The Covid-19 pandemic has challenged hard the national health systems worldwide. According to the national policy issued in March 2020 in response to the evolving Covid-19 pandemic, several hospitals were re-configured as Covid-19 centers and elective surgery procedures were rescheduled according to the most recent recommendations. In addition, Covid-19 protected cancer hubs were established, including the Regina Elena National Cancer Institute of Rome, Central Italy. At our Institute, the Breast Surgery Department continued working under the sign of a multidisciplinary approach. The number of professional figures involved in case evaluation was reduced to a minimum and interactions took place in the full respect of the required safety measures. Treatments for benign disease, pure prophylactic surgery and elective reconstructive procedures were all postponed and priority was assigned to the histologically-proven malignant breast tumors and highly suspicious lesions. From March 15th though April 30th 2020, we treated a total of 79 patients. This number is fully consistent with the average quantitative standards reached by our Department under ordinary circumstances. Patients were mostly discharged the day after surgery and none was readmitted due to surgery-related late complications. More generally, post-operative complications rates were unexpectedly low, particularly in light of the relatively high number of reconstructive procedures performed in this emergency situation. A strict follow up was performed based on the close contact with the surgical staff by telephone, messaging apps and telemedicine.Patients ascertainment for their Covid-19 status prior to hospital admission and hospital discharge allowed to maintain the “no-Covid-19” status at our Institution. In addition, during the aforementioned time window, none of the care providers developed SARS-CoV-2 infection or disease, as shown by the results of anti-SARS-CoV-2 immunoglobulin M and G profiling. In conclusions, elective breast cancer surgery procedures were successfully performed in a lockdown situation due to a novel viral pandemic. The well-coordinated regional and hospital efforts in terms of medical resource re-allocation and definition of clinical priorities allowed to maintain high quality standards of breast cancer care while ensuring safety to the cancer patients and care providers involved. On the 20th of February 2020, in Italy, the first case of acute interstitial pneumonia related to an infection by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was detected. Within few weeks, the number of cases of SARS-CoV-2 infection and related disease Covid-19) increased exponentially until the 21st of March, when a slow and constant decline began. The World Health Organization (WHO) declared the Covid-19 outbreak as a pandemic on the 11th of March 2020 9 increas. In respEarly reports from China have conveyed a quite alarming message concerning an increased risk of SARS-CoV-2 infection and disease with particularly unfavorable outcomes in cancer patients. Subsequent work has clarified the need of interpreting this evidence with caution in light of the restricted sample size, heterogeneity of the study population, bias and confounding which may all concur to limit the generalizability of these findings to the entire cancer patient population, at a national and international level , 6. HoweThe Breast Surgery of the Regina Elena Cancer Institute of Rome is an OECI-accredited tertiary referral facility, which includes two Surgical Divisions, i.e., the Breast and Plastic Reconstructive Surgeries, that overall perform about 600 procedures for primary breast cancer yearly; it is located in a wing of the main hospital building, apart from other surgical Divisions and allocates twenty-four adjustable beds in twelve rooms of twenty square meters with bathroom. At the time the national lockdown was declared, our Institution was identified as a regional oncologic hub. We herein report on the experience matured at the Department of Breast Surgery during the lockdown issued in response to the Covid-19 pandemic. Results are reported and discussed concerning the quali-quantitative standards reached under ordinary circumstances, as well as in light of key safety issues and inherently adopted measures.Triage procedures were applied to each cancer patient prior to hospital admission, independently on the specific regimen, e.g., ordinary vs ambulatory. These procedures were repeated prior to hospital discharge to unveil unnoticed hospital exposures. In both the cases, specifically trained personnel administered an ad hoc questionnaire focused on the recent occurrence of the most common Covid 19-related symptoms and contacts with people from the “red zones”. In addition, prior to their admittance to the hospital building, patients’ body temperature was detected by thermo scannersNasopharyngeal swab 48 h before the scheduled surgeryLimited access to the pre-hospitalization areaPatients staying in single rooms and wearing face masksNo relatives admitted to the ward. In the case of not self-sufficient patients, only one relative with face mask and negative triage/swab was allowedAdequate personal protective equipment, including disposable surgical masks, gloves, gowns and face shields, when deemed necessaryPersonal hand hygiene before and after contact with patientsDaily assessment of body temperature for patients and staffReduced crowding in operative room and adequate distance in the awakening areaLowered amount of aerosol during the operative procedures, e.g., lowest effective power of electrocautery or other energy devices to decrease smoke, extra precaution during creation of pneumoperitoneum and gas deflation in case of concomitant laparoscopic bilateral salpingo-oophorectomy in case of BRCA1/2 mutated breast cancer cases.All the pre-scheduled treatments for benign disease, pure prophylactic surgery as well as elective reconstructive procedures were postponed, and priority was given to the histologically-proven malignant breast tumors and highly suspicious lesions defined as such on the basis of tru-cut biopsies and/or clinical-radiological findings. Ad hoc internal standardized operative procedures were developed and implemented by the institutional risk management team, in full agreement with the guidelines released from the Italian Minister of Health and Health Department of the Lazio Region, which were constantly reviewed and shared through the intranet Institutional web pages. The following safety measures were established:th of May 2020, all staff members have been tested for Anti-SARS-CoV-2 immunoglobulin M and G, and none resulted positive.We continued ensuring multidisciplinary evaluations, which involved one single general surgeon, oncologist, radiotherapist, and plastic surgeon all maintaining adequate social distance and wearing masks. Seven patients had their programmed surgery delayed because of the onset of clinical symptoms , presumably positive swab (2 cases), contact with suspected Covid-19 positive relatives (1 case). All these cases were rescheduled after 15 days following symptoms resolution and 2 consecutive negative swabs. A negative swab was not considered a safety parameter in presence of suspicious symptoms. From March 15th through April 30th, we treated a total of 79 patients (Table This experience clearly shows that elective breast cancer surgery can be safely pursued even in a lockdown situation due to a novel viral pandemic. Thanks to well-coordinated regional and hospital efforts in terms of medical resource re-allocation and definition of clinical priorities, we were able to maintain high quality standards of breast cancer care while mitigating the backlog effect of elective surgical cases once the immediate Covid-19 threat was ebbed. The unexpected absence of increased rates of post-operative complications observed in light of the relative high number of reconstructive procedures performed in this emergency situation confirms what reported elsewhere . It probLastly, we were worried that a reiterated triage could be interpreted by our patients as barrier to their expectations of an expedite operation and induce them to conceal some information. On the contrary, all patients realized the importance of the procedures applied and helped us delineate the complex and rapidly evolving epidemiologic scenario, despite the danger of cancelling previously scheduled surgery.During the lockdown issued in Italy in response to the Covid-19 pandemic, the Breast Surgery Department of the Regina Elena National Cancer Institute continued working according to a multidisciplinary approach. Priority was given to the histologically-proven malignant breast tumors and highly suspicious lesions. From March 15th though April 30th 2020, 79 patients were treated, consistently with our average quali-quantitative standards. Hospitalization was mostly concluded the day after surgery. Post-operative complications rates were unexpectedly low. Telephone contacts, messaging apps and telemedicine allowed for a close follow up. The “no-Covid-19” status of our Institution was maintained. None of the care providers involved developed SARS-CoV-2 infection or disease. In brief, we maintained acceptable quali-quantitative standards of breast cancer care while ensuring safety to our cancer patients and care providers involved.


