graphical user interface. Whilst several packages which can simulate blood flow exist, most target general fluid simulations, and this lack of specialisation means that blood flow simulation is harder to perform, and can require  One of the revolutionary successes of twentieth century in applied mathematics is the development of the finite element method (FEM) into a reliable engineering tool. It is now routinely deployed by practitioners in fields where the problems of interest are described by systems of partial differential equations (PDEs). FEM, in combination with high-performance computing (HPC), has enabled solution of these systems of PDEs rapidly and accurately.computational haemodynamics (CH).In the present work, FEM is applied to the incompressible Navier-Stokes equations in patient-specific vascular geometries. This enables analysis of clinically-relevant blood flow phenomena including the impact of the geometry, vascular wall properties, or prospective surgical decisions on blood pressure, wall shear stress, and mass (e.g. protein or drug) transport. These capabilities support the key applications of surgical planning, patient diagnosis, medical device design and optimisation, and basic cardiovascular disease research. Such applications are collectively called A serious factor limiting widespread adoption of CH has been the arcane and unwieldy nature of existing academic software packages and workflows, coupled with the fact that no commercial package truly supports cutting-edge CH. Specifically, key aspects of the computational modelling workflow have been done in a manual fashion, resulting in cumbersome, manual workflows. This is error-prone and non-systematic. Examples of such operations are: parameter estimation, application of physiologically-relevant boundary conditions such as PC-MRI informed velocity profiles, and the ability to simulate physiologically-varying conditions.CardiovasculaR Integrated Modelling and SimulatiON).More generally, and due in part to the patchwork nature of academic software development involving multiple researchers with differing goals over many years, simulation workflows often require using multiple pieces of software and ad-hoc scripts. One pathway to addressing this issue is specialised, problem-specific commercial enterprise. For example, HeartFlow Ltd. provides CH-as-a-service for diagnosis of coronary artery disease, taking medical imaging data and producing computational clinical reports on the hemodynamic significance of coronary lesions. In their workflow, medical image data are uploaded to the HeartFlow servers, and a report is returned to the clinician . HoweverCRIMSON consists of two components. The first is the CRIMSON GUI, which is a Windows application for setting up simulations via segmenting medical image data, creating finite element meshes, assigning boundary conditions, and examining results. The second component is the CRIMSON Flowsolver, which is a Message Passing Interface (MPI) parallel application, scalable to tens of thousands of cores , which cThe conceptual ancestor of CRIMSON is SimVascular , which hBeyond making the basic workflow as user-friendly as possible, CRIMSON has several unique features which enable novel simulation capabilities. For example, CRIMSON allows users to implement–at run-time–arbitrary rules for adjusting boundary condition parameters during simulations, based upon the simulation state. This allows modelling of cardiovascular control mechanisms, and transitional hemodynamic states–for example, between rest and exercise . FurtherThe CRIMSON workflow, from medical imaging data to simulation results, is shown in The CRIMSON GUI is built upon MITK, which provides tools to load, visualize and manipulate medical image data. A screenshot of CRIMSON during the Geometric Modelling portion of the workflow is shown in BCs are subsequently assigned, including upstream or downstream vascular reduced order models. The vessel walls can be modelled as rigid or made deformable via a coupled momentum method, making use of a linear elastic constitutive membrane model for the vessel wall , and spaThe CRIMSON Flowsolver consists of a core Fortran FEM solver, based on PHASTA  and closTo assist with BC design, CRIMSON provides the Netlist Editor Boundary Condition Toolbox (NEBCT), shown in https://crimsonpythonmodules.readthedocs.io/en/latest/). For example, a Solver Setup has been written for the CHeart fluid solver [The CRIMSON GUI embeds another Python interpreter, which enables functionalities ranging from script-based specification of the local vessel wall thickness and elastic modulus, to definition of Python “Solver Setup” modules; this permits straightforward customization of the CRIMSON GUI’s interface widgets and output files, providing a pathway to compatibility with different fluid solvers. Thus, research groups may write their own Solver Setup to generate simulation files for their own simulation software; the procedure is documented online  highlighting specific aspects of CRIMSON’s capabilities, followed by an example demonstrating the entire workflow (Case C). In Case A, we demonstrate some of the fundamental features of CRIMSON, including running Navier-Stokes simulation in a patient-specific aortic model. In Case B, we demonstrate segmentation of PC-MRI data to create a patient-specific aortic inflow boundary condition. In Case C, we demonstrate the simulation of dynamic adaptations of blood flow in a surgical planning application.We demonstrate CRIMSON using three different examples, with all necessary input files available in File 1 at In Example Case A, we demonstrate the simulation workflow in the case where a geometric vascular model has been created using third-party software, which may be idealised or patient-specific. CRIMSON supports this via a solid model import feature. Note that additional boundary condition data (flow rates at the various model outlets) was assumed in this case; typically, additional patient data such as blood pressure or regional flow rates would be used to parameterize the boundary conditions.In addition to demonstrating how to work with imported geometries, this example highlights how to use the NEBCT to design simple LPN boundary conditions, how to run low-resolution 3D simulations on a desktop PC , how to refine the mesh after a simulation to focus computational effort in regions of high error in subsequent simulations, and how to visualise results within CRIMSON.A unique feature of CRIMSON is the ability to impose image-derived velocity profiles as boundary conditions. Typically, this is used at the aortic root, enabling study of the impact of valvular pathologies–which critically shape the inflow profile–on aortic haemodynamics. https://doi.org/10.7302/4vdx-ek59 - show how to use CRIMSON to segment the provided PC-MRI dataset, and impose it upon the provided model.The supplementary files in Example Case B–available in File 1 at post-reperfusion syndrome (PRS)–the result of a sudden release of vasoactive mediators into the circulation after reperfusion of the new liver. PRS is characterised by a decrease in mean arterial pressure and systemic vascular resistance, and an increase in pulmonary pressure and central venous pressure [In Alagille syndrome patients in need of liver transplant, it is important to understand whether their cardiovascular system can withstand the stresses of the transplant surgery –42. A mapressure . These fTo study this, a subject-specific model of an Alagille syndrome patient was created in CRIMSON, consisting of two (pulmonary and systemic) 3D domains segmented from magnetic resonance images, and a closed-loop circulatory system created using NEBCT . In the https://doi.org/10.7302/4vdx-ek59 describes how to run this case in 0D and visualize the results, as well as how to run in 3D, and visualize parameters such as local pressures and flows. The 0D simulation is presented here so that it is computationally tractable for most readers. Both the 0D and 3D simulations are presented in detail elsewhere [https://doi.org/10.7302/4vdx-ek59 for Cases C1 and C2 are configured to run in a simplified 0D mode. Readers with access to HPCs can follow the instructions to enable full 3D simulation.The data available in File 1 at lsewhere . The cloAnother use-case for CRIMSON is preoperative surgical planning. For example, CRIMSON was applied to a case of open surgical correction of a Fontan procedure, in a patient suffering from unilateral pulmonary arteriovenous malformations. After constructing a model reproducing the patient’s pre-operative haemodynamics, two post-operative models were created representing two possible surgical repairs. One was seen to be superior in terms of balancing hepatic venous flow between the pulmonary arteries, and the multidisciplinary surgical team chose this option for the patient . Post-opin vivo is neither practical nor ethical, so computational modelling is the only option. The results indicated that the different devices offered significantly different hemodynamic metrics in terms of blood shearing and blood flow to the brain [In another study, CRIMSON was used to evaluate the suitability of different designs of a medical device–vascular endografts for aortic arch repair–in terms of their impact on patient haemodynamics. Evaluating design alternatives he brain .CRIMSON has been used to systematically examine anatomical risk factors in type-B aortic dissection (TBAD) using idealized models. CRIMSON models permitted isolated changes to specific parameters present in TBAD, including vessel curvature, tear size and shape, false