Peptide molecule has high bioactivity, good biocompatibility, and excellent biodegradability. In addition, it has adjustable amino acid structure and sequence, which can be flexible designed and tailored to form supramolecular nano-assemblies with specific biomimicking, recognition, and targeting properties via molecular self-assembly. These unique properties of peptide nano-assemblies made it possible for utilizing them for biomedical and tissue engineering applications. In this review, we summarize recent progress on the motif design, self-assembly synthesis, and functional tailoring of peptide nano-assemblies for both cancer diagnosis and therapy. For this aim, firstly we demonstrate the methodologies on the synthesis of various functional pure and hybrid peptide nano-assemblies, by which the structural and functional tailoring of peptide nano-assemblies are introduced and discussed in detail. Secondly, we present the applications of peptide nano-assemblies for cancer diagnosis applications, including optical and magnetic imaging as well as biosensing of cancer cells. Thirdly, the design of peptide nano-assemblies for enzyme-mediated killing, chemo-therapy, photothermal therapy, and multi-therapy of cancer cells are introduced. Finally, the challenges and perspectives in this promising topic are discussed. This work will be useful for readers to understand the methodologies on peptide design and functional tailoring for highly effective, specific, and targeted diagnosis and therapy of cancers, and at the same time it will promote the development of cancer diagnosis and therapy by linking those knowledges in biological science, nanotechnology, biomedicine, tissue engineering, and analytical science. According to the World Health Organization, there were about 18 million new cancer cases in 2019, which caused millions of deaths worldwide and trillions of US dollars economic loss each year. Therefore, the early diagnosis and clinical therapy of cancers is one of the current research directions that the international community pays attention to , 4. ThanPrevious studies have indicated that nanomaterials showed great applications for the diagnosis and therapy of cancers. Various nanomaterials, including noble metal nanomaterials  , 7, semi2 . T. T. demoPeptide nanospheres are 0D polypeptide nanostructures that play an important role in medical fields such as drug and gene delivery. The π-π stacking and hydrophobic interaction between peptide molecules are of great importance on the formation of nanospheres. For example, A diphenylalanine (FF) peptide was a derivative of diphenylalanine with similar molecular properties to diphenylalanine peptide, which can self-assemble into nanospheres because their molecular structure is more rigid than 1D nanostructures with lower degrees of freedom. As they do not rotate around additional C–C bonds, and the steric hindrance is also higher. Similarly, the cysteine diphenylalanine tripeptide could form fullerene-like nanospheres via self-assembly .Another type of nanosphere by the self-assembly of CG3R6TAT cationic peptide has been reported previously . CG3R6TA. reported a single component based aqueous drug delivery system by generating self-assembled dipeptide nanospheres (SPNS) using Fmoc-L-Trp-L-Phe-OCH3 framework . I. I67]. Ipolymers . This peHybrid materials of 0D materials (quantum dots and nanoparticles) and peptides have been widely explored as general building blocks for various applications, such as biomedical scaffolds, tissue regeneration, biomedicine, and nanotechnology. There are 20 kinds of natural amino acids that can be used for peptide synthesis, which provides many possibilities for the design and synthesis of functional materials. As we all know, the motif design of peptide molecules plays an important role in the synthesis of functional peptide hybrid materials.2O2 detection. The proposed strategies shown in this work, such as peptide motif design and self-assembly on GQDs, benefits to further creation of functional peptide materials and understanding of their self-assembly mechanism.Recently, the design of a novel functional peptide molecule was reported , which hBiological enzymes have recently been proved to be an effective means for directing supramolecular self-assembly in a temporal and spatial manner. In the manufacture of certain biological materials, hybrid self-assembly of 0D materials such as peptides and nanoparticles plays an important role . Miryam . developed a simple self-assembly strategy to modify polymer/inorganic hybrid nano-sized drug delivery systems with functional peptides [3 (BCMC/CaCO3) hybrid nanoparticles through biotin–avidin interaction to obtain peptide functionalized nanoparticles (PNP)  Fig. a. The peCombining 1D materials such as carbon nanotubes (CNTs), nanowires and biological suprastructures to form hybrid functional components is an innovative research field with broad application prospects in the fields of medicine, nanotechnology, and materials science. Combining the mechanical and electronic properties of 1D materials, the properties of protein molecular recognition and catalytic activity provide opportunities for chemists, biologists and materials scientists to understand and develop new nanomachines, sensors, or other molecular combinations. The role of peptides is to dissolve CNTs and can be classified according to diameter or chirality. In turn, CNTs can support and immobilize enzymes to create functional materials. Other applications include using peptide to assemble ordered hierarchical objects containing CNTs, and using CNTs that serve as peptide vaccine carriers. Based on this, peptide-CNT hybridization can form biological scaffolds, which have been used as therapeutic and imaging materials .. reported the preparation of a dual composite material in an orderly combination of two tubular elements [Currently, hybrid materials composed of single-walled carbon nanotubes (SWCNTs) and self-assembled cyclic peptide nanotubes (SCPNs) have been reported. For example, Montenegro et alelements . The cou. reported the development of a unique cell capture and release platform based on GaN semiconductor nanowires [In addition to CNTs, nanowires are of great interest due to their potential biological applications, such as drug delivery or sensing devices. Li et alanowires . First, Tumor resection is widely employed to prevent tumor growth. However, the defective tissue at the original tumor site can also cause tissue or organ dysfunction, thereby reducing the patient's quality of life. Therefore, it is very important to regenerate tissues and prevent tumor recurrence. Based on the concept of "kill first and then regenerate", a scaffold-based multifunctional tissue engineering strategy has been developed , in whic. added GO into the peptide self-assembly system during the preparation of peptide hydrogels [Cell-based cancer treatment methods show great promise in tissue engineering, while one of the key challenges is cell delivery and retention. In the past years, great efforts have been made to design injectable biomaterials for containing and transporting cells at the injury site. Recently, the hybrid assembly of biomaterials and inorganic materials, such as peptide-graphene hybrid, have provided insights for cell drug delivery and tumor treatment. These hybrid nanomaterials composed of self-assembled peptides with customized functions were widely used in nanotechnology, tissue engineering, and biomedical engineering due to their unique structure and characteristics. For example, short self-assembling peptide hydrogels (SAPHs) have attracted great interest since they can mimic the natural extracellular matrix and have great prospects for the design of cell microenvironments from the beginning. Ligorio et alydrogels , as showydrogels .In another study, a peptide-mediated biomimetic strategy was adopted by Su and co-workers to create the multifunctional 3D graphene foam (GF)-based hybrid minerals . FirstlyIn the above sections, we demonstrate and discuss the self-assembly formation of various peptide-based pure and hybrid nano-assemblies that related to biomedicine and cancer therapy. In this part, the synthesized peptide nano-assemblies for cancer diagnosis, such as fluorescent, magnetic, and photoacoustic imaging as well as specific biosensing of cancer cells, are summarized.Fluorescence microscopy is an essential experimental technique with the properties of high sensitivity, strong specificity, and minimally invasiveness . It can The first type of fluorescent labels for cancer imaging is the fluorescent groups that bound onto peptide nano-assemblies. For instance, Fan et al. demonstrated that the formation of tryptophan-phenylalanine (Trp-Phe) nanoparticles transferred the intrinsic fluorescence signal of the peptide from ultraviolet to the visible range . VisibleRecently, Yang and co-workers reported the desuccinylation-triggered formation of peptide nanofibers for liver cell imaging As shownFluorescent quantum dots and nanoclusters can also be conjugated with peptide nano-assemblies for cancer imaging. As a new type of fluorescent nanomaterial, GQDs showed extraordinary characteristics related to strong quantum structure and edge effects. GQDs had tunable wavelength, stable photoluminescence, and excellent biocompatibility . In addi2S QDs and tumor-targeting RGD peptide sequence [2S QDs. Under NIR-II fuorescent imaging condition, the tumor metastatic foci with a tiny size of 0.2 mm could be observed clearly, which shows high potential of the synthesized nanoprobe for early diagnosis of tumors.In addition, chemical conjugation of quantum dots onto functional peptide chains could be applied for cancer imaging. For instance, Wen and co-workers demonstrated a novel nanoprobes by functional modification of self-assembled amphiphilic peptide (APP) nanofibers with NIR-II Agsequence , as showMR imaging (MRI) is one of the critical diagnostic methods in medical radiology. The molecular weight of reagent increased by combining with the preparation of protein, polymer, and micelle. Thereby relaxivity will enhance as the rotational correlation time increase, and then the correlation coefficient of the MR reagent increases, revealing a significant contrast over a long period.Bull and co-workers used self-assembling peptide amphiphiles (PAs) to improve the relaxivity of new MR reagents . PAs can. reported the modification of peptide-based soft hydrogels with gadolinium (Gd) complexes for MRI applications [To promote the application of peptide-based nano-assemblies for MRI imaging, gadolinium complexes have been usually conjugated to self-assembled peptide nanomaterials for creating MRI contrast agents . For insications . As showications , as showIn addition to Gd, anticancer agent has been conjugated with peptide nano-assemblies for MRI of cancer cells. For instance, previously Yuan and co-workers