To determine the appropriate number of histopathological cross-sections that are required for a conclusive diagnosis of giant cell arteritis (GCA).In this cross-sectional study, the number of sections per slide for paraffin-embedded blocks for 100 randomly selected cases where GCA was suspected and those for negative temporal artery biopsies (TABs) were compared with the number of cross-sections per specimen for eight positive-TABs. All aforementioned examinations were conducted at our center from 2012 to 2016. Then, negative-TABs were retrieved and re-evaluated using light microscopy considering the histopathological findings of GCA.P = 0.142) among the eight positive-TABs. Similarly, no significant difference was observed in the number of cross-sections per specimen (P = 0.990) for positive-TABs compared to those for the negative-TABs. After the retrieval of negative-TABs, the mean number of total pre- and post-retrieval cross-sections per specimen was 17.66 Ninety-five paraffin blocks were retrieved. The original mean biopsy length was 15.39 Positive-TABs did not reveal more histological cross-sections than the negative ones and increasing the number of cross-sections did not enhance the accuracy of TAB. As per the guidelines of the American College of Rheumatologists (ACR), diagnosis of GCA is primarily based on the presence of characteristic clinical features and laboratory findings of elevated levels of acute-phase reactants.,6,7 Temporal artery biopsy (TAB) is considered as the gold standard diagnostic test for GCA.,9 A positive-TAB test is mainly defined as vasculitis with infiltration of mononuclear cells with or without the presence of multinucleated giant cells, disruption of the internal elastic lamina, and intimal hyperplasia.,11,12 However, sometimes TAB may indicate intermediate findings that make it difficult to distinguish GCA from other pathologies such as healed arteritis or even arteriosclerosis that occurs in elderly patients.,14 Thus, TAB has low sensitivity and it may show negative results in 15–40% of patients.,17,18,19 Additionally, the number of biopsies, length of the artery sampled, sectioning techniques, and histopathological criteria for diagnosing arteritis, presence of skip lesions, and previous treatment with corticosteroids may contribute to false-negative results.,21Giant cell arteritis (GCA) is characterized by granulomatous vasculitis of large and medium-sized vessels, and its worldwide annual incidence rate ranges from 1.28 to 29.1 per 100,000 among individuals aged over 50 years.This study was performed at a tertiary referral center to determine the appropriate number of cross-sections for a TAB examination that are required for a conclusive GCA diagnosis.In our center, TAB cross-sections are routinely cut into 2–3 mm-long slices and each of them is embedded transversely in a paraffin block. Next, hematoxylin and eosin-stained serial sections of 5-μm thickness are prepared at three-step levels with 25-μm intervals. TAB specimens are considered positive if a narrow lumen, irregular intimal thickening, and fragmentation of the internal elastic lamina with inflammation of the vessel wall (composed of lymphocytes and epithelioid histiocytes with or without multinucleated giant cells) are observed. In borderline cases including those wherein inflammation is limited to the adventitia, additional levels are requested. In this cross-sectional study, the histopathology reports of 205 archived temporal artery biopsies  were re-evaluated. The length of the biopsy and total number of cross-sections per specimen for eight positive-TAB cases were compared with those for a 100 computer-assisted randomly selected negative-TABs, which were performed during the same period. Then, paraffin-embedded blocks of these original negative-TABs were retrieved and >90% of each paraffin block was sectioned. A single ophthalmic pathologist (RAAN) re-evaluated all the newly retrieved sections, considering the previously mentioned histopathological findings that characterize GCA. The methods and main outcomes of the study have been summarized in Figure 1. In addition, the revised ACR-2016 (rACR) scores from the available medical records of patients with positive- and negative-TABs conducted in 2016 were evaluated.P-value SPSS software version 22.0  was used for statistical analyses. Results are reported as mean Of the total 205 TABs conducted during 2012–2016, eight reports were positive for GCA. From the remaining 197 negative biopsies, initially a 100 paraffin-embedded blocks were randomly selected for retrieval. Since five paraffin blocks were not suitable for retrieval, finally the results of 95 specimens were evaluated.The mean age of the patients was 62.75 The number of slides per specimen, cross-sections per slide, and the number of slides per mm of biopsy length before and after retrieval have been summarized in Table 1.P = 0.142) and the number of cross-sections per specimen (P = 0.990) among the eight positive-TABs and when the positive TABs were compared to the pre-retrieval negative-TABs (Table 1). Comparison of the number of cross-sections per specimen for pre-retrieval negative-TABs  of healed arteritis with mild intramural lymphocytic infiltration, narrowing of the lumen, fragmentation, and destruction of the internal elastic lamina with scarring of the artery wall . This patient had an rACR score of 3, and had undergone bilateral TAB, with original pathology reports showing negative results for GCA.Currently, no specific guidelines have been formulated regarding the adequate number of cross-sections needed for accurate biopsy results of TAB specimens.,9 The extent of sectioning, length of the artery, and presence of skip lesions as well as unilateral or bilateral biopsies are among the factors that may affect TAB results.Although TAB is considered as the gold standard test for diagnosing GCA, ambiguous findings may lead to inconclusive diagnosis or inaccurate results. However, occasionally, it may be difficult to distinguish the aforementioned pathology from changes resulting from aging and atherosclerosis.,24,25Characteristic histopathological findings of active GCA include pan-arteritis that is most pronounced in media, with or without multinucleated giant cells and fragmented internal elastic lamina. In contrast, healed arteritis is characterized by diffuse intimal thickening, intimal and medial fibrosis with variable degree of lymphocytic infiltration, loss of internal elastic lamina, and adventitial scarring which correlates with prior history of GCA symptoms and a higher-than-normal erythrocyte sedimentation rate (ESR). Increased ESR is part of the reparative process and not considered a marker for active arteritis.,27,28,29 In a study conducted by Taylor et al for determining the threshold specimen length for pathological examination and interpretation, there was no statistically significant difference between the number of total cross-sections per specimen used for positive-TABs (22.3) and those for the negative ones (21.6). In our study, there was no statistically significant difference in the mean biopsy length and mean number of cross-sections per specimen for the eight positive-TABs compared to those of the negative-TABs before retrieval. These results indicate that diagnosis in positive-TAB cases did not require a greater number of cross-sections than those required in negative ones.According to the literature, routine evaluation of TABs at multiple levels does not enhance the diagnostic yield and is not cost-effective.,29,30 TAB processing at our center is performed using transverse sections according to a recommended protocol, with some modifications that have been described in the Methods section.Methods for the technical processing of a temporal artery differ across centers. Some centers examine the artery in one longitudinal section and two transverse ones, which may be obtained from either end of the artery if the arterial length is sufficient.In this study, we determined that 9.87 ,26,32 Skip lesions are not common in temporal arteritis, and skipped areas are approximately 330 μm to 1 mm in length. Although the idea is controversial, it has been suggested that a length of 5–7 mm could be the threshold for diagnostic sensitivity of TAB.,33 This implies that even short TAB specimens might be sufficient to visualize the histological features of arteritis. Our results indicate that there was only one case of healed arteritis among 95 negative-TAB cases. These results are compatible with those of Chakrabarty et al, wherein only 1 out of 132 cases showed positive GCA features after performing sections at multiple levels. However, the length of the artery in our positive case was 13 mm. The extent of the agreement between the first and second slide readings using the Kappa coefficient before and after the retrieval of the negative-TAB specimens could not be calculated due to high similarity between the results. However, regardless of statistical significance, there was approximately a 98% agreement between the two readings since 94 out of 95 negative-TAB specimens were also negative in the second histopathological evaluation.“Skip lesions,” which are foci of discontinuous vasculitis, are found in 8–28% of GCA-positive biopsies. Otherwise, the chance of a positive second biopsy ranges from 5% to 9%, and if the clinical suspicion is low, a unilateral biopsy is sufficient to rule out the diagnosis. The single biopsy after retrieval that was positive for healed arteritis was that of a left temporal artery from a 67-year-old female, which was taken seven days after a negative-GCA result from the first biopsy of the right artery. She had been treated with intravenous methylprednisolone for three days followed by oral prednisolone at a dose of 1 mg/kg before performing TAB.In general, it is standard to perform a unilateral TAB when GCA is clinically suspected; the contralateral artery biopsy is done if the clinical suspicion is high and the first biopsy is negative. In our case of healed arteritis after retrieval, the specimen was taken seven days after starting steroid therapy. Therefore, the findings could be due to a previous episode of GCA rather than aging-related arterial changes.In general, for cases where GCA is suspected, immediate treatment with high-dose steroids even before a biopsy is recommended. Since the resolution of inflammatory infiltration is usually slow, the chance of detecting active inflammation is not affected by steroid therapy if the biopsy is performed within two weeks.,17,18,19 This phenomenon where a high percentage of people who have negative biopsies are diagnosed with GCA has resulted in disagreement among neuro-ophthalmologists and rheumatologists regarding the criteria for GCA. It has been recommended that TAB should be performed only for patients with rACR scores of 3 and 4, since there is higher variability in TAB results for other patients. Among the 95 suspected GCA cases with negative TABs, we reviewed the medical records of 50 patients whose mean overall rACR score was 3.86 et al (mean score of 3.88 The diagnosis of GCA does not always require a positive-TAB, and approximately 15–40% of patients with GCA are TAB-negative. and 3 tesla-magnetic resonance imaging are new technologies that are now being regularly used in the diagnosis and monitoring of GCA disease progression. Although, the use of non-invasive color duplex ultrasonography reduces the chances of false-negative TABs due to skip lesions, it is an operator-dependent technique.Positron emission tomography,41It is important to consider that the final diagnosis in TAB-negative patients may indicate a spectrum of conditions mainly including other rheumatologic diseases, presence of non-temporal arteries with GCA, infectious diseases, neoplastic diseases, and neuro-ophthalmic conditions.In conclusion, positive-TABs in our study did not require more cross-sections than the negative ones. Further, TAB examination at multiple levels did not increase the diagnostic yield of the test. In this study, 9.87 This work was funded by the Eye Research Center of Iran University of Medical Sciences which did not have any role in the design, execution, and presentation of results.There are no conflicts of interest.