lumen location, and treatment state. The results indicated which combinations lead to unfavourable haemodynamic states, and agreed with clinical studies . A similIn a study reproducing haemodynamics in a patient with a Blalock-Taussig (BT) shunt, CRIMSON was used to determine that the BT shunt’s diameter had reduced by 22% since implantation due to neointimal growth. Because the shunt size was below the MRI resolution, CRIMSON was critical in determining this diameter change .A patient-specific model involving three virtual interventions–open repair, conformable endografting, and fenestrated endografting–to repair a kinked ascending aortic graft in a patient-specific model was studied using CRIMSON . The resOne of the key novel aspects of CRIMSON is its tools for studying cardiovascular control systems and auto-regulations. These include the role of the baroreflex system in adjusting blood pressure after a change in body posture , and howwww.crimson.software for both CRIMSON GUI and CRIMSON Flowsolver. These are currently time-limited binaries, but users can compile their own versions from the provided source code. Alternatively, users can follow the documentation on the CRIMSON website, describing how to interface the GUI with their own fluid solver. The source code for the GUI is available on GitHub under GNU Affero General Public License v3.0 (https://github.com/carthurs/CRIMSONGUI), and for the Flowsolver under the GNU General Public License v3.0 (https://github.com/carthurs/CRIMSONFlowsolver). Both licenses further include the Commons Clause. Archived versions of the source code are available under DOIs 10.7302/679b-dw96 and 10.7302/tbx5-7c07 for the GUI and the Flowsolver, respectively. For the avoidance of confusion, a separate CRIMSON GUI called CRIMSON Pro is also available in the CRIMSONGUI GitHub repository. This provides additional interfaces for some advanced features (but does not provide those features themselves). CRIMSON Pro is not the subject of this manuscript.We invite readers to download installers for Microsoft Windows from A further planned enhancement is the integration of a one-dimensional (1D) incompressible Navier-Stokes solver, which enables simulating extensive vascular networks over many cardiac cycles in almost real-time, while retaining features such as pulse wave propagation phenomena . This 1DCurrently, there are no good models in existence for turbulent cardiovascular flow. There is a need to develop models of transitional and mild turbulence, which are the conditions occurring in some cardiovascular flows. The validation of such models would in principle have to be made using appropriate in vitro models, due to the challenges in acquiring in vivo data on transitional / complex flows.Furthermore, there is a pressing need to develop workflows for 3D anatomical model creation that rely on machine learning methods. This would greatly reduce the current time required to create anatomical models, which currently require the use of external commercial packages (such as Mimics) or labour-intensive workflows (CRIMSON and SimVascular).We believe that CRIMSON is an enticing prospect for CH researchers and look forward to working with the community as we continue its development. We aim to be responsive to community input, via our support mailing list, and look forward to receiving feedback from our ever-expanding user-base on how CRIMSON can best support their work.https://doi.org/10.7302/4vdx-ek59. However, a newer version may be available from www.crimson.software, as suggested in each of the cases below. To install CRIMSON, first run the CRIMSON-2019.11.01 exe installer, then run the CRIMSON_Flowsolver exe installer. The order is important. If you use the default installation paths in both, then the GUI will be able to find and run the flowsolver. If you install the GUI to a non-default location, you must change the Flowsolver’s install path in the same manner.The version of CRIMSON GUI and CRIMSON Flowsolver current at the time of publication of this article is provided in File 1 at https://github.com/carthurs/CRIMSONFlowsolver; and analogously for the GUI repository https://github.com/carthurs/CRIMSONGUI.If you wish to build from source, follow the instructions in the readme.md file in the CRIMSON Flowsolver repository https://doi.org/10.7302/4vdx-ek59 - will guide you through the complete process of creating a model, running the simulation and examining the results.The tutorial pdf for this example case–located in File 1 at ExampleCaseA\ExampleA-Meshing-BC-Simulation-visualisation-refinement.pdf–the instructions for running this caseExampleCaseA\DataFiles\Solid_model.stl–the surface triangular mesh of the vascular geometry we will useExampleCaseA\DataFiles\steady.flow–specification file for a constant steady inflow at the aortic valve; for use with the Prescribed Velocities inflow boundary conditionwww.crimson.software, or from the installers in this data package. If using the installers in this data package, install CRIMSON-2019.11.01-win64-trial.exe first (the GUI), followed by CRIMSON_Flowsolver_1.4.2_2019.11.01-installpath.exe (the Flowsolver). If you adjust the installation path for the GUI, ensure you make the corresponding change for the flowsolver, so that the GUI can find the Flowsolver.Download and install CRIMSON from https://doi.org/10.7302/4vdx-ek59. Follow the instructions therein.Open the document ExampleA-Meshing-BC-Simulation-visualisation-refinement.pdf from the ExampleCaseA available in File 1 at https://doi.org/10.7302/4vdx-ek59 - will guide you through segmenting and imposing a patient-specific aortic inflow velocity profile from a provide PC-MRI dataset.The supplementary pdf for this example–available in File 1 at ExampleCaseB\DataFiles\Patient-PCMRI.mitk–the CRIMSON scene save file to start from, containing a geometric model to impose the PC-MRI boundary condition uponExampleCaseB\DataFiles\PC-MRI_Images\Phase\–a folder containing the PC-MRI phase images throughout one cardiac cycleExampleCaseB\DataFiles\PC-MRI_Images\Magnitude\–a folder containing the PC-MRI magnitude images throughout one cardiac cycleExampleCaseB \ExampleB-PC-MRI-specificVelocityProfiles.pdf–the instructions you should follow in order to impose a PC-MRI-derived inflow boundary condition on a model of the aortawww.crimson.software, or from the installers in this data package. If using the installers in this data package, install CRIMSON-2019.11.01-win64-trial.exe first (the GUI), followed by CRIMSON_Flowsolver_1.4.2_2019.11.01-installpath.exe (the Flowsolver). If you adjust the installation path for the GUI, ensure you make the corresponding change for the flowsolver, so that the GUI can find the Flowsolver.Download and install CRIMSON from https://doi.org/10.7302/4vdx-ek59. Follow the instructions therein.Open the document ExampleB-PC-MRI-specificVelocityProfiles.pdf from the ExampleCaseB folder available in File 1 at https://doi.org/10.7302/4vdx-ek59 - will guide you through running a simulation of a patient under rest conditions, and then of the same patient under post-liver-transplant conditions. Many parameters of the haemodynamics could be examined and compared between the two, but in this case we choose to examine the oxygen supply/demand balance in the myocardium under these two states, and will observe that coronary perfusion is insufficient in the post-operative simulation.The supplementary pdf for this case–available in File 1 at ExampleCaseC\Mitk_Scenes for the Resting and PRS conditions–these are the CRIMSON saved state filesExampleCaseC\AdditionalInputFiles–Files prepared for this specific case . These are for combining with the CRIMSON GUI output for each case to create complete simulation input filesExampleCaseC\ReadyToUseFiles–folders containing simulation input files in a state which can be run immediately. These files are configured to run in purely zero dimensions, and essentially consist of a combination of the CRIMSON Solver Setup output from the MITK scenes, and the AdditionalInputFiles. You will only need these if you do not wish to generate your own simulation files, as is one of the two options described in ExampleC-simulating-Rest-vs-PRS-in-Alagille-patients.pdfExampleCaseC\ExampleC-simulating-Rest-vs-PRS-in-Alagille-patients.pdf–the instructions you should follow in order to create and run the two simulation states for the patient.www.crimson.softwareDownload and install CRIMSON from https://doi.org/10.7302/4vdx-ek59. Follow the instructions therein.Open the document ExampleC-simulating-Rest-vs-PRS-in-Alagille-patients.pdf from the Example Case C folder available in File 1 at The following pre-existing libraries are integral to the CRIMSON software. See The Medical Imaging Interaction Toolkit (MITK)  was chosthe Common Toolkit). MITK uses the Qt application framework to manage events and connect user interface (UI) elements, the MITK DataStorage system to manage state data . Qt, tony, 2016 .Volume meshing is provided by the TetGen  libraryOpenCascade [nCascade  is an opVerdandi is an open-source generic C++ library for data assimilation, developed by INRIA . Data aQSapecNG  is an oRecently a Docker container of the CRIMSON flowsolver has been made available in the American Heart Association’s Precision Medicine Platform, which runs on Amazon Web Services. A permanently archived versions of the source code for CRIMSON GUI and CRIMSON Flowsolver, and of binary installers and example case studies described in this manuscript, have been made available using the University of Michigan’s Deep Blue service –65.S1 Fig(PNG)Click here for additional data file.