reported the design of a novel peptide molecule by conjugating anticancer agent olsalazine (Olsa) with the cell-penetrating peptide sequence RVRR, which could self-assemble into large intracellular nanoparticles under the catalysis of tumor-relevant enzyme, furin . Due to With the development of biotechnology and nanotechnology, functional biosensors have shown huge potential in practical application. Biosensors based on enzymes and aptamers have been extensively studied , 94. The2AEAEAELRARARL-OH, was designed for the detection of cancer cells with overexpressed sialyl Lewis X (sLex). In addition, they developed a flowable catechol dye, alizarin red S (ARS), which had a strong binding ability with phenyl-aldonic acid groups. The color of the solution changed from the free state to the coordination state. It was simply mixed with BP to prepare a visually colored BP/ARS indicator to achieve the goal of visual identification of tumor cells. Therefore, the obtained nano-biosensor had a robust adhesion-induced replacement effect and cancer cells could be in situ observed by the naked eye.Early diagnosis of cancer biomarkers with high sensitivity, low detection limit, and quick analysis plays crucial role in the therapy of cancers. The diagnosis of cancers by assembled peptide-based biosensors has attracted full attention from researchers. Previously, Chen et al. developed an eye-observable detection indicator based on the visual recognition of cancer cells . A bioco. reported the fabrication of a fluorescent biosensor based on self-assembled peptide-based nanoprobes for the detection of matrilysin cancer biomarker[2-NAADLEKAIEALEKHLEAKGPCDAAQLEKQLEQAFEAFE-RAG-COOH) with AuNPs and carbon dots (CDs) together. The JR2EC biopolymer has high affinity to the specific protein biomarkers such as MMP-7. The step-wise synthesis of nanoprobes is presented in Fig. Recently, peptide nano-assemblies based biosensor platforms, such as fluorescent , electrobiomarker. As showIn addition, electrochemical biosensors based on peptide nano-assemblies for cancer diagnosis have also reported. Yaman and co-workers demonstrated the synthesis of peptide nanoparticles for the fabrication of a sensitive electrochemical detection platform for cytosensing of DLD-1 cancer cells . Dipheny5 cells/mL.In another case, Tang and co-workers reported the fabrication of electrochemical biosensors based on self-assembled peptide nanofibers for detecting breast cancer stem-like cells (BCSCs) . Figure Beside the fluorescent and electrochemical biosensors, electrochemical immunosensor based on self-assembled peptide nanowires and glucose oxidase has also been fabricated for sensitive detection of tumor necrosis factor α . The elePeptide-based nano-assemblies have been widely used for cancer therapy due to their uniform nanoscale structure, tailorable functions, high biocompatibility, and specific targeting to cells. In this section, we summarize the peptide assembly techniques for directly killing cancer cells, the role of peptide drug assembly and peptide hybridization in chemotherapy, the application of peptide hybridization in PTT, and the application of peptide hybridization in killing cancer cells with multiple therapies.The difference between cancer cells and normal cells lies in the difference in acquisition function. When the drug kills the cancer cells, it will destroy the normal cells at the same time . The ideOf the 30,000 genes predicted by the human genome, only about 3,000 genes encode proteins capable of binding small-molecule drugs . The 3, In the process of peptide directly killing cancer cells, the small peptide molecule is expected to selectively inhibit cancer cells, nevertheless, there are still several key problems to be solved. Particularly important is how to design a small molecule for enzyme-instructed self-assembly (EISA). Feng et al.  demonstr. reported a new method to regulate the collaboration of peptide tree macromolecules and linear peptides with self-assembling garment shell-like nanostructures. Jeena et al. [In addition, there are other ways to use peptide assembly were explored for killing cancer cells. For example, Xu et al. . reportea et al.  describeFor biomedical applications, many biologically responsive peptide nanosystems such as pH-responsive and tumor microenvironment controlled peptide nanosystem assembly have been developed. An endowment of pH responsivity to anticancer peptides is a promising approach to achieve better selectivity to cancer tissues. Tanishiki et al.  designedTo sum up, these conclusions and experimental results indicate that peptide assembly can effectively inhibit the proliferation of cancer cells , which pChemotherapy is a systemic treatment means , by oralTargeting peptide-drug delivery is a promising strategy to overcome the side effects of systemic drug-based therapies, including chemotherapy. On the basis of this research, Boekhoven et al.  describeet al. [With regard to the amphiphiles, the self-assembly of peptide-drug conjugates into supramolecular nanomaterials has been reported . For exaet al.  reportedet al. .et al. [Cancer metastasis is the main cause of chemotherapeutic failure. Inhibiting the activity of matrix metalloproteinases (MMPs) is a common strategy for reducing metastasis. However, broad-spectrum MMP-inhibitors (MMPI) may cause undesired side effects. Qian et al.  screenedIt is necessary to deliver a drug with a prescribed molecular state in order to maximize the efficacy of peptide-drugs in chemotherapy . For exaThe application of peptide-based hybrid components in chemotherapy has great advantages as a therapeutic approach for tumor therapy, as they can effectively avoid the annoying problems such as low efficiency and side effects of anti-tumor drugs. Recently, a list of published works have reported the progress of the relevant research. For example, Peng et al.  reportedThe technology of peptide-based hybrid assembly continues to attract attention among researchers due to their potential applications in various fields. Peptide molecules are not only good gelatos due to the presence of various self-assembling units in their structures, but also possess inherent biocompatibility which enhance their applicability. Interestingly, gel stiffness, drug release capacity and proteolytic stability of these hydrogels have been successfully modulated by incorporating D-amino acid residues, indicating their potential application for drug delivery . MoreoveChemotherapy is still an effective treatment for cancer , and pepThese studies have proved that peptide-based hybrid assembly has the advantages of quick effect and low toxicity in chemotherapy, and has a broad application prospect in cancer treatment .et al.[Chemotherapy has been validated unavailable for treatment of renal cell carcinoma (RCC) in clinic due to its intrinsic drug resistance. However, in recent work, a breakthrough has been made on this issue. Wang et al. first inet al.. FinallyPhotothermal therapy (PTT) is a promise and elegant method for tumor treatment, which has the advantages of minimum invasiveness, easy procedure, short treatment time, and quick recovery . PTT relRecently, Zou et al.  achievedIn recent years, peptide-based hydrogels represent attractive molecular building blocks due to their ease of synthesis, versatile gelation approaches, and excellent biocompatibility. For the delivery of anticancer drugs, especially in PTT, it would be desirable to load photothermal conversion agents (PTCAs) together with therapeutic agents to produce synergistic antitumor effects for reducing the tumor recurrence rate. For example, Jin et al. used melThe self-assembly of peptides with a variety of nanostructures has great potential in functional biomaterials . HoweverCancer therapy via single means such as chemotherapy has certain limitations including restricted curative effect, serious toxic side effects and easy drug resistance. To overcome these long-standing drawbacks, a variety of tumor-targeted drug delivery systems has been developed towards treatment efficiency improvement and side effects minimization. On the other hand, the combination of multi-therapy strategies is another promising strategy to improve the efficiency of treatment and overcome drug resistance. Various therapies such as chemotherapy, radiation therapy, gene therapy, magneto thermic therapy, photothermal therapy and photodynamic therapy can be combined to achieve a synergistic anti-tumor effect. In recent years, the combination of photothermal therapy and chemotherapy has been explored for tumor treatment. For instance, Huang et al.  successfThe peptide-based hybrid assemblies for multi-therapy plays an integral role in most cancer treatments, as it can overcome the problems of multi-drug resistance and tumor recurrence and metastasis. In a recent study, Wu et al. preparedDPMI (1492.5 Da) generated hollow spheres ∼80 nm in diameter named as PSP-DPMI that disintegrated only in the acidic microenvironment of tumor tissues, followed by integrin-mediated cellular uptake of PSP-DPMI monomers. Taking full advantage of the EPR effect, tumor microenvironment sensitivity and RGD targeting, PSP-DPMI can specifically accumulate at the tumor site with a long residence time. In vitro and in vivo experiments show that PSP-DPMI has strong anti-tumor activity and excellent biological safety. This overall strategy will simultaneously overcome the technical barriers of self-assembled nanoparticles as macromolecular drug carriers, as well as the drug barriers of using peptides to regulate the self-assembly of macromolecular drugs into TME-triggered macromolecular therapies in clinical settings [At present, the drug delivery of peptide self-assembled nanoparticles is still hindered by poor tumor specificity and short circulation time, resulting in poor therapeutic effects. The ideal delivery system should be relatively large and negatively charged in its initial state to achieve a longer circulatory half-life and selective extravasation. It can also be switched to positively charged small particles according to the tumor microenvironment (TME) response of the tumor site to promote tumors infiltrate. Multi-therapy is a promising way to give these nanoparticles a tumor microenvironment (TME) response, which can usually mediate the specific formation or fracture of certain nanostructures. He et al.  developesettings .Fig. 15SWith the development of multi-therapy technology, the integration of peptide-based hybrid assemblies  into varBesides, many drug-delivery systems (DDSs) based on various functional nanoparticles have been widely explored for applications in cancer multi-therapy. Chen et al.  further In summary, we presented the progress on the design and synthesis of functional peptide nano-assemblies for cancer diagnosis and therapy applications. Multifunctional peptide nano-assemblies exhibited wide applications for the diagnosis