The generation of few-cycle laser pulses proved to be a key enabling technology in strong-field physics and ultrafast science. The question naturally arises whether one can induce few-cycle localized plasmon oscillations in optical near-fields. Here, we perform a comparative study of different plasmonic nanoresonators illuminated by few-cycle pulses. We analyze the number of cycles (NOC) of the plasmonic field, the near-field enhancement (NFE) as well as the figure of merit NFE/NOC. The pulse length dependence of these quantities is also investigated. Throughout the inspected pulse-length interval silica-gold and silica-silver core–shell monomers have the potential to preserve the NOC of the incoming pulse, silver bow-ties result in the highest NFE, whereas gold core–shell dimers have the highest NFE/NOC. Based on the analysis, silver bow-ties, gold core–shell and silver nanorod dimers proved to be the most suitable for few-cycle near-field amplification. Here, we investigate the possibility of the generation of few-cycle LSPs by analyzing the temporal response of different types of plasmonic nanoparticles and nanoparticle dimers.Few-cycle laser pulses  proved to be highly important in many experiments in strong-field physics, attosecond science and pump-probe methods with ultrahigh time resolution. Therefore, the question naturally arises whether one can combine extreme temporal concentration of electromagnetic energy  intervals by applying the same core and shell materials7. The thick (thin) shell composition supports a plasmonic resonance, which is accompanied by a spectrally wide (narrow) scattering cross-section maximum and low (high) absorbance. Although the scattering of core–shell nanoparticles is always lower than that of a homogeneous sphere, the achievable broad bandwidth and the possibility to control the Q factor of the plasmonic resonance by varying the GAR offers the unique possibility of electric field enhancement combined with the preservation of few-cycle transients9.Dielectric-metal core–shell type nanoresonators offer unique possibility of far-field and near-field control spanning wide spectral intervals via tailoring the plasmon hybridization promoted by two metal-dielectric interfaces10. The achievable electric field enhancement and temporal evolution of the optical response were investigated on monomer and dimer Ag and Au nanoparticles as well as on silver-gold core–shell bimetal nanoparticles11. It was shown that the electric field enhancement on them is higher than on metal spheres composed of either metals, however the plasmonic decay dynamics is slightly different on alloy core-shells.More complex plasmonic structures were also proposed and then used to realize plasmon enhanced spectroscopy14.Bow-tie structures are very efficient plasmonic dimers that can be fabricated via lithography on substrates hence they are frequently used in applications. Further advantage of bow-tie structures is their low apex curvature, which makes it possible to reach high near-field enhancement (NFE) in the nanogap18. Solid sphere dimers were shown to be applicable as coherent, highly localized and tunable photon sources18. In their junction, the relative strength of second-order nonlinearities, such as second harmonic and sum frequency generation as well as third-order nonlinearities, such as four-wave mixing, can be controlled by varying the dimer symmetry. For higher photon energies, frequency doubling occurs and two-photon luminescence emerges, governed by the bandstructure of bulk metals which is typically gold in applications. Intense third harmonic generation and emission occurs from the volume close to dimer gaps, which makes it possible to probe nanoscale optical properties such as sub-cycle plasmon dephasing time, which is in the order of 2 fs19. In case of point symmetry, the second-order nonlinearities are suppressed, while four-wave mixing remains unaffected in the visible frequency range, moreover its intensity can be modulated by tuning the dimer separation. Such a nanoscale photon source can be applied as a building block of integrated plasmonic devices and as a near-field optical probe20.Accordingly, for few-cycle plasmonic field generation, various plasmonic dimers are promising candidates, which offer higher electric field confinement and more degrees of freedom in time-evolution control21. Strong-field photoelectron emission from plasmonic nanostructures was demonstrated to show a well-defined correlation with the plasmonic resonance of nanoparticles23. The photoemission and electron re-scattering effect proved to be useful to measure the plasmonic field enhancement factor precisely within a less than 1 nm layer from the nanoparticles surface24. However, several studies revealed that melting prevents reaching higher near-field intensities in the gaps of dimers25. In addition, few-cycle near-fields at simple nanotips brought important discoveries in photoemission experiments28. Possible applications are also in the next generation of photonic circuitries. Ultrafast, femtosecond optical switching and terahertz modulation bandwidth are important tools in all-optical signal transfer, which has the potential for orders of magnitude faster operation speed than that of already existing technologies29. By using few-cycle plasmonic fields SERS techniques can be extended to the ultrafast regime, where direct probing of plasmon mediated chemical processes including bond-making and breaking down to femto- and picosecond timescale becomes possible30. Single-cycle LSP generation is accompanied by extreme concentration of the energy both in temporal and spatial domains, which makes it possible to study strong-field phenomena already at low laser energy31. Surface plasmons can also be exploited in high harmonic generation required to achieve extreme ultraviolet pulses32 and in several novel application areas of strong-field nano-optics in the ultrafast regime33.The interaction of localized plasmonic modes and propagating waveguide modes in a substrate were shown to result in plasmon dephasing time modification, proving the role of array effects in pulse shapingThe present work focuses on the general question, which type of plasmonic nanoresonator is capable of producing significant near-field enhancement, while preserving the few-cycle nature of the near-field response. Accordingly, several plasmonic nanoresonator types, namely single nanorods and core–shell particles, nanorod and core–shell dimers as well as bow-ties have been thoroughly inspected and an optimization method was developed yielding the best geometries for these purposes.7. Accordingly, the desired resonant behavior can be ensured uniformly by tuning the scattering cross-section (SCS) maximum of the plasmonic nano-objects to the target wavelength . The coincident ACS maximum allows to maximize the near-field enhancement in case of nanorods and bow-ties. In case of core–shell nanoresonators a trade-off arises, since usually a good-quality resonator possessing a narrow scattering cross-section makes it possible to achieve strong electric fields around the plasmonic objects, rather than a loss caused by the resistive heating of the nanoparticle. By applying pre-designed plasmonic architectures, which ensure LSP resonance tunable throughout a wide spectral interval accompanied by a properly large scattering cross-section bandwidth, the quality factor of the resonance can be controlled, and as a result, the few-cycle characteristics of the illuminating pulse can be preserved in the enhanced near-field response.The concept of this research is that the few-cycle characteristic of the plasmonic field can be ensured via nanoresonators, which possess broad spectral responses. The plasmonic resonance is accompanied by almost coincident absorption (ACS) and scattering cross-section (SCS) maxima in case of nanorods and bow-ties, whereas the core-shells exhibit a broad SCS peak with a detuned ACS maximumλ/5 scaled. Tabulated data sets were used to include the wavelength dependent dielectric properties of metallic materials34. Conditional geometry optimizations were realized to ensure full control over the characteristics of the response of nanoresonators by using an in-house developed algorithm35.A finite difference time-domain method  was applied to include the time-parameter into the modeling of electromagnetic near-field distribution around various plasmonic nanostructures. Monomer and dimer nanoresonators were placed on silica-glass substrate-air interface and illuminated by few-cycle laser pulses in total-field scattered-field configuration. The mesh was locally improved around the nanoresonators, the smallest element was 0.5 nm in the dimers’ nanogap, whereas in the dielectric media the mesh was ax:  and ay: ; the inner and outer radius of core–shell monomers: Rinner:  and Router = R + t: , where the minimal t shell thickness was 5 nm. The vertical edge (L), horizontal extension (W), the corresponding, opening angle (α) and thickness (T) of the bow-tie composing triangular antennas were L: , W: , α: , T: . The same nanoresonator parameter intervals were applied for nanorod and core–shell dimers, as for their monomer counterparts. The core–shell dimers were inspected primarily, since in thick-shell  composition the wide SCS necessary for minimal NOC is compromised with a weaker LSP resonance accompanied by smaller absorptance and NFE. The d distance was varied in the  interval in case of core–shell dimers, whereas the optimal core–shell distance was transmitted to nanorod dimers and bow-ties, in order to ensure the dimer’s comparability.The goal was to obtain the maximum near-field enhancement in proximity of the inspected nanoresonators at 800 nm central wavelength of the excitation pulse. Additional optimization criteria were set to ensure a resonant behavior and to preserve the few-cycle response simultaneously. Namely, a primary criterion regarding that the wavelength of the SCS maximum accompanying the plasmonic resonance has to be near 800 nm was set. In addition to this, a variable measuring the number of optical cycles (NOC) in the near-field within the full-width-at-half-maximum (FWHM) of the intensity envelope was defined. Its nanoresonator type dependent value was required to be lower than 2.5 for core–shell monomers and dimers, whereas for