To evaluate, using a classification tree methodology, the ability of the Testing Emotionalism After Recent Stroke – Questionnaire (TEARS-Q) to determine the need for further assessment of post-stroke emotionalism and to identify those whose emotionalism is sufficiently clear that they need assessment for potential intervention.Acute stroke units of nine Scottish hospitals in the context of a longitudinal cohort study of post-stroke emotionalism.A total of 228 stroke survivors recruited between October 1st 2015 and September 30th 2018, within two weeks of stroke.The measure was the self-report questionnaire TEARS-Q, constructed based on recognised diagnostic features of post-stroke tearful emotionalism. The reference standard was presence/absence of emotionalism on a diagnostic, semi-structured post-stroke emotionalism interview, administered at the same assessment point.Nine of 159 subjects scoring 0 or 1 on TEARS-Q were diagnosed with post-stroke emotionalism on the reference standard, compared to 11 of 21 subjects scoring 2 to 5 on TEARS-Q and 42 of 48 participants scoring 6 and above. Adding age, sex, deprivation, stroke type, stroke severity, mood, cognition, daily functioning and education did not improve the prediction accuracy sufficiently to change the classification tree.TEARS-Q reliably identifies those who need no further post-stroke emotionalism assessment, those who need further assessment to clarify diagnosis, and those who almost certainly have post-stroke emotionalism and may benefit from intervention. Post-stroke emotionalism is characterised by lessening of control of emotional expression, in particular unheralded crying episodes.We developed and evaluated a self-reported questionnaire TEARS-Q . The reference standard was a diagnostic, semi-structured post-stroke emotionalism interview , administered at the same assessment point to N = 228 participants recruited within two weeks of stroke to a longitudinal post-stroke emotionalism cohort study .We constructed TEARS-Q based on post-stroke emotionalism crying diagnostic criteria: (i) increased tearfulness, (ii) crying comes on suddenly, with no warning, (iii) crying not under usual social control, (iv) crying episodes occur at least once weekly.TEARS-Q has good internal consistency ; acceptable discriminant validity ; coherent scale dimensionality (one factor accounts for 57% of item response variance), and diagnostic accuracy using a cut-point of 1.5.Having established psychometric performance based on a single cut point, we sought more detailed evidence to inform the use of TEARS-Q in clinical practice. This was determined by means of a simple classification tree.The TEARS study was approved by Scotland A Research Ethics Committee (IRAS Reference 157483). and only brief background details will be given here. Participants were male or non-pregnant female, ⩾18 years of age, recruited up to two weeks after a clinical diagnosis of ischaemic or haemorrhagic stroke from acute stroke units of nine Scottish hospitals 2015–2018. Individuals with aphasia were excluded.This report involves an analysis of the data used in the original study,The reference standard was a standardised diagnostic interview based upon recognised features of emotionalism, comprising sections on post-stroke crying and laughing screening questions, frequency and impact and a diagnostic summary. Stroke research nurses, trained by NB and AH, delivered the diagnostic interview.The index test was TEARS-Q, constructed based on post-stroke emotionalism crying diagnostic criteria, with all eight items valenced identically and a five-point Likert scale to detect positive evidence of symptoms: ‘Strongly Agree, Agree, Unsure, Disagree, Strongly Disagree’, scored 2,1,0,0,0 with maximum total score of 16. The instructional set orients respondents to focus on changes to crying since their stroke, in the past two weeks. Help to complete was offered to a minority of the sample, primarily by reading out questions verbatim. education level, stroke severity on National Institutes of Health Stroke Scale, stroke type on Oxford Stroke Classification, anxiety and depression on Hospital Anxiety and Depression Scale, cognition on Abbreviated Mental Test and daily functioning on Barthel Activities of Daily Living Index). A classification tree provides a set of branching/splitting rules, starting with the entire patient cohort and using each of the variables. The analysis yields two groups, one with a higher prevalence of diagnosed emotionalism than the other, with the split decided by the most statistically significant test from all variables and all the possible cut points (for continuous variables). The two groups are then split further and splitting stops when statistical significance is not reached. The advantage of this approach is that the classification tree selects optimum cut points  for TEARS-Q and the results provide accuracy for a given range of scores, the modelling software R for which has in-built significance tests to determine cut points.11A classification tree methodology was used to predict post-stroke emotionalism determined by diagnostic interview given the TEARS-Q total scores and other participant characteristics  and 97 of the participants were female. Of the 233 patients, 205 participants had sustained ischemic stroke and 61 were classified as mild stroke on National Institutes of Health Stroke Scale using a cut-off of 5.Scores from The fitted classification tree is shown in  Only the TEARS-Q total score was employed in the fitted classification tree: that is once TEARS-Q is known, adding demographic data of age, sex, deprivation and education did not improve the prediction accuracy sufficiently to change the classification tree.Note that the cut point of 1.5 is identical to that which optimised diagnostic accuracy in our original validation work.The classification tree established three ranges of scores on TEARS-Q. The lowest range [0–1] reflects low likelihood of post-stroke emotionalism, so that patients can be screened out. The highest range [6–16] reflects a very high probability of post-stroke emotionalism and patients can be screened in, for consideration of intervention. The middle range [2–5] reflects uncertainty. For patients with scores in this range it is recommended that a full standardised diagnostic interview is conducted. In this sample, only 21/228 (9%) would have needed a full clinical assessment.Testing Emotionalism After Recent Stroke – Questionnaire (TEARS-Q) is the first self-report questionnaire developed for tearful emotionalism in stroke. Our previous research demonstrated acceptable psychometrics for TEARS-Q which eliminates the need for reliance in stroke settings on previous emotionalism measures, not developed to assess tearful emotionalism in stroke populations. The data reported here build on this, by supporting the use of TEARS-Q to identify those who need no post-stroke emotionalism assessment or intervention, and those who do, both in research and in clinical practice. The sample is relatively young, secondary educated with a bias toward mild stroke, and primarily resident in the West of Scotland. The actual sensitivity and specificity of this method will depend upon the prevalence of emotionalism in a sample. Our sample was reasonably representative of people seen in Scottish stroke rehabilitation services.There are several limitations to this study. The final TEARS-Q items were not co-produced by, or sense-checked by, a stroke survivor with emotionalism. The reference standard diagnostic interview was developed in the absence of any published, standardised interview schedule. Clinical diagnosis of post-stroke emotionalism could have been an alternate reference standard, but with the disadvantage it would not have been standardised. Participants with aphasia did not complete the assessments, limiting the generalisability of findings. Also, clinical information was available to the nurses who delivered both TEARS-Q and the reference standard, with minimal time interval in between administrations (same day). Nearly 6% of participants who had emotionalism on the interview were not picked up by TEARS-Q. The actual number of missed cases is not absolute however and will depend on the prevalence (prior probability) of emotionalism. Finally, the participants are the same group of individuals involved in the initial TEARS-Q evaluation study. TEARS-Q has potential as a validated emotionalism outcome measure in the clinical trial context, and to evaluate the impact of non-pharmacological emotionalism interventions. Research is also needed to develop observational and aphasia suitable TEARS-Q versions, and a parallel measure that can reliably detect and inform treatment planning for (much rarer) uncontrollable laughter emotionalism presentation.Replication using a broader UK population will, therefore, be needed across the whole stroke severity range, in other countries and cultures and including independent administration of TEARS-Q and the reference standard. High-quality research is still needed to establish whether anti-depressant medication is a safe and effective treatment for post-stroke emotionalism.By establishing acceptable psychometrics for TEARS-Q in our previous work, clinically we have eliminated reliance, in stroke settings, on previous emotionalism measures which were not developed to assess tearful emotionalism in stroke populations. The present data build on this by informing guidance, based on the outcome of a brief self-report emotionalism measure, as to which patients may require no further emotionalism assessment, which patients may require more detailed emotionalism assessment and which patients almost certainly have post-stroke emotionalism and may benefit from intervention. Further work in other settings is required, and whether targeted or universal patient screening is deployed (and we would recommend the latter), TEARS-Q could be incorporated into emotionalism care pathways in order to improve stroke care.Using the TEARS-Q screen questionnaire, two thirds (42/62) of patients with emotionalism were identifiable without full assessment, nine cases (out of 228 patients) were not detected, and 21/228 would have needed clinical assessment to detect the remaining 11 cases. The actual number of cases per category, including missed cases, is not absolute and will depend on the prevalence (prior probability) of emotionalism.


Background: The clinical benefit from endovascular therapy (EVT) for patients with acute ischemic stroke is time-dependent. We tested the hypothesis that team prenotification results in faster procedure times prior to initiation of EVT.Methods: We analyzed data from our prospective database (01/2016–02/2018) including all patients with acute ischemic stroke who were evaluated for EVT at our comprehensive stroke center. We established a standardized algorithm  in 06/2017 to prenotify team members  about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before  and after  implementation of the EVT-Call.Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT . Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208  +EVT-Call). Median (IQR) door-to-image time , image-to-groin time  and door-to-groin time  were reduced after implementation of the EVT-Call.Conclusions: Team prenotification results in faster patient assessment and initiation of EVT in patients with acute ischemic stroke. Its impact on functional outcome needs to be determined. The benefit from endovascular therapy (EVT) for treatment of stroke due to intracranial large vessel occlusion is time dependent , 2. In pTherefore, an efficient workflow should be paramount to reduce in-hospital treatment times , 5. The Telestroke networks have been shown to facilitate access of ischemic stroke patients to EVT by means of a drip-and-ship model with comparable results regarding safety and outcome , 9, 10. The objective of our study was to test whether the implementation of a semi-automated pre-notification procedure can lead to faster in-hospital treatment times of stroke patients who are transferred for EVT in a telestroke network.We performed a retrospective analysis of prospectively collected data on adult patients who were screened for EVT at our center. This EVT registry was established in January 2016 and contains detailed information on patients' demographics, vascular risk factors, neuroradiological imaging and stroke scores including National Institute of Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS) score. Admission non-contrast CT (NCCT) ASPECTS score, baseline status of the cerebral and pre-cerebral vasculature and reperfusion status after EVT  were prospectively assessed by neuroradiologists. We defined mTICI scores of 2b or 3 as successful reperfusion . NCCT orDuring the study period, all transferred patients received repeated imaging with NCCT and CT angiography (CTA) after arrival at our center to assess the extent of early ischemic changes with ASPECTS and recanalization status. We also performed perfusion CT (CTP) in patients with late time window or in unclear cases. The decision whether to perform EVT was based on current guidelines and institutional protocols. Depending on clinical aspects