of cancers, such as fluorescent and magnetic imaging as well as biosensing of cancer cell biomarkers. Meanwhile, peptide nano-assemblies could conjugate with other components such as metal nanoparticles, QDs, drugs, photosensitive polymers and others to enhance their applications in cancer therapy through biological, chemical, photothermal, magnetic, and combined therapy methods. Compared to traditional nanomaterials for cancer therapy, peptide nano-assemblies revealed a few key advantages. They showed very high biocompatibility, bioactivity, and biodegradability, which are useful for biomedical studies. In addition, they provided adjustable structures from 0 to 3D, which exhibited structure-specific applications. For instance, peptide nanoparticles, nanospheres, and vesicles are beneficial for the loading and releasing anticancer drugs; peptide nanofibers and nanosheets showed importance for photothermal and photodynamic therapies of cancers. Besides, they provided the infinity of space to tailor the functions of synthesized materials. Specific peptide motifs can be designed to improve the functions of binding, targeting, cell-penetration, biomimetic synthesis, and others, promoting the function-specific applications of peptide nano-assemblies by choosing appropriate therapy methods and techniques.Although great achievements have been previously reached on the design, synthesis, and cancer diagnosis/therapy applications of peptide nano-assemblies, here we would like to suggest several potential topics in this promising research field to expand the scope and development of peptide-based nano-assemblies. To start, the motif-design technique is recommended to study the self-assembly of peptide functional conjugates for the formation of novel peptide nano-assemblies with tumor cell-specific properties. The rational design of tumor cell-specific peptide sequences and adjusting the self-assembly conditions in vitro and in vivo could beneficial for this topic. Second, it is necessary to investigate deeper the self-assembly of peptides with designed motifs in live cells, for instance the assembly and disassembly of peptide nano-assemblies under the catalysis of cancer-relevant enzymes and cancer biomarkers. Both experimental and theoretical studies will promote the development of biological agents for in-situ cancer diagnosis and therapy of cancers. Third, as 2D biological materials exhibited higher specific area and more active sites, 2D peptide nano-assemblies are highly interesting for the synthesis of functional 2D materials for imaging, detection, and therapy of cancers. Therefore, peptides could be sequence-tailored to form 2D peptide nanosheets, nanobelts, and nanoplates, which could be utilized as versatile platforms for advanced applications. Fourth, to improve the functional tailoring of peptide nano-assemblies, it is possible to conjugate peptide nano-assemblies with functional 2D materials such as MXene nanosheets, black phosphorus nanosheets, metal–organic frameworks to enhance the cancer diagnosis and therapy efficiency. Finally, more attention should be focused on the development of practical products based on peptide nano-assemblies for cancer diagnosis and therapy. These products should have the characteristics of low cost, high bioactivity, good performance. For instance, it is possible to develop peptide nano-assemblies based rapid detection nanosensors, test kits, peptide nanodrugs, and imaging contrast agents. We believe that supramolecular peptide nano-chemistry will promote the connection between nanotechnology and biotechnology, and show more positive effects on solving problems in disease diagnosis and treatment in the future.


Introduction: Negative symptoms, neurocognitive deficits and functional impairment are prevalent in individuals with major depressive disorder (MDD) and schizophrenia (SCZ). However, unlike neurocognitive deficits, little is known about the role of negative symptoms toward functioning in individuals with MDD. On the other hand, both factors are well-studied in individuals with SCZ. Thus, this study aimed to examine the contributions of negative symptoms and neurocognitive impairments in functioning in individuals with MDD, compared to individuals with SCZ.Methods: Participants included 50 individuals with MDD, 49 individuals with SCZ and 49 healthy controls. The following measures were administered—Negative Symptom Assessment (NSA-16), Brief Assessment of Cognition in Schizophrenia (BACS), Patient Health Questionnaire (PHQ-9), and MIRECC-Global Assessment of Functioning (MIRECC-GAF) to evaluate negative symptoms, neurocognition, depressive symptoms, and functioning respectively.Results: Both MDD and SCZ groups had significantly more severe negative symptoms, depressive symptoms, and poorer functioning than healthy controls. Individuals with SCZ performed significantly poorer on the BACS than the other two groups. Both negative symptoms and neurocognition were significantly correlated with social and occupational functioning in SCZ. Motivation subdomain of the negative symptoms was significantly correlated with occupational functioning, while depressive symptoms correlated with functioning in MDD.Conclusion: Both negative symptoms and neurocognitive deficits appear to play differential roles on individual domains of functioning between MDD and SCZ. Future longitudinal studies with larger sample sizes should be done for a better understanding about the associations between the factors and functioning. According to the World Health Organisation (WHO) , MDD is In the literature, two factors—neurocognitive deficits and negative symptoms often stand out in relation to their strong association with functioning. Specifically in MDD, neurocognitive deficits are prevalent in the individuals and have been reported to be one of the core features of the condition , 7. Thesresidual depressive symptoms alongside sleeping and concentration difficulties, rather than as a construct of negative symptoms. While depressive symptoms have a considerable amount of overlap with negative symptoms  –24. Few Therefore, the aim of the current study is to better understand negative symptoms and neurocognitive deficits in MDD in their individual contribution toward functioning, alongside individuals with SCZ and healthy individuals.Fifty individuals with MDD and 49 individuals with SCZ were recruited from the Institute of Mental Health, Singapore. Forty-nine healthy controls (HC) were recruited from the community. The data collection was completed between September 2017 and April 2019.The inclusion criteria for the patient groups were as follows: diagnosis of SCZ or MDD, aged 21–65 years, English-speaking and has capacity to provide informed consent. The inclusion criteria for the HC group includes aged 21–65, English-speaking, has capacity to provide informed consent and no history of any mental disorder. Individuals with intellectual disability, neurological disorders, and history of cerebrovascular accidents or traumatic brain injuries were excluded.The diagnoses of SCZ and MDD were ascertained on the Structured Clinical Interview for DSM-IV (SCID-I/P) ; HCs werAll the assessments were conducted by trained research psychologists in a single visit. In order to reduce bias in rating negative symptoms, the assessments for negative symptoms were conducted by a research psychologist who was not involved in the SCID interview and blinded to the participant's condition. This study was reviewed and approved by the National Healthcare Group Domain Specific Review Board (DSRB), Singapore. Written informed consent was obtained from all participants.The 16-item Negative Symptom Assessment (NSA-16) , 31 was Z-scores of each subtest were computed based on the results from the original developers and a composite score was then obtained by averaging the z-scores of the six subtests (The Brief Assessment of Cognition in Schizophrenia (BACS)  was usedsubtests . BACS hasubtests –35 and hsubtests .The Patient Health Questionnaire-9 (PHQ-9) , 37 was The MIRECC-Global Assessment of Functioning (MIRECC-GAF)  was usedNormality assumptions and homogeneity of variance were tested using Shapiro-Wilk and Levene's tests respectively. Transformation was performed on those variables that were not normally distributed. The NSA-16 subdomains—social involvement in SCZ and motivation in MDD groups were normally distributed after applying square root transformation. All three MIRECC-GAF domains in MDD and SCZ groups were normally distributed after applying Blom's transformation. However, for the three MIRECC-GAF domains in HC, departure from normality was severe and none of the transformation method could yield a normal distribution. Parametric tests were used for normally-distributed variables while non-parametric tests were used when non-normally distributed variables were involved. For comparisons between the three diagnostic groups, the Chi-squared tests were used for categorical variables; the Univariate Analysis of Variance (ANOVA) was used for continuous variables if normality assumption was met, while the Kruskal-Wallis H test was used if the normality assumption was violated. Correlation analysis was used to measure the association between NSA-16, BACS, PHQ-9, and MIRECC-GAF. The NSA-16 total scores were used in this study. The analyses with NSA-16 global scores are available in the M = 14.30, SD = 10.22) has significantly longer duration of illness than the MDD group .The demographics and clinical characteristics of the participants are shown in M = 62.77, SD = 24.16) were found to have significantly higher MIRECC-GAF occupational functioning scores than females , T(47) = 2.17, p = 0.035. None of the other socio-demographic factors were found to be significantly associated with the three MIRECC-GAF domains.Within the MDD group, males . Within the subdomains of NSA-16, motivation was significantly correlated with the MIRECC-GAF occupational functioning  and symptomatic functioning . Another subdomain, motor retardation was significantly associated with the MIRECC-GAF symptomatic subscale . No significant association was observed between BACS composite score and MIRECC-GAF subscales. The 6 individual BACS domains were also not significantly associated with the MIRECC-GAF subscales  and symptomatic  domains. In view of the significant relationship of gender on occupational functioning in MDD, a multiple regression for occupational functioning was performed using gender and NSA-16 motivation as predictors ; this revealed a significant effect of NSA-16 motivation  on occupational functioning in MDD.The results of correlational analyses between cognition, negative symptoms, depressive symptoms, and functioning across groups are presented in r = −0.49 p < 0.001), while social involvement was associated with MIRECC-GAF social functioning . Communication was significantly correlated with two MIRECC-GAF subscales—Social  and Symptomatic . PHQ-9 score was significantly correlated with only MIRECC-GAF symptomatic domain .For individuals with SCZ, both the NSA-16 total and BACS composite score were significantly correlated with most MIRECC-GAF subscale scores. Within the NSA-16 subdomains, motivation was significantly correlated with the MIRECC-GAF occupational functioning (p = 0.007) and social  subscales respectively. PHQ-9 score was not significantly correlated with MIRECC-GAF.In HC, neither the BACS nor NSA-16 total scores were significantly correlated with the MIRECC-GAF score. However, two of the NSA-16 subdomains—emotion/affect and motivation were significantly associated with the MIRECC-GAF occupational . The patients/participants provided their written informed consent to participate in this study.YQ has been involved in the data entry, data analysis, drafting and revision of the manuscript, and the final approval of the final submission. ZY has been involved in the conception and design of research study, writing the protocol, data collection, data entry, data analysis, revision of the manuscript, and final approval of the final submission. JD has been involved in the conception and design of research study, and final approval of the final submission. JL has been involved in the conception and design of research study, data collection, data analysis, revision of the manuscript and final approval of the final submission. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Objectives: Lately, many countries have restricted or even banned transfat, and palm oil has become a preferred replacement for food manufacturers. Whether palm oil is potentially an unhealthy food mainly due to its high content of saturated Palmitic Acid (PA) is a matter of debate. The aim of this study was to test whether qualitative aspects of diet such as levels of PA and the fat source are risk factors for Metabolic Syndrome (MS) and Metabolic Associated Fatty Liver Disease (MAFLD). Methods: C57BL/6 male mice were fed for 14 weeks with three types of Western diet (WD): 1. LP-WD—low concentration of PA (main fat source—corn and soybean oils); 2. HP-WD—high concentration of PA ; 3. HP-Trans-WD—high concentration of PA (mainly transfat). Results: All types of WD caused weight gain, adipocyte enlargement, hepatomegaly, lipid metabolism alterations, and steatohepatitis. Feeding with HP diets led to more prominent obesity, hypercholesterolemia, stronger hepatic injury, and fibrosis. Only the feeding with HP-Trans-WD resulted in glucose intolerance and elevation of serum transaminases. Brief withdrawal of WDs reversed MS and signs of MAFLD. However, mild hepatic inflammation was still detectable in HP groups. Conclusions: HP and HP-Trans-WD play a crucial role in the genesis of MS and MAFLD. Metabolic Associated Fatty Liver Disease (MAFLD) is characterized by the presence of hepatic steatosis in addition to any of the following three criteria: overweight or obesity, presence of Type 2 Diabetes Mellitus (T2DM) or evidence of metabolic dysregulation . Since iMAFLD is often referred to as a self-inflicted disease, implying the influence of personal behavioral and dietary choices. However, the impact of the surrounding “fast and processed food” obesogenic environment on the choices of children and adults should not be neglected . ProcessThe food industry and especially the fast-food industry, extensively uses the types of lipids with long shelf life that are easy and inexpensive to produce . ProcessIn the early 1990s, researchers began to identify the adverse health effects and reported that intake of Trans FA increased the risk of coronary heart disease by altering the ratio between Low-Density Lipoprotein (LDL) cholesterol and the “good” High-Density Lipoprotein (HDL) cholesterol .Increased consumer awareness of the health implications of Trans FA resulted in local and state efforts to limit or ban their use .Elaeis guineensis). Palm oil is abundant, low-cost and chemically stable. Currently, it is the most widely produced edible vegetable oil in the world [“Anti transfat” measures introduced by governments accelerate the use of an accessible alternative—palm oil, obtained from the fruit of the palm tree . All animals were maintained in the Animal Facility at the Faculty of Biology, Complutense University Madrid, in a temperature-controlled room with 12-h light/dark cycle with ad libitum feeding condition, according to the guidelines of the Federation for Laboratory Animal Science Associations (FELASA).We randomly distributed 10-week C57BL/6J male mice into 4 groups with a sample size of 7 to 9 animals per group.Control (CTRL) group was fed with chow diet and normal water. Three treated groups received different types of Western Diet (WD)  and sweePlease see https://www.graphpad.com/scientific-software/prism/), accessed 27 December 2018  was used for statistical analysis and graph design. Statistical significance was determined by one-way analysis of variance ANOVA, followed by a Tukey post hoc test. One-way paired ANOVA followed by Bonferroni’s post hoc test was used to evaluate the differences between feeding groups. Significant differences are denoted by * for p < 0.05, ** p < 0.01, *** p < 0.001; **** p < 0.0001.Data were expressed as mean ± SD. GraphPad Prism version 8.0 , fructose (22%) and cholesterol (2%) . HoweverBody Weight (BW) steadily increased in all treated groups during the experimental period. Nevertheless, as shown in A,B, throObesity is associated with significant changes in White Adipose Tissue (WAT), which has profound systemic and hepatic consequences . Mice feBasal glucose levels after 12 h of fasting, did not increase in all WD treated groups compared with CTRL . Finally, the serum level of total cholesterol was significantly higher in HP-WD and HP-Trans-WD fed animals compared with LP-WD and CTRL groups F.Obesity, hypercholesterolemia and glucose intolerance are the main features of MS and are closely associated with the progression and severity of MAFLD . AnatomoHepatomegaly was caused by a combination of hypertrophy and hyperplasia. Hepatocytes of livers from animals of all WD-fed groups were almost twice enlarged compared to CTRLs, as shown by phalloidin staining B. At theEvaluation of histologic sections, by an experienced pathologist, revealed significant hepatic steatosis in 30–80% hepatocytes of WD-fed animals. The cellular content was a mixture of micro- and macrovesicular vacuoles, mainly located in the periportal regions . These vNext, a quantitative lipidomic analysis was performed in order to identify lipids discriminating the pathological statuses of the liver. A lipidomic approach was taken to quantify the major lipid classes.Lipids were extracted from the liver tissue and further separated by Thin Layer Chromatography (TLC). Total hepatic Triglyceride (TG) content was markedly increased in all mice fed with WD compared with CTRL group A. HowevePparγ, early induced lipogenic transcription factor mediating an adipogenic transformation of hepatocytes  secretion in HP-Trans-WD  staining C. AdditiTrans-WD .Cell death, inflammation and TNF-α overproduction induces the activation of Hepatic Stellate Cells (HSCs) in the liver . ConsistLastly, we investigated whether WD withdrawal could ameliorate MS and MAFLD-related liver phenotype. The restoration of a chow diet feeding regimen for 20 days was performed after 14 weeks of WD in all treated groups, while CTRL group was maintained on chow diet for 17 weeks in total A. The swIn light of these metabolic improvements, pathological changes in the liver were explored next. All WD withdrawal groups, showed significant improvement in hepatocellular morphology A and attOver the past two decades, some light has been shed on a number of aspects of MAFLD pathogenesis and the complex relationships between liver steatosis, obesity and modifiable risk factors such as food habits and sedentary lifestyle. Despite the increase in knowledge, there is still no universally approved medical treatment for MAFLD patients . The curTherefore, the aim of the present study was to investigate the effects of three different WDs on the liver and the pathophysiological modulation that these diets perpetrate as a mechanism to develop MAFLD. The consumption of all types of WDs rich in fat, fructose and cholesterol for 14 weeks predisposed mice to the development of obesity, hepatomegaly, hepatic cell death and steatosis. Even LP-WD promoted obesity, hepatomegaly and significant liver fat accumulation, with modulation of FA metabolism. Thus, only HP-WD and HP-Trans-WD induced hypercholesterolemia and immune cell infiltration resembling the pattern of Nonalcoholic Steatohepatitis (NASH). Moreover, only mice treated with HP-WD and HP-Trans-WD developed significant liver fibrosis, an important hepatic feature of MAFLD that is usually observed in patients with persistent necroinflammatory changes  Supplem.Our observations are in line with previously published murine models fed with a high fat diet (HFD) containing transfats—mice receiving American Lifestyle-Induced Obesity Syndrome (ALIOS) diet . ALIOS mApob (hepatic TG secretion) and Acox (FA β-oxidation). Both decreased FA oxidation and secretion are not able to offset the diet-induced increase in intrahepatic lipid and together contribute to the diet-induced fatty liver and hepatic accumulation of fat.The mechanisms of hepatic steatosis caused by transfats are the subject of considerable debate. We examined mRNA expression of key lipid metabolic genes involved in FA uptake, export and oxidation. Our data showed that the diet rich in transfat promotes hepatic lipid accumulation by more than one mechanism. We found that HP-Trans-WD in the liver reduced expression of Consistently, it has been demonstrated in vitro ,29, as wTnf-α expression. Concomitant with our observation, recent human studies showed that Trans FAs modulate human macrophage response, increasing the production of TNF-α [Interestingly, we found that feeding with HP-Trans-WD did not increase the expression of key genes of de novo lipogenesis, but in fact FASN expression was profoundly suppressed. This appears paradoxical because FASN suppression markedly improves steatosis in other experimental models of fatty liver, and FASN antagonists are under development as plausible treatments for hepatic steatosis . Therefoof TNF-α .Lipidomic analysis revealed a marked step from DG to TG (precursor/product) in HP-Trans-WD. These findings are highly consistent with human lipidomic MAFLD data published by A.J. Sanyal’s group . MoreoveDG are derived from lipogenesis and membrane phospholipids (PL). The lower level of de novo lipogenesis and the parallel decrease in PC suggest that the membrane PC may definitely contribute to the observed increase in DG in HP-Trans-WD mice in the current study . Indeed,Apo-B100 gene expression in HP-Trans-WD.Furthermore, PC