nanorod monomers, dimers and bow-ties this value had to be less than 1.7. The geometrical parameters were varied in the following intervals: (i) the long and short axis of nanorod monomers x component parallel to the E-field oscillation direction of the incoming pulse that was monitored at 1 nm distance uniformly from the nano-objects.The optimizations were performed by using linearly polarized Gaussian light pulses of 2.7 fs length; the NOC of the excitation pulse is 1.1 in this case. Subsequently, the wavelength dependence of the scattering cross-section was determined via numerical computations for all inspected structures. This was realized for all inspected pulse lengths to enable comparison with the spectral distribution of each pulse that we used. The time-dependent response of the optimized nanoresonators as a function of pulse length was also investigated, namely all optimized nanoresonators were re-illuminated by 4 and 5 fs pulses as well, corresponding to 1.56 and 1.92 optical cycles. The NOC and NFE were determined based on the EThe fundamental studies were performed on individual nanorods and core–shell particles, nanorod and core–shell dimers as well as on bow-ties. To realize a comparative study, the time-evolution of the optical response and the achieved electric field enhancement were compared for the optimized nanoresonators. The pulse length dependence of NOC, NFE and the figure-of-merit FOM = NFE/NOC was also studied.The SCS in all optimized configurations exhibits one single broadband peak inside the 800 ± 20 nm wavelength range according to the broadband resonance of optimized configurations. It is also a common characteristic that the scattering cross-section spectra are almost independent of the length of the incoming pulse in the inspected wavelength interval, due to the sufficiently large spectral overlap. All optimized nanoresonators exhibit the typical time-response of near-resonant nanoantennae so that after reaching a maximum, a nearly exponential smooth decay is observed. The longer (shorter) decay compared to free space correlates with the narrower (broader) SCS spectrum of the resonant plasmonic nanoresonators. Considerable NFE is achieved with all inspected resonators, therefore the free-space pulses were rescaled to ensure comparison of the time evolutions. The NFE of optimized structures for different pulse lengths is almost identical, only a slight decrease is observable by increasing the pulse length. The achieved optical response parameters are summarized in Table The geometry and SCS of optimized Au and Ag nanorod configurations are similar Fig. a. AlthouThe broader SCS of the optimized gold nanorod results in slightly lower NOC 1.60) in the intensity envelope than that in case of the silver nanorod (1.70). The SCS maximum is slightly lower according to the smaller Ag nanorod volume, which promotes higher, 12.45-fold NFE. The NFE/NOC ratio is considerably higher in case of the silver nanorod for each inspected pulse length, according to the higher NFE, which makes Ag nanorods better candidates for few-cycle pulse enhancement  detuning from the central wavelength is just slightly higher (lower) in case of Au nanorod dimers, the NFE is considerably higher in case of silver nanorod dimers, due to its material properties and due to the smaller size of the components Table . MoreoveIn contrast, gold core–shell dimer exhibits higher NFE/NOC ratio, as a result of commensurate NOC and considerably higher NFE, which makes it a reasonable choice instead of silver core–shell dimer counterpart for short pulse amplification Table . The conChange from monomers to dimers is advantageous considering NOC in case of nanorods Table . The NFESimilarly to nanorod dimers, the silver bow-tie allows to reach smaller NOC and slightly higher NFE, as a result higher NFE/NOC value is achieved Table . Thus, tComparing all dimers, the Ag bow-tie has the highest NFE. The NOC is the lowest in case of Au and Ag core–shell dimers. Gold core–shell dimers outperform all other dimers in their NFE/NOC ratio due to the relatively low NOC and strong NFE. In case of nanorod dimers and bow-tie structures, the use of silver is most advantageous based on its higher NFE and NFE/NOC ratio.Comparing all inspected nanoresonators, all types have some advantageous characteristic property. Gold and silver core–shell monomers exhibit the lowest NOC, silver bow-tie and gold core–shell dimer possesses the highest NFE and NFE/NOC values, respectively. Based on our results, we propose Ag bow–tie, Au core–shell and Ag nanorod dimers for the generation of few-cycle plasmonic fields.Our comparative study shows that the generation of few-cycle plasmonic transients is indeed possible, however this requires optimization of the nanostructures so that best results are achieved. In addition, a trade-off has to be found between the contradictory requirements of large field enhancement and short transients. Depending on the given application, such an optimization can yield satisfactory results. The conditional optimization method that we applied in this study is an important step forward towards adaptive near-field control. These results have the potential to enhance applications in strong-field physics, such as the harmonic conversion of light in the vicinity of nanostructured surfaces. In addition, applications in ultrafast switching and processing of optical signals with surface-integrated nanophotonic structures are also envisaged.


The hypothalamus–pituitary–gonadal (HPG) axis is the endocrine regulation system that controls the woman’s cycle. The gonadotropin-releasing hormone (GnRH) plays the central role. In addition to the gonadotrophic cells of the pituitary, GnRH receptors are expressed in other reproductive organs, such as the ovary and in tumors originating from the ovary. In ovarian cancer, GnRH is involved in the regulation of proliferation and metastasis. The effects on ovarian tumors can be indirect or direct. GnRH acts indirectly via the HPG axis and directly via GnRH receptors on the surface of ovarian cancer cells. In this systematic review, we will give an overview of the role of GnRH in ovarian cancer development, progression and therapy. Ovarian carcinomas are the eighth most common malignant tumor disease in women diagnosed in the world . AlthougOvarian cancer is a hormone-dependent disease that is influenced by hormonal signaling pathways ,14. Thisclinicaltrials.gov for currently ongoing trials on GnRH and ovarian cancer did not yield any results -GnRH-II with isolated cell membranes of human ovarian cancer cells provided a signal at about 43 kDa. A Western blot of the same gel showed that this signal could be a GnRH-II receptor-like antigen, which would indicate the existence of a shortened GnRH-II receptor [125I-labelled (4-azidobenzoyl)-N-hydroxysuccinimide-[D-Lys6]-GnRH-II to its binding site. Treatment with the GnRH-I antagonist cetrorelix led to a significantly greater decrease, while the GnRH-II agonist [D-Lys6]-GnRH-II was the strongest competitor -GnRH-II has agonistic characteristics at the GnRH-I receptor, while GnRH-II antagonists clearly act as antagonists on the GnRH-I receptor  GnRH. After GnRH receptor-mediated internalization of zoptarelin doxorubicin into the cell, the active part is split off and the now free doxorubicin accumulates selectively in the cell nucleus. The competitive inhibition of the uptake of zoptarelin doxorubicin by an excess of another GnRH agonist proves that zoptarelin doxorubicin enters the cell specifically via the GnRH receptor. In tumor cell lines that have no GnRH receptors, no intracellular zoptarelin doxorubicin could be found [Cytotoxic GnRH agonists have been developed in which a cytotoxic substance is covalently linked to a GnRH agonist . These sbe found . In addibe found . This mebe found . In addibe found .2. This dose was proposed for the therapeutic phase II studies [2. This is equimolar to 76.8 mg/m2 of free doxorubicin. Six (14.3%) of these 42 patients had a partial response, 16 (38%) had stable disease, and 16 (38%) had progressive disease. Four patients could not be evaluated. The median time to progression was 12 weeks : 8-20 weeks). Median overall survival was 53 weeks (95% CI: 39-73 weeks). The side effects were tolerable [In in vivo experiments with tumor-bearing mice, zoptarelin doxorubicin showed lower toxicity than free doxorubicin. In addition, zoptarelin doxorubicin showed better efficacy in inhibition of the growth of GnRH receptor-positive tumors ,149. Thi studies   is covalently linked to GnRH, was created to deliver lytic peptides to GnRH receptor-positive cancer cells  Table 2Table 2. Expression of the GnRH receptor can not only be used for target therapies. The selective expression of the GnRH receptor is also suitable to detect metastases that also express the GnRH receptor. Liu et al. have successfully developed a selective fluorescence probe to detect peritoneal metastases of ovarian cancer. For this purpose indocyanine green was conjugated to a GnRH antagonist .GnRH is an important player in the control of the HPG axis. In addition to this classical hypophysiotropic function, GnRH is important as a regulator of cell proliferation and invasion in a number of human malignancies, including ovarian carcinoma. Furthermore, the selective expression of GnRH receptors makes it an ideal target for new effective therapeutic strategies with little side effects. First studies using GnRH analogs for direct tumor treatment were only moderately successful. Probably the used dosages were too low. Therefore, further studies focused on the use of high-dose GnRH analogs showing better efficacies. Following the discovery of GnRH-II, analogs were developed and successfully tested in vitro and in vivo. Since the existence of a functional GnRH-II receptor in humans is still controversial, this strategy has not been continued. The most promising strategy so far is the use of the GnRH receptor for target therapy. Cytotoxic GnRH agonist zoptarelin doxorubicin was shown to be an effective and safe compound. No phase III trial was conducted in ovarian cancer so far. Even if a single phase III study was unsuccessful, it still makes sense to pursue the concept further. In addition, the specific expression of GnRH receptors could be used diagnostically to detect metastases.