we performed EVT under conscious sedation or general anesthesia with routine perioperative management by an anesthetist . GeneralWe assessed functional outcomes at 3 months by standardized telephone interview to determine the modified Rankin Scale (mRS) score . We defiOur stroke network provides stroke expertise for the eastern part of the German state of Saxony and the southern part of the German State of Brandenburg . ApproxiTo analyze the effect of the EVT-call on treatment times, we included all patients who were treated with EVT from January 2016 to February 2018 after transfer from remote hospitals without EVT capability in our stroke network. We excluded patients who were directly admitted to our emergency department.We established an EVT-call as a phone-based semi-automated pre-notification procedure in July 2017 in order to shorten door-to-groin puncture times in our hospital:EVT-call 1: After teleconsultation of the stroke fellow with the colleague at the remote hospital and decision to transfer the patient for EVT, the stroke fellow informs a central dispatcher, who is a member of the 24/7 staffed central communications office of our hospital, that a patient is to be expected. The dispatcher informs the interventional neuroradiologist, stroke neurologist, anesthetist, registered nurse in the emergency department, CT technician and angiography technician via a pre-recorded message on Digital Enhanced Cordless Telecommunications (DECT) telephones. The EVT-call 1 contains information on patients' sex and age as well as the name of the remote hospital.EVT-call 2: After the patient transfer has started , the physician at the remote hospital informs the stroke fellow that the patient has departed. The stroke fellow then sets up the EVT-call 2 to announce the transfer mode (helicopter or ambulance), the expected time of arrival and if the patient has been intubated prior to transfer. The expected time of arrival is determined according to distance and means of transportation based on prior transfer times. By communicating with the emergency service control center, the stroke fellow is able to ensure that the expected time of arrival is upheld, if necessary.Before implementation of the EVT-call, the stroke neurologists telephonically informed the interventionalist to discuss eligibility for EVT on an individual basis. During on-call periods, the interventional neuroradiologist routinely assessed images from home and came into hospital if a patient was EVT eligible. With the implementation of the EVT-call, all team members were present in the emergency department at the expected time of arrival to streamline patient assessment and treatment decision making whether to perform EVT. If the patient was intubated prior to transfer a team consisting of one anaesthesiologist and one specialized nurse was present on patient arrival. In non-intubated patients, the anesthetist remained on stand-by and was called immediately after the decision for EVT was made. In general, we tried to avoid intubation for patient transfer in our stroke-network .T-Test, Fisher's exact test (two-sided), Mann-Whitney-U-test and non-parametric analysis of variance ANOVA, where appropriate .We applied non-parametric statistics because time-to-event data is often right-skewed. Continuous and non-continuous variables are presented as median  and percentage. Statistical comparisons were performed using ropriate . We consDuring the study period, we screened 494 patients for EVT at our center of whom 328 patients were transferred from remote hospitals. Of these, 120 patients presented before and 208 patients after implementation of the EVT-call . Clinicap = 0.026)  who presented before and 66 patients (55%) who presented after implementation of the EVT-call received EVT . Major r= 0.026) . Among t= 0.026) .p < 0.001) and image-to-groin time (p = 0.042) were further reduced with a resulting decrease of the door-to-groin time from 74 min (58–86) to 60 min . Reduced treatment times had no effect on favorable functional outcome and mortality  in 2019 and 60 min (49–74) in 2020 despite the COVID-19 pandemia.n = 122 patients) compared to on-call periods (n = 204 patients) is summarized in p-value, p = 0.98).The effect of the EVT-call on treatment times during working hours (workdays, 7:00 a.m. to 5:00 p.m.; Our study demonstrates that standardized team prenotification of all team members who are involved into acute treatment decision making and treatment of patients with acute ischemic stroke considered for EVT results in faster treatment times. Particularly, door-to-imaging times and image-to-groin were decreased with a resulting reduction of door-to-groin time by nearly 15 min. Time-reduction was particularly observed during on-call periods, though this interaction was not statistically significant. As a side effect, overall awareness for acute ischemic stroke as a medical emergency increased at our hospital.Treatment times were in line with proposed time metrics from guidelines and with treatment time targets of trials with focus on rapid treatment work-flow , 8, 17. It is debatable whether repeated imaging is required for stroke patients transferred from primary stroke centers for EVT. However, in our cohort, nearly 40% of transferred patients did not receive EVT due to extensive early ischemic changes or vessel recanalization, probably secondary to long distances and transfer times in our network , 20, 21.Rates of periinterventional intubation may have prolonged treatment times in our center. Treatment times until groin puncture tended to be delayed in patients who received EVT under general anesthesia in the randomized GOLIATH and AnSTROKE trials . WhereasOur faster treatment times did not translate into better outcomes measured by mRS at 3 months. It is possible that our patient population is too small to show this effect. Despite this, there is no doubt that faster treatment times generally translate into improved clinical outcomes in stroke treatment, it can be challenging to show this association outside of randomized controlled trials . FurtherThough a numerically greater time benefit of the EVT-call was observed during on-call periods , this inTreatment times had already decreased in 2016 compared to 2014 and 2015, potentially as a result of positive trial results with, thereafter, clear criteria for EVT .The EVT-call at our hospital is semi-automated and phone-based and delivered by a central dispatcher. To avoid an intermediary person and possible delay of information, other forms of delivery like a paging system or a secured messaging system could enhance our pre-notification procedure.Our study is limited by its monocentric design. However, as the EVT-call itself is simple if expected transfer times are known or can be calculated, widespread external validity is likely. Centers with different patient workflow and in-hospital logistics may need to find individual solutions, e.g., presence of all team members on patient arrival may be difficult to accomplish in smaller teams. Technical solutions like electronic image analysis and smartphone image transfer may help to fasten treatment times in such scenarios. Apart from in-hospital workflow after patient arrival at the EVT center, patient selection in remote hospitals or preclinical patient selection of EVT patients and methods to speed-up transport to the intervention center are of critical importance and not addressed in this study , 31. TheWe have demonstrated that team prenotification with an EVT-call, which informs all team members about impending arrival and expected arrival time of patients who are potentially eligible for EVT, can decrease in-hospital treatment times and—potentially—improve functional outcomes of acute stroke patients. Door-to-groin puncture time reduction of 15 min translates into nearly 3 months healthy life-time gain, on average, emphasizing its clinical relevance . SeveralThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.The studies involving human participants were reviewed and approved by Ethikkommission an der Technischen Universität Dresden. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.L-PP and VP contributed to the study design. MK, SW, VP, and L-PP were involved in statistical analyses. L-PP, SW, KH, JG, CH, VP, and JL were involved in data collection. L-PP, KB, JB, SW, TS, MK, HT, JR, and VP were involved in drafting the manuscript and revising it critically for important intellectual content. Each author has made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. All authors have given final approval of the version to be published.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The battle between pathogens and hosts began on primitive Earth, and will probably continue forever. New infectious diseases in humans, such as COVID-19, AIDS, Ebola hemorrhagic fever, and SFTS (severe fever with thrombocytopenia), are appearing and spreading. Tuberculosis, which once appeared to have been suppressed in some countries, has begun to spread again (re-emerging infectious diseases). In addition, the spread of tropical/subtropical infectious diseases, such as Malaria, Dengue fever, Zika fever and West Nile disease, is feared due to global warming and globalization. Emerging and re-emerging infectious diseases are also seen in animals . Zoonosis and livestock-derived food poisoning caused by eating contaminated meat and eggs, are also important; thus, in a way, veterinary medicine might contribute not only to animal but also to human health.Since the first vaccine developed by Edward Jenner, “The father of immunology”, the vaccine has proven to be one of the greatest innovations, saving countless lives. The vaccine is a highly powerful weapon against pathogens by inducing strong immunity and immunological memory; for example, smallpox has now been eradicated thanks to the smallpox vaccine. Additionally, now, the vaccine is not only applicable for the prevention of infectious diseases, but also to prevent or treat cancers/tumors. The ancient vaccine method called “variolation” was developed in India in B.C. 1000. It goes without saying that the wisdom and efforts of our predecessors are the basis of the prosperity of modern society. Now is the time that vaccine scientists in this age can contribute to a better future by developing next-generation vaccines against pathogens and cancer for humans and animals, just as our ancestors did.In this Special Issue, we will share novel results from Austria, Canada, China, Japan, Korea, Mexico, Netherlands, Russia and Taiwan regarding next-generation vaccines and basic techniques/knowledge for the next step.Next-Generation Vaccine Development related to Bacteria and Toxins.Mycobacterium tuberculosis [Mycobacterium tuberculosis. Their vaccine strategy enhanced T-cell responses.Bacille Calmette–Guérin (BCG) is a vaccine against tuberculosis (TB). To overcome the disadvantage of BCG due to the administration route, Vasilyev et al. developed the mucosal vaccine based on the recombinant attenuated influenza vector (Flu/THSP) co-expressing TB10.4 and HspX proteins of Shigellae and enterotoxigenic Escherichia coli (ETEC) cause diarrheal disease. Harutyunyan et al. developed the Shigella and ETEC combination vaccine (ShigETEC) based on a live attenuated Shigella strain [a strain . The ShiSalmonella enterica that was safer than the live attenuated vaccine [Kim et al. developed a vaccine against fowl typhoid caused by  vaccine . They deLactcoccus garvieae on the chitosan particle. The biofilm vaccine was orally administered to fish “Mullet” to prevent L. garvieae; it induced a greater phagocytic response and a higher production of pro-inflammatory cytokines than a whole-cell vaccine. The biofilm vaccine confers better protection against the challenge infection of L. garvieae than the whole-cell vaccine [Su et al. developed a biofilm vaccine that was created using  vaccine . EffectiMichiels et al. developed a new assay for the quality control of tetanus toxoids . Animal Next-Generation Vaccine Development related to Viruses.Viruses are currently used as a key tool in many viral vectors and licensed vaccine products and gene therapy. Extracellular vesicles (exosomes and macrovesicles) share many features with enveloped viruses. Minh and Kamen reviewed the characteristics and similarities of EVs and enveloped viruses, as well as the processing steps and analytical techniques currently implemented to manufacture and document viral vector and vaccine products .Coxsackievirus causes hand, foot and mouth disease. Chen et al. optimized the condition of Vero cell culture in a disposable bioreactor . The VerNext-Generation Vaccine Development against Cancer/Tumor.Imai developed a DNA vaccine against cancer and showed the effect of immunological differences in N-terminus amino acid on the target antigen . In ordeMartinez-Perez et al. developed a next-generation vaccine that enables the destruction of the cancer cell and induces immunity against human papillomavirus (HPV). Their vaccine is an oncolytic adenovirus vector expressing the fusion antigen of HPV-16 E7 and adjuvant SA-4-1- BBL . HPV-16 I believe the articles of this Special Issue constitute one step closer to a better future.