is the only phospholipid molecule that is known to regulate the assembly and secretion of lipoproteins. It has been found that low hepatic PC levels due to its synthesis disruption impair the VLDL secretion, and significantly decrease the levels of circulating VLDL lipoproteins and result in hepatic accumulation of TG , which iAdditionally, a low PC/PE ratio possibly leads to a rearrangement of outer monolayer, loss of membrane integrity and increased permeability to pro-inflammatory molecules such as cytokines, initiating the inflammation in HP-Trans-WD mice .Glycerophospholipids are another component of cellular membrane associated with cellular signaling and cellular apoptosis. Decreased levels of PS and PI were previously reported in liver biopsy samples of patients with NASH .Another striking observation was the increase in FC in mice fed HP-Trans-WD. FC is well-known to be highly cytotoxic . FC accuNotably, we found that only HP-Trans-WD induced a significantly impaired glucose tolerance after 14 weeks of feeding. Actually, transfats already have attracted critical attention as a potential modifiable risk factor for T2DM in several previous studies. Diet enriched in transfat intake has been associated with diabetes, insulin sensitivity and systemic inflammation ,45. AnimOverall, our findings raise a red flag on the food high in transfats because of the harmful effects on liver and metabolism in general. However, the proposed industrial substitute—palm oil does not seem to be a good alternative either, mainly because of high saturated FA, especially PA (C16:0 ≈ 44%). PA treatment has been known to induce inflammation and cellular injury in various tissues. For example, Chen et al. showed that for each kilogram of palm oil consumed annually per capita, the mortality due to ischemic cardiomyopathy increases to the equivalent of 68 for 100,000 deaths in developed countries .The effects of saturated PA on the liver are another pressing issue ,16. BolaThe main difference between groups was that HP-WD feeding was not associated with glucose intolerance and did not prompt the increase of transaminases as HP-Trans-WD. In addition, the hepatic, metabolic and lipidomic changes were much more pronounced in HP-WD compared with LP-WD fed animals. In accordance, a previous in vitro study showed that saturated PA fatty acids induce hepatocyte lipoapoptosis, and it is more toxic than with unsaturated fatty acids .Lifestyle modifications including diet, exercise and weight loss have been found to be effective in controlling MAFLD. Indeed, we found that WD withdrawal for only 3 weeks resulted in significant improvement in several features of MS and MAFLD, and in general was very efficient in returning most of the analyzed parameters to control-like levels. The withdrawal from all types of WDs promoted lower body mass; decreased visceral fat accumulation; remarkably improved steatosis, serum transaminases, cholesterol and hepatic TG content; and attenuated hepatic fibrosis. Importantly, it also normalized glucose tolerance in HP-Trans-WD. However, the specific lipid composition of the diet seems to also be important in this setting. Liver inflammation in HP and HP-Trans-WD as seen post-withdrawal, is not fully reversible. This, of course, raises concerns, pondering the frequent cycling of diet and weight in the population with obesity.Mouse models have been extensively used in many mechanistic studies of MAFLD pathogenesis. In spite of this, the natural rodent diet is not fatty-acid-based, limiting the extrapolation of results to humans. Moreover, mice exhibit significant differences in lipid metabolism versus humans. For example, mice carry most of the plasma cholesterol in HDL, while humans carry much of it in LDL . It is sIn summary, dietary recommendations to prevent and manage MAFLD should focus not only on quantity but also quality of the diet. Our study clearly demonstrated that modifying types of fat in the diet can lower risk of MAFLD progression and improve features of MS. Yet, it is very important to understand that “transfat free” and/or “palm oil free” labeling should not indulge people in buying high fat or processed food.Altogether, this study provides important information on the role of different types of fat for development and progression of MAFLD and could be used to inform policy makers discussing the new European Union (EU) regulations to promote better food environments.


Background: There is a high prevalence of mental illness among healthcare students, and most students with mental health problems are reluctant to seek help from mental health professionals. Help-seeking is a component of mental health literacy (MHL). Although MHL is conceptualized as multi-dimensional, a theory-based multi-construct of MHL is still lacking. We aimed to build a theory-based multi-construct of MHL to explore the pathways of help-seeking. Methods: The data were obtained from a survey on MHL among healthcare students in 2018 (n = 1294). The Mental Health Literacy Scale for Healthcare Students was used to measure the maintenance of positive mental health, recognition of mental illness, mental illness stigma attitudes, help-seeking efficacy, and help-seeking attitudes. Descriptive analysis and structural equation modeling (SEM) were conducted. Results: The findings of the SEM model indicated recognition of mental illness had a positive direct effect on both help-seeking efficacy and maintenance of positive mental health. Additionally, help-seeking efficacy fully mediated the relationship between recognition of mental illness and help-seeking attitudes. Conclusions: Help-seeking efficacy plays a significant role in healthcare students’ willingness to seek professional help when mental health care is needed. Accordingly, improving help-seeking efficacy strategies would increase the use of mental health services and contribute to the prevention of mental health problems. College students often find themselves suffering from mental health problems , with clMental health literacy (MHL) plays an important role in seeking mental health professional help . Based oSeveral theories and models have been applied to mental health help-seeking. First, the model for mental health help-seeking shows three stages of the pathway for seeking help from mental health professionals: problem identification, decision to seek help, and service selection . It is wSome factors are related to recognition of mental illness and help-seeking attitudes, such as mental illness stigma attitudes, help-seeking efficacy, and the maintenance of positive mental health. First, it has been indicated that individuals with better knowledge of mental health disorders have less stigma toward mental illness ,29,30. STo understand the process of mental health help-seeking among healthcare students, we aimed to propose, build, and validate a theory-based construct of MHL. Based on previous studies, a hypothesized model linking recognition of mental illness to help-seeking attitudes was proposed : higher We used data from the MHL survey in Taiwan . The parWe used the Mental Health Literacy Scale for Healthcare Students (MHLS-HS) , which cThe maintenance of positive mental health subscale comprised 10 items to assess knowledge about the maintenance of positive mental health. All items used a 5-point Likert rating scheme, ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicated better levels of positive mental health information. Internal consistency was good (Cronbach’s α = 0.87) .The subscale of mental illness recognition included items that identify serious and common mental disorders . The participants were asked to indicate the extent to which they agreed with each statement describing the symptoms and characteristics of someone with a specific mental illness. Responses were rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicated a better ability to correctly recognize the signs and symptoms of mental disorders. It demonstrated acceptable internal consistency (Cronbach’s α = 0.70) .The subscale of mental illness stigma attitudes measured the concepts of stigma, including public stigma , dangerousness , and emotional reactions . There were six items rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher levels of mental illness stigma attitudes. The internal consistency reliability was 0.76 .The help-seeking efficacy subscale included items regarding knowing who, where, and when to seek mental health professional help. There were three items rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater knowledge of mental health resources. The internal consistency reliability of the subscale was good (Cronbach’s α = 0.81) .The subscale of help-seeking attitudes measuring the attitude toward seeking professional help from psychological difficulties was composed of three items on a 5-point Likert scale. Responses to the subscale ranged from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicated a more positive attitude toward seeking mental health professional help. The subscale demonstrated acceptable internal consistency (Cronbach’s α = 0.72) .SPSS version 23 was used for the descriptive and other statistical analyses. AMOS version 21  was usedp (p + 2) (where p is the number of observed variables), it shows multivariate normality. SEM with a maximum likelihood estimation was conducted to test the fitness of the hypothesized model for the maintenance of positive mental health, recognition of mental illness, mental illness stigma attitudes, help-seeking efficacy, and help-seeking attitudes. To assess the goodness of fit of the proposed model, the following indices were used [2/df), goodness-of-fit index (GFI), comparative fit index (CFI), square error of approximation (RMSEA), and standardized root mean squared residual (SRMR). The procedure of the bootstrap bias correction procedure was used to examine the mediation effects [p < 0.01 to reduce type II errors [p-value less than 0.01.Before performing SEM, the multivariate normality should be tested. It was established using Mardia’s coefficient using Bollen’s method . Accordiere used ,43,44: t effects . StandarI errors ,47. The n = 970) and public health students (n = 324). Accordingly, we used the MHLS-HS scores of all students, including medical and public health students, for subsequent analyses. The values of the five components of MHL met the criteria for skewness (range between −0.67 and 0.24) and kurtosis (range between −0.14 and 0.89), indicating that the data satisfied the assumption of normal distribution. Tolerance was 0.92–0.95 (>0.10), and VIF was 1.04–1.09, which were smaller than the criterion value of 5 [There was no significant difference in the scores of the five subscales of the MHLS-HS between medical students  = 483, confirming multivariate normality. The model fit indices indicated that this model fit the data . p < 0.001) and maintenance of positive