Ferroptosis has been described recently as an iron-dependent cell death driven by peroxidation of membrane lipids. It is involved in the pathogenesis of a number of diverse diseases. From the other side, the induction of ferroptosis can be used to kill tumor cells as a novel therapeutic approach. Because of the broad clinical relevance, a comprehensive understanding of the ferroptosis-controlling protein network is necessary. Noteworthy, several proteins from this network are flavoenzymes. This review is an attempt to present the ferroptosis-related flavoproteins in light of their involvement in anti-ferroptotic and pro-ferroptotic roles. When available, the data on the structural stability of mutants and cofactor-free apoenzymes are discussed. The stability of the flavoproteins could be an important component of the cellular death processes. Human flavoproteome encompasses slightly more than one hundred enzymes that participate in a number of key metabolic pathways. The chemical versatility of flavoproteins relies on the associated cofactors, flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD). In humans, flavin cofactors are biosynthesized from a precursor riboflavin that has to be supplied with food. To underline its nutritional essentiality, riboflavin is called vitamin B2.In compliance with manifold cellular demands, flavoproteins have been accommodated to operate at different subcellular locations . The larOne of the reasons for the association of flavoproteins with cellular membranes is their involvement in lipid biochemistry. This activity brings flavoproteins into the spotlight of the cellular death pathways. The membrane lipid reduction and oxidation (redox) reactions, specifically phospholipid peroxidation, has recently become a focus of intense research following the discovery of ferroptosis, an iron-dependent non-apoptotic cell death ,7. FerroHuman flavoproteins constitute an important component of the cellular metabolic network . The enzFlavoenzymes catalyze a large variety of diverse reactions. The tricyclic isoalloxazine ring system of flavin cofactors provides necessary redox versatility, explaining the metabolic importance of the flavoproteome . Both onHuman flavoenzymes are typically intracellular proteins. There are only a couple of exceptions. For example, renalase is an FAD-dependent amine oxidase that is secreted into the blood from the kidney. Its activity decreases cardiac contractility and rate. Catecholamines promote synthesis and secretion of renalase . AnotherFerroptosis is a type of eukaryotic cell death characterized by the iron-dependent accumulation of lipid hydroperoxides to lethal levels . FerroptLipid oxidation can proceed autocatalytically or enzymatically. Considering the enzymatic pathway, lipoxygenases (LOXs) have been implicated in driving ferroptotic damage of PUFAs ,19. EspeThe endogenous membrane antioxidant ubiquinone (coenzyme Q) is synthesized by the mevalonate pathway. In preventing peroxidative damage to lipids, reduced ubiquinone is as effective as α-tocopherol . Not surIn the following sections, ferroptosis-related human flavoproteins will be discussed in more detail paying particular attention to the available data on structural and functional stability of the proteins.E. coli [Glutathione reductase (GSR) is a FAD-containing flavoprotein localized in the cytosol. Glutathione is the reducing substrate in the GPX4 reaction and thus it is the key component of the anti-ferroptotic network. Its cellular availability mirrors the interplay of diverse biochemical processes, such as the uptake of the precursor cystine, the GSH synthesis, conjugation, oxidation and reduction. GSR uses NADPH, two essential cysteins and an activated histidine to reduce an oxidized GSSG dimer into two GSH molecules . NADPH aE. coli . In contE. coli . HoweverThe first pathogenic mutation identified in human GSR was its C-terminal truncation, which manifested in hemolytic crises after eating fava beans and in cataract development ,31. The As discussed above, thioredoxin reductases (TXNRDs) can complement the GSR function in regenerating the reduced glutathione pool in the cell. Conceivably, TRXNDs should be able to support GPX4 in its anti-ferroptotic activity. Thus, it came as a surprise that the loss of TXNRD1 protected pancreatic cancer cells from ferroptosis upon GPX4 inhibition . The autIn humans, apoptosis-inducing factors (AIF)M1-M3 comprise a family of flavoproteins, all of which have been thought to reside in mitochondria and participate in caspase-independent apoptotic cell death. AIFM1 is the most-analyzed member of the group ,24,34. Iapoptosis-inducing factor-homologous mitochondrion-associated inducer of death; AMID) shows significant sequence similarity with AIFM1 and both proteins were assumed initially to have similar subcellular localization and pro-apoptotic functions [AIFM2 H, NQO1 catalyzes the two-electron reduction in endogenous and exogenous quinones to hydroquinones. The production of semiquinones by one-electron reductases would be much more dangerous for a cell, because the redox cycling of semiquinones in the presence of molecular oxygen results in the formation of reactive oxygen species [Human NAD(P)H:quinone oxidoreductase (NQO)1 belongs to a family of quinone reductases found across such diverse taxa as bacteria, fungi and archea. There is a highly similar paralog of NQO1 in humans, that is called NQO2. However, a number of organisms contain only one of the two proteins. Mammalian NQO1 was discovered and characterized some 70 years ago ,45. At t species .One of the remarkable features of NQO1 is its high inducibility by diverse environmental insults. NQO1 expression is driven by the antioxidant response element (ARE) and the xenobiotic response element (XRE) located in its promoter region . Accordi2) in NQO1 allows for the reduction in superoxide. The relevance of this activity remains unclear, though, because the rate constant of reduction is very low, going four orders of magnitude below that of superoxide dismutase [The presence of the flavin cofactor in its hydroquinone form  protects cellular membranes from oxidative damage. The capacity of NQO1 to reduce ubiquinones has been known for quite some time . Beyer aC terminus of HSC70-interacting protein). CHIP recognized its targets directly via the flexible C-terminus of NQO1 because the C-terminal truncation of NQO1 strongly affected the ubiquitination.The reducing activity of NQO1 can be lost to a different degree due to structural changes caused by mutations. Proline-to-serine change at position 187 (P187S) is an interesting variant for several reasons. First, the allele is found relatively often, showing the frequency of 25. In some groups, such as East Asian populations, the allele frequency reaches as much as 46%. Second, P187S renders the protein highly unstable. In cells homozygous for the mutation, NQO1 levels were very low or not detectable and the enzymatic activity was lacking . The lacIt remains to be determined how general the recognition mechanism used by the cellular protein quality control (PQC) machinery to detect cofactor-free flavoproteins is. It is interesting to note here, that the paralog NQO2 naturally lacks the 43 amino acid-long C-terminal tail of NQO1, otherwise showing high structural similarity. The truncation translates into an altered site to bind pyridine nucleotides. As a consequence, NQO2 prefers nicotine riboside over NAD(P)H and differs also in its substrate preferences. The lack of the flexible tail in NQO2 was conceivably the reason why CHIP failed to recognize the flavoprotein regardless of the presence/absence of the cofactor . At the Cytochrome P450 oxidoreductase (POR) is an example of a flavoprotein that accommodates two flavin cofactors in its structure. POR is associated with FMN at the N-terminal flavodoxin domain and with FAD at the C-terminal ferredoxin reductase domain. The two cofactors orient toward each other in an alignment necessary for efficient electron transfer, their isoalloxazine rings being only 4 Å apart at the closest . ElectroOpposite to the anti-ferroptotic roles of other flavoprotein as discussed above, POR was recently shown to possess a pro-ferroptotic activity ,61. Two Because of its many client enzymes, POR defects are expected to result in complex metabolic disturbances, including manifold defects of steroidogenesis. This assumption proved true by the first molecular description of the clinical POR deficiencies that had manifested in the combined insufficiency of 17α-hydroxylase and 21-hydroxylase . Many moCan the availability of the flavin cofactors affect the structural stability and enzymatic performance of POR? We are not aware of the respective data regarding the wild-type enzyme. In the case of disease-causing mutations, the localization of the structural defect determines the remaining association of the variant protein with the cofactor. For example, V492E contains stoichiometric amounts of FMN and almost completely lacks FAD, whereas R475H, next to the normal amount of FMN, still contains FAD at ca. 35% of the wild-type value . Both muPOR belongs to the so-called class II redox partners of cytochrome P450. This class is widely represented among eukaryotes. The bacterial class I redox partner system is composed of two separate components, an FAD-bound ferredoxin reductase and a 2Fe-S cluster-bound ferredoxin. The eukaryotic mitochondria contain a class I system. Because of mitochondrial localization, the involvement of the flavoprotein ferredoxin reductase in ferroptosis is less probable, similarly as in the case of the FSP1 paralog AIFM1.In addition to the four described flavoproteins, several more can be reasonably considered as members of the ferroptosis network in human cells. For example, the flavoprotein squalene monooxygenase (SQLE) is, next to HMG-CoA reductase (HMGCR), the rate-limiting step of the mevalonate pathway. The pathway is involved in the biosynthesis of the endogenous membrane resident antioxidant ubiquinone. As expected, inhibition of HMG-CoA reductase with statins enhanced FIN56-induced ferroptosis, and this effect was reversed by the supplementation of cell cultures with mevalonic