PyPhase is a free and open-source Python package for propagation-based near-field phase reconstructions, which implements some of the most popular phase-retrieval algorithms in a highly modular framework supporting the deployment on large-scale computing facilities. This makes integration, development of new phase-retrieval algorithms, and the deployment on different computing infrastructures straightforward. PyPhase, a free and open-source package for propagation-based near-field phase reconstructions, which is distributed under the CeCILL license, is presented. PyPhase implements some of the most popular phase-retrieval algorithms in a highly modular framework supporting its deployment on large-scale computing facilities. This makes the integration, the development of new phase-retrieval algorithms, and the deployment on different computing infrastructures straightforward. Its capabilities and simplicity are presented by application to data acquired at the synchrotron source MAX IV .X-ray propagation-based imaging techniques are well established at synchrotron radiation and laboratory sources. However, most reconstruction algorithms for such image modalities, also known as phase-retrieval algorithms, have been developed specifically for one instrument by and for experts, making the development and diffusion of such techniques difficult. Here,  However, the high penetration power can lead to low contrast in imaging, especially for microscopic samples when exploiting attenuation contrast. Propagation-based techniques can enhance the contrast and sensitivity by exploiting phase contrast. X-ray propagation-based phase-contrast imaging has seen a large increase in interest and development since its origins 25 years ago  depicts a phase-contrast experimental setup using X-ray optics for high-resolution imaging. The images recorded by such experimental setups approach the holographic regime. In this regime, the direct interpretation of the images becomes more and more difficult with increasing resolution. Examples of holographic images of a test pattern, from higher to lower magnification, are shown in Figs. 1b)–1(f). The images were acquired at beamline NanoMAX at the MAX IV synchrotron . X-rays were focused using Kirkpatrick–Baez reflective optics  of the exit wave using phase retrieval becomes a mandatory step for exploiting such images.Near-field propagation-based techniques record images that can be described as the intensity of the Fresnel transform of the exit wave as a function of energy, propagation distance, and length scale. The first images recorded with these approaches had resolutions not better than the optical domain. More recently, the advent of X-ray optics has offered the opportunity to image at higher resolutions than conventional light microscopy  A flexible phase-retrieval toolbox for expert users.(ii) An interface, currently a command-line interface and in the future a graphical user interface, for non-expert users.(iii) Tools for deployment on computer clusters and heterogeneous computing infrastructures.(iv) Tools for implementation and development of phase-retrieval algorithms.e.g. registration, tomography, fast Fourier transform (FFT), reading and writing data, and visualization.(v) High level of modularity to facilitate the integration of different packages, The package consists of a number of modules, namely:Phaseretrieval contains functionality for phase-retrieval algorithms. Table 1(i) Propagator contains functionality for the propagation of a wavefield and generation of intensities. The propagators are typically used in iterative phase-retrieval algorithms. Currently, a Fresnel operator is implemented, as well as linearized versions based on transport of intensity (TIE)  Tomography contains functionality for tomographic operations: forward projection, back-projection, as well as 3D image processing operators. The main part of this module wraps other codes for tomographic reconstruction, currently PyHST  Dataset contains functionality to read and write images in different formats and from different data sources. Current data sources are ESRF-style EDF data sets and NanoMAX-style HDF5 data sets, with support for TOMCAT-style TIF data sets in development. Compatibility with other data sources is planned, e.g. by interfacing DXChange  Utilities contains supporting functionality, such as image registration and visualization. Registration is currently implemented as a wrapper of Elastix  Parallelizer contains functionality for parallelization. This is implemented as decorators decorating functions that take a range of projections as input. Currently, the supported infrastructures are OAR (http://oar.imag.fr/start), SLURM  PyPhase is written in Python 3.3.e.g. algorithms where the contact plane radiograph is not necessary, capable of reconstructing the attenuation and improving the high-frequency content (necessary for high-resolution imaging). The algorithms currently implemented in PyPhase, suitable for both edge-enhancement and holographic regimes, are listed in Table 1Several phase-retrieval algorithms are currently implemented in the package. On the one hand, some of the algorithms are appropriate for the edge-enhancement regime due to model limitations on relative propagation distance or the necessity of a contact-plane image. On the other hand, appropriate algorithms for the holographic regime are provided, et al., 2018et al., 2018et al., 2007et al., 2010et al., 2014XOP software . Assuming a weakly attenuating object (WTIE) or a homogeneous object (TIEHOM) permits phase retrieval from a single measurement. If multiple images are used, the least-squares solution (Yu CTFPurePhase) can be used.Holographic regime algorithms listed in Table 1The remaining three algorithms are iterative schemes that can be used to refine a reconstruction from one of the other algorithms. They find local optima of the optimized function, so initialization from zero or from noise will usually not yield satisfactory results. Gradient descent (GD) is a simple steepest descent implementation. Error reduction (ER) is an iterative constraint satisfaction scheme in which each constraint in turn is imposed on the current solution. The measured images are considered one constraint. Currently implemented object domain constraints are support and non-negativity. Since the current version is more focused on simplicity and readability, we provide no performance benchmarks.PyPhase. Here, a selection of simple and tested algorithms are provided as a base for further developments. The aim, however, is to progressively include as many algorithms as possible. Planned additions include, but are not limited to, compressed-sensing approaches such as ADMM-CTF . In the current version, the numpy FFT is used. Interfaces to other FFT packages, such as FFTW, can then be easily implemented and used with minimal modification of the code.The package contains classes representing the building blocks of phase-retrieval algorithms. This modularity makes it simple to swap between different implementations, Iterative phase-retrieval algorithms require the implementation of propagators. An implementation of the Fresnel transform as well as a linearized propagator based on the CTF are provided. The modular implementation makes it simple to interface with other codes and algorithms.PyHST2 can be used and a TomoPy interface is in development. However, the modularity of PyPhase makes interfacing other packages straightforward.For the implementation of 3D phase-retrieval algorithms, it is necessary to implement the Radon transform and its inverse transformation. These tomographic operations are provided as wrappers of specialized tomographic reconstruction packages. Currently e.g. by interfacing DXchange . Other dependencies are currently (i) Elastix for image registration, since no adequate pure Python implementation is available, and (ii) PyHST2 for tomographic operations.The number of dependencies is kept as low as possible. All arrays and matrix-vector operations are implemented using NumPy (5.a) using the CTF pure phase algorithm is:The implementation choices yields extremely compact code. For example, the code for the reconstruction of the image in Fig. 2PyPhase using a similar code for three different algorithms are depicted in Fig. 2https://pyphase.readthedocs.io). PyPhase can be installed from PyPI using PIP.Reconstructions obtained with 6.PyPhase. PyPhase has the potential to lower the entry barrier to phase retrieval in the Fresnel regime and thus make the technique more accessible to non-expert users. The package covers the most popular phase-retrieval algorithms presented in the literature. Furthermore, it provides tools and an interface that facilitate the implementation and deployment of other phase-retrieval algorithms. To improve usability by non-expert users, we will provide a command line interface and, in the future, a graphical user interface. Contributions are welcome: contact the authors for more information or go directly to the project repository (https://gitlab.in2p3.fr/mlanger/pyPhase).We have presented an open-source and modular Python package for phase retrieval, christened


Prokaryotic viruses, which infect bacteria and archaea, are the most abundant and diverse biological entities in the biosphere. To understand their regulatory roles in various ecosystems and to harness the potential of bacteriophages for use in therapy, more knowledge of viral-host relationships is required. High-throughput sequencing and its application to the microbiome have offered new opportunities for computational approaches for predicting which hosts particular viruses can infect. However, there are two main challenges for computational host prediction. First, the empirically known virus-host relationships are very limited. Second, although sequence similarity between viruses and their prokaryote hosts have been used as a major feature for host prediction, the alignment is either missing or ambiguous in many cases. Thus, there is still a need to improve the accuracy of host prediction.In this work, we present a semi-supervised learning model, named HostG, to conduct host prediction for novel viruses. We construct a knowledge graph by utilizing both virus-virus protein similarity and virus-host DNA sequence similarity. Then graph convolutional network (GCN) is adopted to exploit viruses with or without known hosts in training to enhance the learning ability. During the GCN training, we minimize the expected calibrated error (ECE) to ensure the confidence of the predictions. We tested HostG on both simulated and real sequencing data and compared its performance with other state-of-the-art methods specifically designed for virus host classification .HostG outperforms other popular methods, demonstrating the efficacy of using a GCN-based semi-supervised learning approach. A particular advantage of HostG is its ability to predict hosts from new taxa.The online version contains supplementary material available at (10.1186/s12915-021-01180-4). Prokaryotic viruses (shortened as viruses hereafter) play an important role in the microbial system dynamics. They regulate the ecosystem by limiting the abundance of their hosts through ongoing lytic infections. Because of the threat of antibiotic resistant pathogens, there is resurging interest of using phages as an alternative strategy to treat bacterial infections . A fundaHowever, despite its importance, the identified virus-host relationship is only the tip of the iceberg. The gap between the sequenced prokaryotic viruses and the known virus-host relationship is expanding quickly. Experimental methods, such as single-cell viral tagging , can detThere are three main challenges for computational prediction of the virus-host relationships. First, the known virus-host interactions are limited. One of the most widely used datasets, the VHM dataset , containSeveral attempts have been made to predict hosts for viruses based on the genomic sequences . They cak-mer-based features for prediction. VHM employs similar oligonucleotide frequency patterns between viruses and hosts and predicts the candidate host with the smallest distance for each input virus. PHP applies a Gaussian model to learn Gaussian distributions for the known virus-host pairs and outputs the probability for each input pair. Then, it uses the pair with the highest probability to assign a label for each virus. Unlike VHM and PHP, WIsH Fig S2 – [Associations between accuarcy and similarity at genus level. X-axis: Mash distance. Left Y-axis: Accuracy. Right Y-axis: number of testing virus.]Fig S3 – Tables S1-S2.Table S1 –[Parameters used for training CNN and GCN.]® Xeon® Gold 6258R CPU with 8 cores.]Table S2 – [Elapsed time for each tool. All the methods were run on Intel