mental health , showing that individuals had greater ability to recognize mental illness, and greater knowledge about mental illness care resources, and positive mental health. Furthermore, help-seeking efficacy was found to directly influence help-seeking attitudes , revealing a higher help-seeking efficacy and a more positive attitude toward seeking mental health professional help. Comparable results were observed when using the original 26 items of the MHLS-HS . However, the indirect effects of mental illness stigma attitudes  and the maintenance of positive mental health  were not significant. In summary, only help-seeking efficacy mediated the relationship between recognition of mental illness and help-seeking attitudes, whereas the direct path from recognition of mental illness to help-seeking attitudes was not significant . This indicated a full mediating effect of help-seeking efficacy on the relationship between recognition of mental illness and help-seeking attitudes. The similar findings were reported when we conducted mediating effect testing with the original 26-item scale  between recognition of mental illness and help-seeking attitudes were examined to determine statistical significance using the bootstrap assessment procedure. The results are shown in This is the first study to build a theory-based multi-construct of MHL to examine the relationship among the five components of MHL, providing a more thorough understanding of the relationship between the maintenance of positive mental health, recognition of mental illness, mental illness stigma attitudes, help-seeking efficacy, and help-seeking attitudes within healthcare students. We found that recognition of mental illness was positively correlated with help-seeking efficacy and the maintenance of positive mental health. Additionally, healthcare students with better knowledge of mental health resources were willing to seek help for mental health problems. Finally, improving recognition of mental illness led to a greater help-seeking efficacy, which eventually enhanced attitudes toward help-seeking.Several pathways were found to have direct effects in the present study. First, individuals with better recognition of mental disorders enhanced their help-seeking efficacy, which is consistent with previous studies ,52. IndiIn the parallel mediation model of MHL, three indirect effects were examined. First, help-seeking efficacy was found to have a fully mediating role in the relationship between recognition of mental illness and help-seeking attitudes. This result is consistent with help-seeking theory , implyinSecond, the results indicated that mental illness stigma attitudes did not mediate the relationship between recognition of mental illness and help-seeking attitudes. Only a handful of studies have examined the mediating role of mental illness stigma attitudes on the association between awareness of mental health problems and willingness to seek help, with mixed findings to date ,20. A poFinally, we found that the maintenance of positive mental health did not mediate the relationship between recognition of mental illness and help-seeking attitudes. Although recognition of mental illness had a direct effect on the maintenance of positive mental health, the maintenance of positive mental health was not found to correlate with help-seeking attitudes. The knowledge, attitude, and practice (KAP) model posits that knowledge positively influences an individual’s attitude; and attitude, in turn, influences practice or behavior . MoreoveThe present study has several limitations. First, this study was cross-sectional, and clear causal associations among the five components of MHL could not be determined. Second, the scale is a self-reported measurement, which may be vulnerable to social desirability bias. Finally, the participants were limited to medical and public health students rather than a representative sample of healthcare professionals and students, suggesting that results may not be able to be generalized for health professionals and students in other disciplines. A suggestion for future studies is to investigate the actual help-seeking behaviors of the participants. Moreover, more studies are needed with longitudinal data to better understand the causal associations between help-seeking attitudes and help-seeking behaviors. Such studies may explain why individuals sometimes fail to behave in a way they would like to, even though they have existing and strong intentions .To conclude, the present study established a theory-based multi-construct of MHL to explain the process of mental health help-seeking among healthcare students. We demonstrated that help-seeking efficacy mediated the relationship between recognition of mental illness and help-seeking attitudes. Healthcare students with better recognition of mental illness improve their help-seeking efficacy, which eventually enhances their willingness to seek help from mental health professionals. These findings have important implications for mental health promotion, which should target help-seeking efficacy in healthcare students. This study adds support to previous literature on mental health education to promote the need to seek help by providing empirical evidence, suggesting that, among Taiwan healthcare students, the effect of recognition of mental illness on mental health help-seeking attitudes is mediated by one’s knowledge about mental health care services. Mental health education would be a crucial step to improve recognition of mental illness, strengthen help-seeking efficacy, and ultimately promote better attitudes toward mental health help-seeking and actual help-seeking behavior.


The application of chimeric antigen receptor (CAR) T-cell therapy as a tumor immunotherapy has received great interest in recent years. This therapeutic approach has been used to treat hematological malignancies solid tumors. However, it is associated with adverse reactions such as, cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), off-target effects, anaphylaxis, infections associated with CAR-T-cell infusion (CTI), tumor lysis syndrome (TLS), B-cell dysplasia, hemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS) and coagulation disorders. These adverse reactions can be life-threatening, and thus they should be identified early and treated effectively. In this paper, we review the adverse reactions associated with CAR-T cells, the mechanisms driving such adverse reactions, and strategies to subvert them. This review will provide important reference data to guide clinical application of CAR-T cell therapy. Several studies have explored various methods for treatment of malignant tumors. In 2008, American immunologists James P Alison and Japanese immunologists Tasuku Honjo won the 2018 Nobel Prize in physiology or medicine for their contributions to the field of tumor immunity. The findings of the study provide basis for development of novel treatment methods for malignant tumors, and indicate that tumor immunotherapy has a huge potential for treatment of various tumors. CAR-T cell therapy, a type of tumor immunotherapy has been widely explored over the past few years, and is widely used in treatment of malignant tumors. CARs can target any cell surface molecules. CAR does not require antigen processing or human lymphocyte antigen (HLA) presentation unlike T cell receptor (TCR)-modified T cells. Therefore, it is broadly applicable to patient populations with different HLAs  CAR-T cells release numerous cytokines after being activated, such as IL-6, IL-10, TNF-α, GM-CSF, and IFN-γ. Out of these cells levels of IL-6 are significantly higher compared with the levels of other cytokines. These cytokines thus induce CRS , 24. (b)Clinically, different treatment plans are used for treatment of CRS based on the CRS grade. Symptomatic treatment is adopted for patients with grade 1 CRS; supportive and symptomatic treatment are adopted for patients with grade 2 CRS, and patients who are elderly or have serious complications should receive immunosuppressive therapy. Supportive treatment and immunosuppressants are adopted for patients with grade 3 and 4 CRS . Most coCurrently, diagnosis of CRS mainly depends on clinical manifestations of patients. Cytokines or other biomarkers related to occurrence and development of CRS are screened, and targeted intervention and treatment is administered on time based on changes in levels of these biomarkers, to effectively prevent, block and treat CRS. However, it is challenging to find key cytokines of CRS and their associated treatment time points. This is mainly because CRS is caused by a variety of cytokines and multiple factors. Furthermore, the onset time of CRS is different in different patients. Some patients may develop CRS on the first or second day after receiving CAR-T cells, and some patients may develop CRS several days later or even later, therefore the timing of detecting cytokine changes is not definite. In addition, several types of related cytokines are present during the onset of CRS, and it is expensive to detect CRS-related cytokines at regular intervals (a few hours or every day). The optimum time point for anti-cytokine therapy for CRS is still being investigated. Freyer et al.  reports ICANS also known as neurotoxicity, is the second most frequent adverse event of CAR-T cell therapy. It can occur simultaneously with or after presentation of CRS. ICANS is activation or participation of T cells (autologous or exogenous) and/or other immune cells after receiving any immunotherapy, resulting in neurotoxic symptoms . The terPathogenesis of ICANS has not been fully explored. Studies report that ICANS pathogenesis may be related to the following factors: (a) Levels of IL-1, IL-6, IL-15, TNF-α, and IFN-γ in blood are elevated, and are positively correlated with severity of ICANS , 52, 53.The therapeutic regimens of ICANS include  fasting Currently, diagnosis of ICANS mainly depends on clinical manifestations of patients. However, similar to CRS, it is challenging to find key cytokines associated with ICANS pathogenesis and the time points of treatment related to them. CRP and ferritin can be used in prediction and diagnosis of ICANS. Karschnia et al.  analyzedFor effective targeted therapy, tumor antigens to be targeted should only be expressed on tumor cells, and not expressed or expressed in very low on normal cells. These tumor antigens are known as tumor-specific antigens (TSAs). However, TSAs are few, and tumor-associated antigens (TAAs) are mainly used for targeted therapy Most CAR-T cells currently used in clinical trials contain antigen-recognition domains derived from murine monoclonal antibody (mAb) , which mInfections associated with CTI are relatively common in CAR-T cell therapy. In a clinical trial using CD19-CAR-T cells to treat relapsed B-cell acute lymphoblastic leukemia (B-ALL), about 42% of 53 