acid . In the Among electron-receiving POR partners are cytochromes b5, the small heme-bound proteins localized at cellular membranes. A group of five human flavoproteins is specialized in the reduction in cytochrome b5 and in this aspect they can be considered as functional POR analogues. The cytochrome b5 reductases (CYB5Rs) are membrane proteins found predominantly at the endoplasmic reticulum and the outer mitochondrial membrane. It was shown that CYB5R purified from liver plasma membrane can reduce CoQ in reconstituted liposomes . In the Thioredoxin reductases (TXNRDs) have been mentioned in the section on GSR, yet these flavoproteins deserve additional discussion because they constitute another major thiol-dependent antioxidant system in mammalian cells. Human TXNRD1 is mainly, but not exclusively, found in the cytosol. The localization of its “v3” splice variant at the plasma membrane  and the Mitochondria are one of the major cellular sources of reactive oxygen species. Interestingly, it turned out that mitochondria have a key role in cysteine deprivation-induced ferroptosis but not in GPX4 inhibition-induced ferroptosis . The autIt cannot be excluded that more flavoproteins will be assigned the ferroptotic function. In silico approaches might help discovering new members and better understanding the function of the already known members of the ferroptosis-related flavoproteome. The analyses of shared structural features seems to be a promising strategy to this end .Since 2012, when it was proposed, the concept of ferroptosis as a distinct form of cell death driven by the iron-dependent lipid peroxidation underwent impressive development. The mechanistic details of ferroptosis and its contribution to redox biology and disease have been rapidly clarified ,76,77. T


Seed-based functional connectivity analysis exhibited that significantly modulated FC was observed between ipsilesional motor regions (primary motor cortex and supplementary motor area) and contralesional areas , and the effects were sustained after 6 months. The fALFF analysis showed that local neuronal activities significantly increased in central, frontal and parietal regions, and the effects were also sustained after 6 months. Consistent results in FC and fALFF analyses demonstrated the increase of neural activities in sensorimotor and fronto-parietal regions, which were highly involved in the BCI-guided training.Hand function improvement in stroke survivors in the chronic stage usually plateaus by 6 months. Brain-computer interface (BCI)-guided robot-assisted training has been shown to be effective for facilitating upper-limb motor function recovery in chronic stroke. However, the underlying neuroplasticity change is not well understood. This study aimed to investigate the whole-brain neuroplasticity changes after 20-session BCI-guided robot hand training, and whether the changes could be maintained at the 6-month follow-up. Therefore, the clinical improvement and the neurological changes before, immediately after, and 6 months after training were explored in 14 chronic stroke subjects. The upper-limb motor function was assessed by Action Research Arm Test (ARAT) and Fugl-Meyer Assessment for Upper-Limb (FMA), and the neurological changes were assessed using resting-state functional magnetic resonance imaging. Repeated-measure ANOVAs indicated that long-term motor improvement was found by both FMA (FClinical Trial Registration: This study has been registered at ClinicalTrials.gov with clinical trial registration number NCT02323061. Stroke survivors require high demand in rehabilitation and long-term care services, especially for upper extremity motor function -guided training therapy has been promoted as a post-stroke motor rehabilitation training tool. It is designed to enhance motor recovery by modulating sensorimotor activity through repetitive practice with corresponding feedback or reward, thereby modifying the neuronal activity  could be an essential tool to understand the effects of rehabilitation therapies on neuroplasticity. It is one of the most commonly used neuroimaging tools for assessing the cortical modulations in stroke  or left (n = 5) hemisphere impairment were recruited from the local community. The inclusion criteria were (1) first-ever stroke, (2) onset of stroke diagnose more than 6 months, (3) a single unilateral brain lesion, (4) sufficient cognition and comprehensive ability to understand and perform corresponding tasks assessed by Montreal Cognitive Assessment (MoCA) with a score of >21, (5) moderate to severe motor dysfunctions for the paretic upper extremity (Fugl-Meyer Assessment for upper-extremity score <47)  with right (Fugl-Meyer Assessment for upper-extremity (FMA)  displayed on the monitor. The task of motor imagery of opening and grasping the paretic hand is frequently used in our daily life, however, it is very challenging for stroke survivors. Through this task, the alpha suppression is detectable in the motor regions, according to previous studies  was calculated as follows  using a T1-TFE sequence (ultrafast spoiled gradient echo pulse sequence), and BOLD fMRI images  using a FEEPI sequence (gradient-echo echo-planar-imaging sequence). The sequences were displayed using EPrime 2.0 . During the acquisition of rs-fMRI data, subjects were presented with a white cross in a black background and instructed to rest while focusing on the fixation cross. One rs-fMRI block lasted for 8 min.MRI scans were acquired for all the 14 subjects at Pre and Post sessions. Ten subjects had a Post6month session scan, while four subjects did not attend the Post6month session. A 3T Philips MR scanner  with an 8-channel head coil was used to acquire high resolution T1-weighted anatomical images  with the significance level set at corrected p < 0.05. Moreover, the minimal clinically important difference (MCID) was also calculated to reflect the clinical significance by setting minimal changes in clinical assessments. The MCID of FMA is 4.25  at time level  were applied to examine whether the FMA and ARAT scores improved after the intervention. Paired mm3 voxels, and smoothed with a Gaussian kernel with a full-width at half-maximum (FWHM) of 6 mm. To perform group statistical analysis later, subjects with left-hemispheric lesions were flipped along the midsagittal plane using MRIcron (www.mccauslandcenter.sc.edu/mricro/mricron), so that the lesions of all subjects were in the right hemisphere. For the preprocessing steps for the fALFF analysis, the bandpass filter was not applied.The rs-fMRI data were preprocessed using DPARSF toolbox. The first 10 volumes were discarded to assure the remaining volumes of fMRI data were at magnetization steady state. The remaining volumes were corrected with slice timing and realigned for head motion correction. Nuisance variables were then regressed out, including white matter, cerebrospinal fluid (CSF), global mean signal, and Friston 24 head motion parameters   and supplementary motor area (iSMA), and the seed locations were  and  in MNI space, respectively. The seeds were defined as spherical balls with a radius of 5 mm in MNI standard space. The average time course of the BOLD signals within the seeds was used to calculate the FC with every other voxel in the brain, producing maps of FC with the seeds. A paired t-test was carried out between each pair of sessions for results from fALFF analysis.The fALFF values were computed on preprocessed data using the DPARSF software  was observed. Post-hoc tests indicated that there were significant increases in FMA scores between Pre and Post  as well as between Pre and Post6month . No significant change was found between Post and Post6month . The repeated measure ANOVA on ARAT scores with time  as within-subject factor indicated that a significant effect of time  was observed. Post-hoc tests indicated that there were significant increases in ARAT scores between Pre and Post , marginally significant between Pre and Post6month . No significant change was found between Post and Post6month . The result indicated that the BCI robot hand training was able to promote motor recovery with a long-term effect. For FMA scores, 43% of the subjects achieved the MCID at Post and 36% of the subjects achieved the MCID at Post6month. For ARAT scores, 36% of the subjects achieved the MCID at Post and 29% of the subjects achieved the MCID at Post6month. For suppression score at the ipsilesional motor area (Subject demographic and assessment scores are shown in tor area , a slightor area , an incrtor area . The resSeed-based whole-brain FC was explored between each pair of sessions with the seed set at iM1 and iSMA. The FC map in the Pre session with the iM1 seed was shown in the left panel of Significantly increased fALFF was observed in the ipsilesional precentral area and superior parietal lobule  when comThis study explored the effects of BCI-guided robot hand training on the paretic hand in chronic stroke survivors by providing repetitive exercise with integrated sensorimotor feedback. The subjects showed upper-limb motor function improvement, as reflected by the FMA and the ARAT scores, after the 20-session training and these improvements were sustained 6 months after the intervention. Moreover, this study also revealed the neuroplasticity changes after the intervention. The FC between iM1 and contralesional premotor cortex and SMA significantly increased immediately after the 20-session training; The FC between iSMA and bilateral SPL also significantly increased immediately after the 20-session training. Besides, the fALFF analysis showed that local neuronal activities significantly increased in central, frontal, and parietal regions. Our study demonstrated the modulated neuroplasticity changes introduced by the BCI-guided robot hand training immediately and 6 months after the intervention.Stroke survivors experience spontaneous recovery within the first few months after stroke onset and they then become clinically stable with hand weakness (Tombari et al., In our study, the seed-based whole-brain analysis showed that the FC between iM1 and contralesional premotor cortex and SMA was significantly increased after the 20-session training. Studies