This study explored risk parameters of obesity in food decision-making in mother-child dyads. We tested 45 children between 8–12 years and their biological mothers to measure the decision weights of food health attributes, the decision weights of food taste attributes, self-regulated food decisions, and self-reported self-control scores. Maternal body mass index (BMI), and children's BMI-percentiles-for-age were also measured. We found a positive correlation between children's and their mothers' decision weights of taste attributes in food decision-making. We also found a positive correlation between children's BMI %iles and their mothers' BMIs. Children with overweight/obesity demonstrated lower correlations between health and taste ratings and a lower percentage of self-regulated food decisions  than children with healthy weight. Our findings suggested that the decision weights of taste attributes and weight status shared similar patterns in mother-child dyads. Also, the findings suggested that establishing dynamics of unhealthy food-decision making may increase the risk of childhood obesity. Helping children to develop the dynamics of healthy food-decision making by increasing the importance of health while decreasing the importance of taste may promote resilience to susceptibility to unhealthy eating and weight gain. Obesity is a significant health condition that costs over $190 billion of healthcare spending in the U.S.  lower decision weights of healthiness attributes, (2) higher decision weights of taste attributes, and (3) weaker associations between food healthiness and tastiness , and/or (4) lower percentages of self-regulated food decisions along with lower self-control capacity within children and mothers. Importantly, we hypothesized that mother-child dyads would demonstrate similar dynamics of food decision-making. Lastly, we hypothesized that children with overweight/obesity would show dynamics of unhealthier food decision-making than children with healthy weight.M = 10.4 years, SD = 1.5) who spoke English as their first language, and their biological mothers , who communicated in English fluently for understanding experiment directions and survey questions. Families were recruited using flyers distributed to schools, hospitals, and community centers in Kansas City metropolitan and nearby rural areas. In addition, flyers were posted on social media, or sent with a letter to parents of prospective child participants who agreed to be contacted for future research studies at the University of Kansas Medical Center identified using HERON database   aged 8 to 12 years (2), we measured participants' heights and weights using a Perspective Enterprises standard stadiometer  and a Befour scale  in light clothing without shoes. We computed each child's BMI percentile-for-age that considers a weight for height, age, and gender using the Baylor College of Medicine calculator . The mean BMI percentile-for-age was 63.4 . When considering the weight status category, there were 29 children with healthy weight , and 16 children with overweight/obesity . The mean BMI for mothers was 30.0 . There were 12 mothers with an underweight or healthy weight  and 33 mothers with overweight or obesity . We excluded data from one additional mother-child dyad before data analysis for the computation of decision weights was impossible because the child responded to food rating trials with the same response throughout all trials.To assess the body mass index . The larger the negative correlation coefficient of health and taste ratings, the stronger the association between food unhealthiness and tastiness . To note, the health or taste beta coefficient and the correlation between health and taste ratings are independent constructs, while the formers estimate the decision weight of health or taste ratings in food decisions and the latter indicates individuals' perceived association between food healthiness and tastiness.To estimate the association between food healthiness and tastiness, we computed a Pearson's correlation coefficient between healthiness and taste ratings of 60 food items in each individual  or not-tasty (“bad” or “very bad” ratings) for 30 healthy and 30 unhealthy food items separately. Next, we categorized food items as unhealthy/tasty, unhealthy/non-tasty, healthy/tasty, and healthy/non-tasty. Then, we classified the self-regulated food decisions that needed self-control to make healthier choices when individuals resisted the temptation of eating tasty but unhealthy food items successfully  or when individuals chose to eat not-tasty but healthy food items successfully . Lastly, we computed the percentages of self-regulated decisions out of unhealthy/tasty and healthy/not-tasty food items.Further, we computed the percentages of self-regulated food decisions  = 0.50, p < 0.001. As the BMI-percentile-for-age increased, the percentage of self-regulated decisions decreased, r(43) = −0.31, p = 0.042. As the correlation between health and taste ratings decreased, the percentage of self-regulated decisions decreased, r(43) = 0.63, p < 0.001. These results suggest that children are less likely to incorporate health attributes in food decision-making as the “unhealthy = tasty” association is stronger. Furthermore, children are more likely to make poorly self-regulated unhealthy decisions as the “unhealthy = tasty” association is stronger and the BMI is higher.Descriptive statistics are listed in r(43) = −0.41, p = 0.006. As the self-reported self-control score decreased, the percentage of self-regulated decisions decreased, r(43) = 0.37, p = 0.013. These results suggest that mothers incorporate taste attributes more in food decision-making as the “unhealthy = tasty” association is stronger. Additionally, lower self-controllers are more likely to make poorly self-regulated unhealthy decisions.Similar to children's data, we conducted Spearman's rho correlational analyses across the BMI, the health beta coefficient, the taste beta coefficient, the correlation between health and taste ratings, the self-control score, and the percentage of self-regulated decision see . As the r(43) = 0.30, p = 0.043. Also, as mothers' taste beta coefficients increased in food preferences, children's taste beta coefficients increased in food preferences, r(43) = 0.33, p = 0.029. In addition, as mothers' self-regulated food decisions decreased, children's taste beta coefficients increased, r(43) = −0.30, p = 0.043. These results suggest that the weight status and the decision weights of food taste attributes in food decision-making show similar trends in mother-child dyads. Also, it suggests that children are more likely to have higher importance of the taste in food decision-making as mothers make poorly self-regulated food decisions.To explore the similarity in the dynamics of food decision-making in mother-child dyads, we conducted Spearman's rho correlational analyses across the aforementioned variables of mothers and those of children see . It was U tests to explore whether the dynamics of food decision-making would be different between children with healthy weight and children with overweight/obesity  and 12–19 years (34.5%) (Ogden et al., The findings of this study identify that mothers and children show similar taste-oriented unhealthy food decision-making dynamics that could increase the risk of obesity in children. Moreover, the findings of this study confirm that children with overweight/obesity engage in poorly self-regulated food decisions incorporating mostly taste attributes of unhealthy foods while ignoring health attributes of foods in food decision-making. The current findings imply that family-based obesity prevention and intervention approaches that focus on establishing healthier dynamics of food-decision making could be effective in reducing the prevalence of childhood obesity.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was carried out following the recommendations of the Human Subjects Committee at the University of Kansas Medical Center and the Institutional Review Board at the University of Missouri-Kansas City. The protocol was approved by the Human Subjects Committee at the University of Kansas Medical Center. All participants gave written informed consent following the Declaration of Helsinki. All parents of participants in this study gave written informed consent, and all children gave written assent.O-RH, AB, and S-LL contributed to the conception and design of the study. O-RH and HK organized the database. HK collected the data. O-RH and S-LL performed the statistical analysis. O-RH wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or NCATS.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Environmental problems caused by excessive carbon emissions are becoming increasingly prominent and have received heightened attention in recent years. Encouraging people to adopt low-carbon behavior to reduce carbon emissions is desirable. Based on social learning theory, we developed and tested a moderated mediation model to investigate when and how environmentally specific servant (ESS) leadership impacts employees’ low-carbon behavior . We tested our theoretical framework with a sample of 483 subordinates and their direct supervisors working in northern China. The results indicate that ESS leadership is positively related to employees’ low-carbon behavior, and that environmental self-accountability plays a mediating role in this relationship. In addition, power distance orientation strengthens the direct effects of ESS leadership on employees’ environmental self-accountability and low-carbon behavior, as well as the indirect effect of ESS leadership on private low-carbon behavior via environmental self-accountability. Our findings contribute to the literature surrounding ESS leadership and low-carbon behavior, and help to promote green development and thus achieve the goals of carbon neutrality and decreasing carbon dioxide emissions. The observed increases in carbon dioxide concentration has led to numerous serious environmental problems, such as climate change, sea-level rise, and species extinction ,2. Such Previous research on low-carbon behavior focuses predominantly on government, region, and corporate levels ,12,13. FIn order to address the above issues, the current research aims to explore the impact of ESS leadership on low-carbon behavior based on social learning theory. Social learning theory proposes that individuals learn by observing and imitating the attitudes, values, and behaviors of role models in society . LeadersMoreover, ESS leaders’ attitude towards the environment in their work may be observed and learned by their subordinates. Consequently, subordinates’ eagerness to protect the environment according to internal self-standards is stimulated . Such exThis research contributes to the existing