patients developed infections during the first 30 days after CTI. The infections were mainly bacterial, with bloodstream infections (BSIs) showing the highest incidence . From 31Currently, the mechanism of CTI occurrence is unclear, and there is no unified treatment plan for prevention and treatment of CTI. The most commonly used CD19-CAR-T cell therapy and causes of infection after CTI may include (a) Severe CRS and/or CRES as a result of CAR-T cell therapy. These patients mostly undergo treatment in intensive care unit (ICU), which may increase the risk of nosocomial infections , 99; (b)The main prevention and treatment measures for CTI related infections include (a) Paying attention to protection and avoiding cross-infections; (b) Administration of antibiotics and immunoglobulins to prevent and treat infections ; (c) RedA large number of tumor cells appear necrosis in a short time, resulting in the release of high amounts of intracellular substances and metabolites into the blood. Kidneys do not completely eliminate these substances, resulting in a range of serious metabolic disorders and clinical symptoms. This condition is known as TLS. Main clinical manifestations of TLS include hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. In severe cases, patients may develop acute renal failure and severe arrhythmia. Incidence of TLS in hematological malignancies is significantly higher compared with that of solid tumors, especially large volume tumors and tumors characterized by vigorous metabolism, such as B-cell lymphoma, which has the highest risk of TLS . Use of Principles of treatment of TLS are similar despite the cause. Prevention and treatment principles of TLS include (a) Adequate hydration ; (b) Urine alkalization is no longer recommended due poor efficacy and can also precipitate calcium phosphate in the renal tubules; (c) Hypouricemic agents can be used. For patients with low or moderate risk, allopurinol can be used as a first preventive drug , 105. RaCurrently, CD19 is the most frequently used target for CAR-T cells in treatment of hematological malignancies. Other targets include CD20, CD22, CD23, CD33, and CD123. CD19 is highly expressed on benign and most malignant B cells (non-B cells are characterized by low expression levels) . In addiHLH is a clinical syndrome characterized by excessive inflammation. It is caused by abnormal proliferation of lymphocytes and tissue cells, resulting in release of high levels of inflammatory cytokines. The main clinical manifestations of HLH include fever, hepatosplenomegaly, abnormal liver function, decreased blood cells, increased triglycerides, increased serum ferritin [≥500μg/L ] and decHLH/MAS is a relatively rare disease with high mortality  anEBV) induce occurrence of sHLH (Mechanisms of CAR-T-related HLH/MAS include (a) Lysis of tumor cells result in release of large quantities of inflammatory cytokines and pro-inflammatory cytokines , 117; b, 24; (d) of sHLH .EBV infection. Cyclosporine, a second line drug causes neurotoxicity , in combination with gamma globulin , the regimen can be repeated on day 14 . If clintoxicity  and shoutoxicity . MoreoveCoagulation dysfunction often occurs during treatment with CAR-T cell therapy. Approximately 51%-56.6% of patients with hematological malignancies develop coagulation disorders after receiving CAR-T cell therapy , 125. CoMechanisms of CAR-T-related coagulation disorders are not fully known, and may be linked to the following mechanisms: (a) Blood from patients with malignant tumors is in a hypercoagulable state ; (b) HigPatients with coagulation disorders can be treated with conventional treatment approaches. Most patients with coagulation disorders can recover without intervention . When CRCytopenia is a common adverse reaction in CAR-T cell therapy which is characterized by neutropenia, thrombocytopenia and anemia. Its incidence is not consistent, which can be attributed to different types of diseases and treatment options. Studies from the last three years Table 3,To improve the efficacy of CAR-T cells, patients should be given the lymphodepleting chemotherapy regimen before CAR-T cell therapy. Currently, the most commonly used regimen is the combination of fludarabine and cyclophosphamide. Patients often develop cytopenias after receiving lymphocyte clearance therapy. Early cytopenias may be as a result of lymphatic failure chemotherapy .It has been shown that cytopenias developing after CAR-T cell therapy may last for a long time, exceeding 30 days , 139. ThAlthough the development of PHT is not well understood, it may be triggered by the following factors: (a) PHT can be caused by a previous administration of higher-intensity chemotherapy ; which mThe treatment of cytopenia: (a) Patients with early and mild cytopenias, symptomatic and nutritional support are recommended. For such patients with neutropenia, active prevention or anti-infective treatments can also be given. (b) For patients with long-term neutropenia, granulocyte-colony stimulating factor (G-CSF) treatment is recommended. Currently, the U.S. Food and Drug Administration has approved the use of G-CSF (filgrastim) in the treatment of congenital and acquired neutropenia . The recAs an emerging anti-tumor therapy, CAR-T cell therapy has made great achievements in the treatment of hematological malignancies. Currently, this therapy has begun to be applied to the research and treatment of solid tumors. However, it is associated with adverse reactions which limits its clinical application to a certain extent. Only by minimizing the incidence and impact of these adverse reactions can the safety of CAR-T cell therapy be effectively enhanced. By effectively preventing and treating these adverse reactions, more and more tumor patients will benefit from CAR-T cell therapy.LM: Writing-Original draft preparation, Investigation, table and figure preparation. ZZ: Investigation, table and figure preparation. ZR: Investigation. YL: Conceptualization, Methodology, Supervision. All authors contributed to the article and approved the submitted version.This work was supported by Special Research Project of Lanzhou University Serving the Economic and Social Development of Gansu Province (054000282), Lanzhou Talent Innovation and Entrepreneurship Project (2020-RC-38), and Supported by the Fundamental Research Funds for the Central Universities (lzujbky-2020-kb14).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.


We used longitudinal data from the Health and Retirement Study (1998-2016) to estimate sex-specific age-graded changes in global cognition and memory among White, Black, and U.S.- and foreign-born Latino adults 51 years and older. Among males, racial/ethnic and nativity differences in cognitive function were mainly evident at younger ages, particularly for Blacks compared to Whites. We found no evidence to support male racial/ethnic or nativity differentials in trajectories of cognitive aging. For women, older Blacks and U.S.-Born Latinas, and to a lesser degree foreign-born Latinas, had lower cognitive function at younger ages. However, White women showed more pronounced cognitive aging in comparison to U.S.- and foreign-born Latinas. Results applied to both global and memory outcomes. Our findings support calls for nuanced considerations of racial/ethnic and nativity effects on cognitive aging and ADRDs. Continued monitoring of differential cognitive aging trends is warranted as the vascular and neurologic sequelae of COVID-19 manifests.


The recent advancement in spatial transcriptomics technology has enabled multiplexed profiling of cellular transcriptomes and spatial locations. As the capacity and efficiency of the experimental technologies continue to improve, there is an emerging need for the development of analytical approaches. Furthermore, with the continuous evolution of sequencing protocols, the underlying assumptions of current analytical methods need to be re-evaluated and adjusted to harness the increasing data complexity. To motivate and aid future model development, we herein review the recent development of statistical and machine learning methods in spatial transcriptomics, summarize useful resources, and highlight the challenges and opportunities ahead.The online version contains supplementary material available at 10.1186/s13059-022-02653-7. In unicellular and multicellular organisms, arranged cells work collaboratively in intact tissues. Spatially resolved transcriptomics performs high-throughput measurement of transcriptomes while preserving spatial information about the tissue context and cellular organizations –8 spati–12] . Therefore, an important preprocessing step is to estimate the proportions of different cell types in each capture location using spatial decomposition algorithms, which is similar to the concept of cellular deconvolution. Traditionally, cellular deconvolution commonly refers to estimating the proportions of different cell types in each sample based on its bulk RNA-seq data. Theoretically, methods designed for bulk RNA-seq data deconvolution could be adopted for spatial transcriptomics data . DWreoscope  also utireoscope  assumes k-nearest neighbor (KNN) to identify mutual nearest neighbors and to construct a link graph. In the constructed link graph, two nodes are connected if they are mutually nearest neighbors   predictst-distributed stochastic neighbor embedding (t-SNE) to embed the scRNA-seq cells into a three-dimensional map based on a cell-by-cell affinity matrix learned from ligand-receptor expression networks . CommonThere exists an increasing number of resources for spatial transcriptomics research. SpatialDB  is a curChallenges remain in the algorithm development for analyzing spatial transcriptomics data. As the field has achieved transcriptome-wide sequencing, spatial transcriptomics data quality is still limited by reduced coverage and low cellular resolution . scRNA-ssystematic benchmark studies, like what has been done for scRNA-seq data analyses . Even tiewed in . A methoiewed in  is a comnowledge , the introteomes , whereasroteomes . By emplroteomes . Additioussed in , and theussed in . CCFs haa tissue . Computaa tissue . Furtherch as in , 111.Spatial transcriptomics grants us a spatial perspective in addition to the expression data and hence allows for new angles to explore different areas of biological research. In this review, we surveyed the current advances in computational methods for integrating and analyzing spatial transcriptomics data, with a focus on the topics of localized gene expression pattern identification, spatial clustering, spatial decomposition, gene imputation, spatial location reconstruction, and cell-cell/gene-gene interaction inference. To aid future method development, we thoroughly summarized the datasets . Summary of datasets and baseline methods for benchmark studies reviewed in the paper.Additional file 2. Review history.