have suggested that premotor cortex and M1 play a crucial role during motor-imagery as well as during motor execution tasks (Bajaj et al., Investigating different dimensions of resting-state BOLD activity is important, as differences may lie not only in the patterns of connectivity but also the power of local neuronal activity. Apart from the FC, we also investigate the changes in fALFF. While FC measures the temporal correlation between the activations at two given regions, the fALFF measures the power of low-frequency fluctuations, which allows us to study the amplitude of regional neuronal activity. As different frequency bands originate from different neural sources, they could relate to different aspects of brain processing. With the oscillation in the range that is most closely related to gray matter signal, it shows the most extensive change after stroke (Zhu et al., This pilot study has shown the potential of the intervention for promoting hand function recovery and its long-term effect in chronic stroke survivors. fMRI might be able to provide insights into neural mechanisms underlying the recovery of motor function and reorganization of brain networks. Our findings provide some insights into the effects on neuroplasticity changes induced by the BCI-guided upper-limb training. Several limitations need to be stated in this study. First of all, the current study lacks a control condition. In order to differentiate the effects brought by volitional BCI based training and pure robot hand training, a control condition is needed. Second, the sample size is relatively small which might limit the generalization power. More subjects should be recruited to validate and extend the findings of this study.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee. The patients/participants provided their written informed consent to participate in this study.CL, KY, and RT made substantial contributions to data analysis and drafting the manuscript. CL and W-wW contributed to experimental design and data collection. PW, WC, and TL offered their expert advice in screening the subjects and interpreting the results. All authors contributed to the article and approved the submitted version.RT is one of the inventors of the Hong Kong Polytechnic University-held patent for the hand exoskeleton robot which was used in this study. All authors, however, are of no financial relationship whatsoever for the submitted work with Rehab-Robotics Company Ltd., the company which manufactures the commercial version of the original device under a license agreement with the University.


Wireless monitoring of the physio-biochemical information is becoming increasingly important for healthcare. In this work, we present a proof-of-concept hydrogel-based wireless biochemical sensing scheme utilizing ultrasound. The sensing system utilizes silica-nanoparticle embedded hydrogel deposited on a thin glass substrate, which presents two prominent interfaces for ultrasonic backscattering (tissue/glass and hydrogel/glass). To overcome the effect of the varying acoustic properties of the intervening biological tissues between the sensor and the external transducer, we implemented a differential mode of ultrasonic back-scattering. Here, we demonstrate a wireless pH measurement with a resolution of 0.2 pH level change and a wireless sensing range around 10 cm in a water tank. Assessments of the analytes in biofluids through biochemical monitoring have been a major goal for healthcare. To achieve this, much progresses have been made in developing different biochemical monitoring modalities lab-on-a-chip, wearable sensors, implantable sensors, and etc.  were purchased from U.S. Research Nanomaterials (USA). PZT plates were purchased from Mide Technology (USA).3-(trimethoxysilyl)propyl methacrylate (γ -MPS), acrylamide(AAm), N,N′-methylenebisacrylamide(BIS), methacrylic acid(mAA), N,N,N′,N′-tetramethylethylenediamine(TMEDA) were purchased from Sigma-Aldrich (USA). Ammonium persulfate(APS) and standard buffer solutions were purchased from Daejung Chemicals & Metals (South Korea). Silica dioxide nanoparticles  with three different silica loading concentrations of 0, 5, and 10 w/v% with a 3D printed acrylic mold . The mixed pre-gel solutions were poured into the mold. After the complete polymerization of the hydrogel (≈ 10 min), the cuboids were removed from the mold. The silica-loaded hydrogel cuboids were then immersed in buffer solutions with different pH, ranging from 3 to 9, for 24 h. The swelling behaviors of the silica-loaded hydrogel were characterized by a stereo microscope (Leica MZ10F).Although the swelling/deswelling behaviors of the pH-sensitive mAA-co-AAm hydrogel itself were well-studied in our previous investigations  for 10 min. A silica loaded hydrogel pre-gel solution (15 w/v%) was deposited on the pre-treated substrate (2) with 200 μm spacing using a CO2 laser cutter   were firstly pre-treated in a 10 vol % solution (in acetone) of organosilane coupling agent (γ -MPS) for 1 h, rinsed with IPA and acetone and dried in an oven(120 ubstrate  by squeeubstrate . The rese-laser) . The pate-laser)  were inte-laser) . The patVhp) by the hydrophone's sensitivity (Shp).The acoustic intensity of the applied ultrasound was measured by a fiber optics hydrophone  connected to an oscilloscope . The hydrophone was placed at the focal plane of the transducer. The pressure of the applied ultrasound was obtained by dividing the voltage output of the hydrophone .The peak pressure was then converted to the average acoustic intensity by the following equation . The ultrasonic waves reflected at the sensor interface were captured by the transmitting transducer connected to an oscilloscope.The experimental setup for the wireless ultrasonic pH sensing is shown in 3) maximum volume increase.The silica nanoparticle loading is introduced to the hydrogel network to increase the scattering of the propagating ultrasonic waves, which enables the inference of the hydrogel volume from the pressure ratio of the backscattered ultrasonic waves (Equation 5). However, high loading concentrations of the silica nanoparticles can potentially retard the swelling behavior of the hydrogel. Thus, we investigated how the pH-sensitive hydrogel swelling behaviors are affected by the particle concentration. The identical silica-loaded hydrogel cuboids were immersed in buffer solutions with different pH levels ranging from 3 to 9 for 24 h prior to characterization. Applying the silica-loaded hydrogel to the sensor geometry  requires adhesion between the hydrogel and the substrate. In our fabrication, the organosilane coupling agents covalently bond the hydrogel to the substrate; this would result in a different swelling behavior of the hydrogel since one interface is clamped. To maintain the equal swelling behavior as a function of pH, we micropatterned the hydrogel to create cubical form factor . With the confirmed volume response of the silica-loaded hydrogel sensor, we carried out the ultrasonic pH measurement with the prototype device. P0 is the initial acoustic pressure of the transmitted ultrasonic wave from the transducer, Agel is the area of the hydrogel, Asample is the area of the sample surface interacting with the ultrasound, dtissue is the distance between the transducer and the sample surface, αtissue is the attenuation coefficient of the tissue, dgel is the thickness of the hydrogel, and αgel is the attenuation coefficient of the silica-loaded hydrogel. While the varying tissue properties  can affect the attenuation of the ultrasonic waves in the biological tissues, the normalized ratio between the two measured pressures is independent of the tissue properties (Equation 5).Since the area, the thickness, and the attenuation coefficient of the hydrogel are functions of the hydrogel's volume, the target analytes can be inferred from the simple backscattered ultrasonic waves. We note that the Equations (3)–(5) were derived based on the ultrasonic transmission, similar to formulations presented in the pulse-echo ultrasonic fingerprint sensors  will determine the attenuation ratio. Thus, we will expect a linear relationship between the areal coverage of the hydrogel and the attenuation ratio as shown in To rationalize the observed monotonic decrease, which is a result of competing effects of decreased attenuation coefficient due to lower silica concentration and the increased hydrogel thickness and area, we plotted the attenuation coefficient as a function of hydrogel area per block . We obset = 0, the media was replaced with pH 7 buffer (the complete solution exchange occurred within a minute). Immediately following the pH change from 3 to 7 . At 2). The sensing distance could easily be extended with the use of a higher ultrasonic intensity as long as it is under the FDA regulation on the imaging ultrasonic intensity (720 mW/cm2). The proposed sensing modality using a differential pulse-echo scheme is enabled by the sensor geometry of patterned gel and a reference surface. The introduction of the silica-nanoparticles serves as the scattering medium for the propagating ultrasound. Moreover, the patterning of the hydrogel enables reversible response of the hydrogel swelling behaviors.The proof-of-concept ultrasonic hydrogel pH sensor presented in our work successfully measured pH with a working distance of ≈ 10 cm using moderately weak acoustic intensity  our prototype device can perform biochemical sensing based on backscattered ultrasonic waves and (2) the general method presented in our work can be easily adopted to different analytes by incorporating other types of hydrogel, which is sensitive to different analytes. Thus, our hydrogel-based ultrasonic backscattering wireless biochemical sensing scheme has a potential to be a long-term implantable biochemical sensing solution.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.SS conceived the idea. Under the guidance of SS, JN, EB, HS, and EK carried out the experiments and analyzed the data. Under the guidance of AK, SI, and MP examined initial feasibility. JN, AK, and SS wrote the manuscript. All authors read and commented on the manuscript.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.