literature in three ways. First, the relationship between ESS leadership and low-carbon behavior is not well understood because no empirical research has tested this possible relationship. Understanding the impact of ESS leadership helps obtain a more complete picture of how ESS leadership works. Second, although previous research explored possible boundary conditions of ESS leadership  , the effTo investigate the relationship between ESS leadership and low-carbon behavior, we draw upon social learning theory, which explains human behavior from the perspective of the “continuous reciprocal interaction between cognitive, behavioral, and environmental determinants” . A key tESS leadership promotes environmental values, attitudes, and actions in the workplace. Following the logic of social learning theory, by considering the ESS leader as a role model, followers are more likely to gain a sense of high environmental self-accountability and participate in more low-carbon behavior.Many scholars have recently paid attention to environmental protection , leadingSimilar to pro-environment behavior, low-carbon behavior is mentioned to describe the behavior of establishing a low-carbon society through low-carbon consumption, low-carbon electricity saving, and other behaviors to reduce energy consumption . Stern  divided This research argues that ESS leadership positively influences low-carbon behavior. To begin with, in conjunction with social learning theory, individuals can acquire new behavior patterns by observing the behavior of others in a social system and imitating the behavior of essential role models around them . Thus, eMoreover, since ESS leaders are devoted to green goals, they can provide employees with environmental protection knowledge and skills to encourage them to conduct environmental behaviors . ExistinHypothesis 1.Environmentally specific servant leadership is positively related to (a) private low-carbon behavior and (b) public low-carbon behavior.Environmental self-accountability is defined as the desire of individuals to live up to their environmental self-standards . This coDrawing on social learning theory, this research speculates that ESS leadership positively influences employees’ environmental self-accountability for the following reasons. First, Bandura  indicateThis research argues that ESS leadership can improve employees’ environmental self-accountability and assumes that environmental self-accountability is positively related to employees’ low-carbon behavior. Bandura , Bower , and NeiFollowing the above analysis, this research goes a step further and posits that environmental self-responsibility plays an essential mediating role in the leadership–employee behavior path. Under the guidance of leaders, employees classify themselves as socially and environmentally responsible citizens by improving self-accountability, which consequently spurts them to engage in more low-carbon behavior. Specifically, they tend to promote environmentally friendly living, practice private low-carbon behavior, and provide a path that indirectly influences public policy and other environmental behavior. Therefore, this research hypothesizes that:Hypothesis 2.Environmental self-accountability mediates the relationship between environmentally specific servant leadership and (a) private low-carbon behavior and (b) public low-carbon behavior.Power distance orientation refers to how individuals accept unequal power distribution in institutions and organizations . The accThrough the lens of social learning theory, the influence of the demonstrator on the observer is affected by the differences in observers . AligninPower distance orientation affects individuals’ behavior and significantly impacts their thinking ,60. ThusHypothesis 3.Power distance orientation moderates the positive relationship between environmentally specific servant leadership and employees’ (a) private low-carbon behavior and (b) public low-carbon behavior, such that these relationships will be stronger  for employees reporting higher as opposed to lower power distance orientation.Hypothesis 4.Power distance orientation moderates the positive relationship between environmentally specific servant leadership and employees’ environmental self-accountability, such that this relationship will be stronger  for employees reporting higher as opposed to lower power distance orientation.According to social learning theory, individuals’ characteristics affect the acceptance and absorption of indirect experience gained from other aspects. Logically, employees with high power distance orientation are more likely to be influenced by ESS leadership. They are more inclined to recognize the status gap between themselves and their superiors and agree with ESS leaders’ green values, reflecting more private low-carbon behavior. Additionally, there is a preference for employees with high power distance orientation to engage in public low-carbon behavior by persuading team members, friends, and family members to comply with green norms and encouraging them to participate in the activities. Accordingly, this research hypothesizes that:Hypothesis 5.Power distance orientation moderates the indirect effect of environmentally specific servant leadership on employees’ (a) private low-carbon behavior and (b) public low-carbon behavior via environmental self-accountability, such that these indirect effects will be stronger for employees reporting higher as opposed to lower power distance orientation.Our data came from several companies located in Shandong Province, China. The industries included textiles, food processing, and battery, which consume large amounts of energy and electricity and emit large amounts of carbon dioxide. With the help of those companies’ human resources management departments, a total of 650 subordinates and 216 immediate supervisors volunteered to participate in our survey. All participants were presented a 15-min orientation meeting in their own company. In this meeting, we explained the purpose of this survey, emphasizing the importance of how the participants think and feel. We also guaranteed that all their responses would be confidential and anonymous. Unique identification codes were assigned to each participant to match supervisor–subordinate responses. Respondents were required to write down their codes before submitting the questionnaire. Moreover, each completed questionnaire was placed in a separate sealed envelope. Participants received ten yuan in exchange for completing the questionnaire.To reduce the detrimental effects of common method bias, we not only used the supervisor–subordinate dyadic design, but also adopted a multi-wave design with a one-month interval. At time 1, subordinates rated ESS leadership, power distance orientation, and covariates ; 603 completed questionnaires were collected at time 1. One month later, at time 2, subordinates were asked to rate their environmental self-accountability, and 524 completed questionnaires were collected. One month later at time 3, supervisors rated subordinates’ low-carbon behavior, and 182 completed supervisor questionnaires were collected.SD = 7.27); 60.04% of the subordinates were male; and 48.24% held an undergraduate degree or higher.To improve data quality, we took further steps to remove invalid responses. For example, if the time taken to complete the questionnaire was less than half the average time needed for questionnaire completion, or the same choice was selected in the whole questionnaire, or the wrong choice was selected for the attention check items. Subsequently, we matched the completed supervisor and subordinate questionnaires. Finally, the valid samples comprised 483 subordinates and 182 supervisors, yielding a 74.31% response rate of subordinates and an 84.26% response rate of supervisors. The average age of the 483 subordinates was 30.99 years old  displays a better fit than other five models.To examine the discriminant validity of the focal construct in this research, a confirmatory factor analysis was conducted with Amos 23. As shown in p < 0.01), private low-carbon behavior , and public low-carbon behavior . Environmental self-accountability is significantly positively related to private low-carbon behavior  and public low-carbon behavior .Means, standard deviations, and correlations are shown in To test hypotheses 1 to 5, this research constructed a structural equation model using maximum likelihood estimation along with 5000 bootstrap estimations. As shown in Moreover, the interaction between ESS leadership and power distance orientation is positively associated with environmental self-accountability , private low-carbon behavior , and public low-carbon behavior . Furthermore, the results in This research constructed a moderated mediation model based on social learning theory to explain the impact of ESS leadership on employees’ low-carbon behavior. Specifically, we examined the impact of ESS leadership on employees’ low-carbon behavior through environmental self-accountability. We used the questionnaire to collect data, and the results of the data analysis ultimately confirmed most of our initial hypothesis. The results indicate that ESS leadership positively influences employees’ low-carbon behavior, and environmental self-accountability mediates the effect of ESS leadership on employees’ low-carbon behavior. This finding validates previous research on pro-environmental behavior, suggesting that ESS leadership promotes pro-environmental behavior and green behavior among employees ,32,66,67However, the results suggest that power distance orientation fails to moderate the indirect effects of ESS leadership on public low-carbon behavior via environmental self-accountability. This result indicates that although subordinates with high power distance orientation tend to follow the values of ESS leadership, they are more likely to conduct low-carbon behavior privately, rather than spend time and energy persuading friends and family members to engage in low-carbon behavior.This research has several theoretical implications. First, we constructed a research model to confirm the positive effect of ESS leadership on employees’ low-carbon behavior, contributing to low-carbon behavior literature. Previous studies indicated that environmental psychological factors ,64,72,73Second, this research unpacks the “black box” underpinning the relationship between ESS leadership and low-carbon behavior by examining the mediating role of environmental self-responsibility. Prior research pointed out that individuals’ values and beliefs towards environmental issues predict low-carbon behavior . HoweveThird, this research further investigates the question of under what conditions ESS leadership has a stronger effect on employees’ low-carbon behavior. There is almost no existing literature that focuses on the boundary conditions regarding the influencing factors of employees’ low-carbon behavior. To fill this gap, this research tests the moderating effect of power distance orientation on the relationship between ESS leadership and employees’ low-carbon behavior. The results show that compared to employees with low power distance orientation, employees with high power distance orientation learn the environmental protection behavior of ESS leadership more actively and participate in more low-carbon behavior. Moreover, employees with high power distance orientation also agree more with the environmental values of ESS leadership. This results in stronger environmental self-accounting, which is an essential factor to promote low-carbon behavior. Therefore, this finding provides theoretical evidence for enhancing the role of ESS leadership and how to promote low-carbon behavior by employees. At the same time, this research provides a response to Zhang et