There is compelling support for widening the role of computed tomography (CT) for COVID-19 in clinical and research scenarios. Reverse transcription polymerase chain reaction (RT-PCR) testing, the gold standard for COVID-19 diagnosis, has two potential weaknesses: the delay in obtaining results and the possibility of RT-PCR test kits running out when demand spikes or being unavailable altogether. This perspective article discusses the potential use of CT in conjunction with RT-PCR in hospitals lacking sufficient access to RT-PCR test kits. The precedent for this approach is discussed based on the use of CT for COVID-19 diagnosis and screening in the United Kingdom and China. The hurdles and challenges are presented, which need addressing prior to realization of the potential roles for CT artificial intelligence (AI). The potential roles include a more accurate clinical classification, characterization for research roles and mechanisms, and informing clinical trial response criteria as a surrogate for clinical outcomes. Computed tomography (CT) is not being used to its full potential toward a better understanding of COVID-19. The reverse transcription polymerase chain reaction (RT-PCR) test is the current gold standard for diagnosing COVID-19 through the detection of nucleic acid present in SARS-CoV-2, the virus that causes COVID-19 . One of To complement the use of standard chest CT for COVID-19 characterization and to further contribute to the body of knowledge for combating the pandemic, artificial intelligence (AI) could be utilized to improve the ability of CT to swiftly and accurately flag CTs for immediate interpretation, characterize COVID-19 for clinical research, such as response to medical countermeasures, and potentially increase patient safety by optimizing radiation exposure.To address the aforementioned weaknesses of RT-PCR , CT could be used in conjunction with RT-PCR in selected target populations with a high risk for COVID-19, such as at the point of care (POC) in an outbreak setting. In such a POC setting, CT could be used to identify possible cases, and RT-PCR would be used to confirm conclusive diagnosis. CT might solve the problem of delayed results because CT results with or without AI models are obtained more quickly compared to RT-PCR. CT scanners are widely available and offer reliable daily accessibility. Moreover, CT has been shown to assist with detecting possible cases of COVID-19, even among asymptomatic patients, which may be important given the public health conundrum of presymptomatic and asymptomatic transmission . Some stCertain high-risk patients who undergo CT in an outbreak setting or after a high dose exposure might be identified by CT and isolated or quarantined while they await RT-PCR results, thus reducing the risk of transmission . CT scanThere is a precedent for widening the role of chest CT in COVID-19 evaluation. Although some US and UK guidelines have recommended against using chest CT for screening , other cFurthermore, early in the pandemic, the United Kingdom provided intercollegiate guidelines stating that patients undergoing elective surgery required chest CT beforehand if the procedures were high risk or if the patients were expected to require admission to the intensive therapy unit or high dependency unit postoperatively . AdditioAI is a promising tool to increase the potential suitability of chest CT for COVID-19 screening, detection, monitoring, and research in certain highly constrained settings. AI has already been applied in many technologies developed in response to the emergence of COVID-19 , includiCurrently, a common recommendation among medical and public health organizations is that CT should not be used for screening, and it should only be used for COVID-19 in patients with moderate to severe symptoms of COVID-19, worsening respiratory status, or indications of cardiopulmonary complications, and only when RT-PCR is unavailable or RT-PCR access is highly limited. Despite the high sensitivity of chest CT for COVID-19 in high-prevalence settings, one reason why chest CT is not more widely recommended for COVID-19 diagnosis is that the imaging findings are nonspecific, overlapping with many other diseases such as influenza, H1N1, SARS, MERS, and pneumonias with underlying causes other than SARS-CoV-2 . One stuIn a particularly promising study by However, the overall pool of research on AI-assisted chest CT is at a very early stage, with many limitations, generalizations, overfit models, and reproduction of similar models. Image-based AI models abound that lack external validation, clinical metadata and relevant clinical labs, phase of disease parameters, or background prevalence data. Two separate reviews on this research topic have highlighted the shortcomings. One was a systematic review on machine learning literature related to the use of CT and CXR imaging for COVID-19 diagnosis and prognosis . It did One of the risks associated with CT imaging is radiation exposure. Regarding patient safety, AI-based estimations of body region thickness could calculate optimal X-ray exposure parameters and AI-generalized adversarial networks could facilitate low-dose imaging. The population risks of more broadly using chest CT scans for enhanced indications in COVID-19 remain to be defined or fully justified for specific settings and remain a concern.Looking forward, AI could be used to improve the sensitivity and efficiency of chest CT for detecting COVID-19 and to increase the effectiveness of CT as a disease response or a monitoring tool for both research and clinical practice. AI could further enhance the ability of CT to provide quantification of objective biomarkers of response to experimental treatment programs for specific cohorts of patients. AI could also help optimize the CT image quality through the development of automated, high-precision Iso-centering and scan range determination.CT AI might provide a standardized measure and surrogate biomarker metric for lung disease. Speculative uses of CT AI include the measurement of clinical response to therapeutics like steroids, monoclonal antibodies, or anti-inflammatory medications. It is unknown whether CT AI could help identify chronic lung changes in chronic COVID-19 breathlessness, variant-specific features, or early detection of at-risk phases of disease exacerbations (either primary infectious opacities or immune or inflammatory phase reactions). We have a lot to learn and CT AI adds a tool to the discovery toolbox.In conclusion, there are compelling reasons to be attracted toward studying chest CT as a tool for developing a better understanding of COVID-19. Clinical public health and research goals for COVID-19 might be enlightened by a targeted application of chest CT and CT AI to seeking answers for specific clinical and research questions in specific outbreak or therapeutic settings. Additional research and data are required to determine the exact roles of chest CT in early detection, classification, and triage of resource-limited therapies, and its potential role as an epidemiology tool in limited targeted populations. The pandemic has proved to be an “AI-instigator”; however, AI-assisted CT tools will require more rigorous academic development, broader clinical metadata, and more thorough critical review in hopes of more generalized tools with clinical or research relevance. We can do better. The times demand it.


In sub-Saharan Africa, there is a significant unmet need for emergency care, with a shortage of trained providers. One model to increase the number of providers is to task-share: roles traditionally filled by clinicians are shared with lay workers who have received task-specific training. Separately, there has been much recent interest in the possible implications of artificial intelligence (AI) on healthcare. This paper proposes that, by combining the task-sharing model with AI, it is possible to design an Emergency Unit (EU) that shares the tasks currently undertaken by physicians and nurses with lay providers, with the activities of lay providers guided and supervised by AI. The proposed model would free emergency care clinicians to focus on higher-acuity and complex cases while AI-supervised routine care is provided by lay providers. The paper outlines the model for such an implementation and considers the potential benefits to patient care, as well as considering the risks, costs, effect on providers, and ethical questions. The paper concludes that AI and healthcare workers can operate as a team, with significant potential to augment human resources for health in sub-Saharan Africa. In sub-Saharan Africa, there is a significant unmet need for emergency care . MultiplDesign hypothesis for AI-supervised low- and moderate-acuity care: this section outlines a model of AI-supervised care in the EU. It argues that a team of four LPs, supervised by AI, can safely deliver high-quality patient care in an efficient, cost-effective manner. Practically, AI ‘supervision’ will involve the AI system giving LPs instructions and prompts (via an electronic device) to direct patient care. The inputs that AI will receive include: responses to AI-directed questions, vital signs and basic examination findings, results of bedside, imaging and/or laboratory tests. The proposed patient journey begins with a dedicated triage LP who takes the patient´s demographic information, history, and performs a focused examination. AI-assisted prompts will ensure that relevant questions are covered, tailored to the presenting complaint. AI interprets the history in conjunction with the clinical findings and arranges the appropriate further investigations and treatment. The patient then moves to a procedural LP who performs routine EU procedures  as necessary, directed by AI. Next, the patient moves to a treating LP who can administer medications, as directed by the AI system, and can perform basic orthopaedic procedures . The patient then moves to a waiting area where a nursing LP re-checks vital signs and engages in shared decision-making with the patient as directed by AI-given prompts. The ultimate disposition of the patient, guided by the interpretation of the history, of clinical examination, of investigations, is decided by this final shared decision-making process, overseen by the AI system. Finally, the patient is provided with discharge and follow-up instructions, or a handover is generated to clinical staff if the patient is being admitted or transferred. Importantly, it should be noted that the AI-supervised model can be operated in parallel; namely, multiple teams of four LPs can operate side-by-side simultaneously. An example of AI-supervised patient flow is given in Table 1.Impact on patient care: almost two-thirds of patients presenting to African EUs require assessment that is either routine or moderately urgent [y urgent . Evidency urgent , 18. Regy urgent , 20. Oney urgent . There iy urgent ; though y urgent . In the y urgent . AI-supey urgent . A secony urgent , 27. Resy urgent , 29. They urgent , and inty urgent . TherefoRisks: as the proposed model is hypothetical, there are no data comparing clinician-led to AI-led emergency care. A recent observational study in India found that Watson for Oncology, an AI-driven cognitive computing system, made treatment recommendations that were 93% concordant with a multidisciplinary team of oncology experts [ experts . This de experts . These r experts . However experts . NonetheImpact on providers: while the evidence suggests that LPs can be as effective as traditionally-trained healthcare workers [ workers , it is o workers , 38. Thu workers . SimilarCost: based on existing data for personnel costs and emergency physician productivity [uctivity , 41, oneuctivity , 43. Theuctivity .Ethics: mistakes will be made in an AI-supervised EU. Some of these mistakes will lead to ‘AI-atrogenic’ morbidity and mortality. The question of whether the mortality benefits outweigh the harms is an empirical one, but the question of how to design and test such a system is ethical. AI-led care can be delivered in areas where experienced ECPs are in short supply. Should an AI-supervised EU be compared to existing care? Or to a traditional EU run by ECPs? Or to an EU run by ECPs and with AI-directed care (and no lay providers)? Given the complex and problematic history of medical research in Africa [n Africa , it is cn Africa .Africa has a recent history of ‘leap-frogging’ its Western cousins in the adoption of technology; recent examples include drone-delivery services for medical products in Rwanda and bank accounts held via mobile phones in East Africa. Emergency care could become another example whereby a limitation (a paucity of trained ECPs) forces an innovation (AI-led emergency care) which surpasses the equivalent in the West. This essay has proposed a model whereby a team of LPs, supervised by AI, provides routine care for low- and moderate-acuity patients in EUs in sub-Saharan Africa. It has been argued that, if correctly implemented, such a model could deliver consistent high-quality patient care and widen access with substantial running cost savings relative to the traditional model of EU care. Considering possible risks, effects on providers, and ethics, it was concluded that while AI-supervised care may offer benefits, the design, testing and implementation would need to be judiciously and carefully guided by a range of African stakeholders. The role of AI in facilitating healthcare delivery resource-poor settings is increasingly being realised. The hypothesised model could become part of a solution to enrich human resources for health in Africa.