al.  and furtThis research has some practical implications for managers and organizations. First, climate change and environmental pollution caused by the continuous increase of carbon emissions threaten human survival . For theSecond, the results show that ESS leadership could enhance employees’ low-carbon behavior by improving their environmental self-accountability. This finding suggests that to maximize the effectiveness of ESS leadership, managers and organizations should pay attention to the cultivation of employees’ environmental self-accountability. In response to this, our research provides several recommendations to managers. First and foremost, given that employees tend to imitate the behaviors of leaders, leaders are encouraged to set a good example in caring for the environment. By doing so, employees are predicted to increase their environmental self-accountability . Second,Third, various industries, especially energy-intensive and carbon-intensive industries, should strive to reduce carbon emissions. After the Chinese government pledged to achieve peak carbon emissions by 2030 and carbon neutrality by 2060, reducing carbon emissions has become an important development strategy for China’s industry. Since leaders have an irreplaceable influence on employees’ behaviors and the development of companies, leaders must have a clear understanding of the development of the industry. Only in this way can they better lead the development of enterprises. Here are three suggestions. First, leaders should be aware of the importance of reducing carbon emissions for the development of the industry and set the reduction of carbon emissions as one of the main development goals of the enterprise, so as to lead the low-carbon development of the industry. Second, leaders should clarify the carbon emission requirements of policies and regulations on the industry, and strive to learn and apply low-carbon technologies in enterprise development to reduce carbon emissions and meet the requirements . Third, This research may also have several limitations. First, while the current research examines the impact of ESS leadership on employees’ low-carbon behavior with multi-wave data, our research design is cross-sectional, which limits our inference of causality. Future research is encouraged to explore whether ESS leadership always has a positive impact on employees’ low-carbon behavior by utilizing a longitudinal design. Moreover, this research was conducted only in Shandong Province, China, which limits the generalizability of the results to some degree. Future research could examine whether ESS leadership influences employees’ low-carbon behavior through environmental self-accountability in other provinces and countries, particularly in developed countries with completely different social cultures from China. Second, this research only focuses on ESS leadership and ignores other organization members’ impact on employees’ low-carbon behavior. The relationship between team members is closer. The words and deeds of coworkers may also have a potentially significant impact on focal employees’ low-carbon behavior and awareness. Future research could investigate the influence of lifestyle habits, low-carbon values, and behaviors of other organization members  on focal employees’ environmental self-accountability and low-carbon behavior.Third, our research only investigates the moderating role of power distance orientation. However, aside from power distance orientation, other factors, such as organization internal competition , individual consciousness , corporate culture, and government policy requirements might also influence employees’ low-carbon behavior. For example, in terms of organization internal competition, employees who consciously perform well in low-carbon behavior may receive additional rewards from the organization . Such experience may lead coworkers to exhibit similar behaviors. Therefore, we encourage future research to explore the boundary effect of these factors.Following the primary tenet of social learning theory, this research expands our understanding of why, how, and when ESS leadership affects employees’ low-carbon behavior by investigating practically meaningful mediator and boundary conditions of ESS leadership. We found that ESS leadership positively impacts employees’ low-carbon behavior, including private low-carbon behavior and public low-carbon behavior. Moreover, environmental self-accountability plays a mediating role between ESS leadership and employees’ low-carbon behavior. In other words, ESS leadership improves employees’ low-carbon behavior by driving their environmental self-accountability. In addition, we also found that power distance orientation strengthens the positive effect of ESS leadership on environmental self-accountability, low-carbon behavior, as well as the indirect effect of ESS leadership on private low-carbon behavior. Our findings contribute to the literature by investigating the antecedent variable of low-carbon behavior, its underlying mechanism, and potential contextual factors. Meanwhile, our research provides managerial implications for organizations to help achieve reduced carbon and carbon neutrality. We encourage future studies performing more profound research based on our results, such as expanding the scope of data collection and testing different underlying mechanisms and contextual factors.


Significance: Fluorescence lifetime imaging microscopy (FLIM) measures the decay rate of fluorophores, thus providing insights into molecular interactions. FLIM is a powerful molecular imaging technique that is widely used in biology and medicine.Aim: This perspective highlights some of the major advances in FLIM instrumentation, analysis, and biological and clinical applications that we have found impactful over the last year.Approach: Innovations in FLIM instrumentation resulted in faster acquisition speeds, rapid imaging over large fields of view, and integration with complementary modalities such as single-molecule microscopy or light-sheet microscopy. There were significant developments in FLIM analysis with machine learning approaches to enhance processing speeds, fit-free techniques to analyze images without a priori knowledge, and open-source analysis resources. The advantages and limitations of these recent instrumentation and analysis techniques are summarized. Finally, applications of FLIM in the last year include label-free imaging in biology, ophthalmology, and intraoperative imaging, FLIM of new fluorescent probes, and lifetime-based Förster resonance energy transfer measurements.Conclusions: A large number of high-quality publications over the last year signifies the growing interest in FLIM and ensures continued technological improvements and expanding applications in biomedical research. The fluorescence lifetime is sensitive to the environment of the fluorophore, including pH, temperature, viscosity, and binding state. Fluorescence lifetime imaging microscopy (FLIM) provides information on molecular interactions that are advantageous for biological and medical imaging. FLIM captures the decay time of fluorophores at each pixel of the image, and therefore, provides unique information compared to intensity (photon flux) or spectral (photon wavelength or energy) imaging of fluorescence. Unlike intensity-based measurements, lifetime is self-referenced and independent of the absolute number of photons. Therefore, FLIM is not corrupted by variations in intensity between pixels. Our previous review covered the fundamentals of FLIM instrumentation and analysis, along with applications to live cell and tissue imaging.22.1FLIM instrumentation has seen major advancements in recent years. FLIM is typically characterized by slow acquisition speed because high photon counts are needed for accurate decay rate estimation. Thus recent efforts have focused on improving FLIM instrumentation to increase acquisition speed. Karpf et al.2.2Wide-field FLIM can image a larger field of view (FOV) by employing single-photon avalanche diode (SPAD) arrays or SPAD detectors with complementary-metal-oxide semiconductor (CMOS) technology, which has gained popularity in the last year. SPAD arrays can have temporal resolution in picoseconds and single-photon sensitivity that is advantageous for lifetime measurements. AD array , this te2.3A super-resolution microscope that can also acquire lifetime data is advantageous for detecting fluorophores with similar spectral properties and for lifetime-based Förster resonance energy transfer (FRET) measurements. Thiele et al.2.4FLIM with a light-sheet illumination scheme enables volumetric lifetime data acquisition in large samples . Hirvone2.5Fiber-optics-based lifetime imaging enables FLIM for clinical applications. Marsden et al. presented a novel lifetime system based on fiber-optics excitation and detection. The point measurement system can be used intraoperatively and is capable of real-time processing , flavin adenine dinucleotide (FAD), and porphyrins. This tool called FLImBrush can be used in the operating room to detect cancer margins in a label-free manner and uses a deep learning-based image segmentation, block-matching-based motion correction, and interpolation-based visualization. This allows for real-time imaging and image processing to enable intraoperative imaging and surgical guidance, as demonstrated on surgeries of head and neck cancer patients [ex vivo tissues have also been investigated this year. Erkkila et al. showed that FLIM of NAD(P)H, and protoporphyrin identify tumor margins in low- and high-grade human gliomasex vivo mouse brains and showed that there are significant differences in the NAD(P)H lifetime dynamics between neurons and astrocytes.Autofluorescence FLIM of 4.2New studies have generated molecular probes with fluorescence lifetimes that are sensitive to physical conditions, including new FLIM probes for protein concentration and cell cycle. Yi et al. developed a small squarine dye with a fluorescence lifetime that changes depending on serum albumin concentrations.A novel fluorescence lifetime probe, FUCCI-Red, relies on the different fluorescence lifetimes of the red proteins mCherry and mKate2.4.3,in vitro and in vivo. Intracellular glucose imaging of single cells provides an exciting new tool to investigate metabolic heterogeneity and its effects on treatment response.Finally, FLIM-FRET can capture extracellular and subcellular interactions on the nanoscale, including several studies this year. For example, an FLIM-FRET pair of eGFP and mCherry, both tagged to histones, detected changes in chromatin architecture after induction of DNA damage.5FLIM is a widely used tool for biomedical imaging and has advanced the field of microscopy in the past few decades. In this perspective, we provided updates of innovations in FLIM within the last year that we as experts in the field found compelling. These new developments have been categorized into advances in instrumentation, new approaches to analyze FLIM data, and recent applications of FLIM in biology and medicine. Recent updates to FLIM instrumentation include faster acquisition speed, improved spatial resolution, and translation into the clinic. Rapid advances in algorithms for FLIM analysis in the past year aim to improve image segmentation, analysis speed, quantify multidimensional heterogeneity, and perform multiparametric investigation. Additionally, there is an emphasis on open source FLIM analysis tools that can be integrated into other data processing pipelines. These computational tools unravel spatial and molecular features of cellular physiology that are not apparent with qualitative observation of FLIM images. Some of the advantages and limitations of these new instrumentation and analysis techniques are summarized in