Breast cancer is the most common cancer in women. Early diagnosis improves outcome and survival, which is the cornerstone of breast cancer treatment. Thermography has been utilized as a complementary diagnostic technique in breast cancer detection. Artificial intelligence (AI) has the capacity to capture and analyze the entire concealed information in thermography. In this study, we propose a method to potentially detect the immunohistochemical response to breast cancer by finding thermal heterogeneous patterns in the targeted area. In this study for breast cancer screening 208 subjects participated and normal and abnormal  conditions were analyzed. High-dimensional deep thermomic features were extracted from the ResNet-50 pre-trained model from low-rank thermal matrix approximation using sparse principal component analysis. Then, a sparse deep autoencoder designed and trained for such data decreases the dimensionality to 16 latent space thermomic features. A random forest model was used to classify the participants. The proposed method preserves thermal heterogeneity, which leads to successful classification between normal and abnormal subjects with an accuracy of 78.16% (73.3–81.07%). By non-invasively capturing a thermal map of the entire tumor, the proposed method can assist in screening and diagnosing this malignancy. These thermal signatures may preoperatively stratify the patients for personalized treatment planning and potentially monitor the patients during treatment. Breast cancers caused an estimated 41,760 deaths out of 606,808 overall deaths for females and 500 deaths for males, while the estimated new cases were 271,270 deaths for both genders  in the United States in 2019. This evidence shows that despite considerable advancement in breast cancer screening and treatment, breast cancer is still the second cause of cancer death among women [Mammography has been the gold standard for diagnosing breast cancer since the early 1960s despite numerous studies indicating the variability of this imaging modality is affected by breast density, age, type of problem, and family history ,3,4,5. MThe risk of radiation using mammography is one of the important disadvantages of using this imaging modality. Younger women are more susceptible to the risk of radiation-induced breast cancer than older women due to their undifferentiated cells being prone to influence by ionizing radiation ,13,14,15BRCA1/2 gene mutations are other factors that this gene mutation may be the result of radiation effect, which might be induced indirect effects to damage DNA by producing reactive oxygen species (ROS) from the cell’s water molecules [Family history of breast cancer and/or the olecules ,17. Someolecules ,17,18,19For the dense breast, ultrasound can be an adjunctive tool used with mammography screening for detecting the abnormality . HoweverInfrared thermography is used as an additional cost-effective alternative for breast cancer screening as a non-invasive procedure that does not pressurize the breast tissue nor expose the body to ionizing radiation. The skin emission is about 0.98, which is close to the emission of the blackbody. Thermal radiation emitted from the body has a wavelength of 8–10 µm bandwidth, which can be captured by the infrared camera ,29,30. DBlood circulation is the main contributor to heat transfer in the body. Vascularity is also considered an important parameter for heat transfer . EvidencTumor angiogenesis and metastatic behavior are biomarkers of breast carcinoma and c-Met pathway activation, which are used also for tumor progression. Also, there is an association of c-Met and downstream signaling pathways with angiogenesis that can be assessed by microvessel density (MVD) . InfrareDNA damage occurs once nitric oxide reacts to form other reactive metabolites as well as nitrite, peroxynitrite, nitrate, or S-nitroso-thiols, which provoke genotoxic effects ,49. Reac3 and the range between 100K–1200K W/m3 for two types of tissues, respectively [Such process metabolic heat generation investigated for normal and cancerous breast tissues and its rates reached 20K W/mectively . Despiteectively ,58. A viavatars, which concatenate in three different channels similar to a red, green and blue (RGB) image as the input for our pretrained model.The sparse principal component analysis in the thermography (Sparse PCT) is used to compress the input thermal sequence and capture high temporal variance across the acquisitions. This leads to capture thermal heterogeneity patterns in three first initial bases, called deep-thermomics inspired by radiomics, are extracted to measure thermal heterogeneity in breast cancer screening using infrared thermography.Deep thermal features, called curse of dimensionality in deep-thermomics using a sparse deep autoencoder without using traditional human-engineered feature selection methods.The proposed approach tackles the problem of the The multivariate models trained and validated using the obtained descriptors successfully classify between symptomatic and non-symptomatic subjects. We also provided a comparative analysis using a non-sparse PCT.This study shows the association between thermal heterogeneous patterns and potential vasodilation in the breast area, as a new potential imaging biomarker.In this study, we propose a method to use high-dimensional deep-learning features to track the vasodilator activities in the breast area as a potential biomarker in detecting breast cancer. The contributions of the paper are as follows:The rest of the paper is organized as follows. In the next section, thermal transfer in passive thermography is summarized. In A thermal camera captures the spatial heterogeneity of temperature on the targeted region of interest (ROI) over time. This heat transient can be through active or passive thermography techniques. In general, the thermal transfer/heat conduction equation of a specimen can be summarized by the following equation:Applying infrared thermography on biological organs and tissues, as a complex structure, composed of fat, blood vessels, parenchymal tissues, and nerves with some uncertainty for the rate of blood perfusion and metabolic activity. Pennes’ bioheat equation  providesInfrared thermography records thermal heterogeneity in the subdermal area of the breast in temporal order. To capture such effect by abstracting such patterns, low-rank matrix approximation is used to maximize the variance across thermal acquisition time.X, which is n is the vectorized thermal image (breast screening) in every sequence and p corresponds to the number of observations and decomposes to:n × n matrix. The method captures the spatiotemporal variance by selecting the bases correspond to 80% of variance from the eigenvector matrix. Matrix U represents the bases of the input matrix.Low-rank matrix approximation is commonly used in thermography ,66,67,68The PCT is a linear transformation technique that decomposes the input zero-mean data matrix into the bases and coefficient matrix. To find the optimal solution for such transformation, arse PCT ,62 and iSuch modifications in Sparse PCT not only turned PCT into a nonlinear transformation but following the same maximization of the variance among the bases. If the empirical covariance matrix of Letmization . Sparse Let Deep neural networks and particularly convolutional neural networks (CNN) are widely used by researchers in various fields with diverse applications, comprising image processing, and particularly medical imaging. CNN is a group of connected deep neural networks that uses a variation of multi-layer perceptron with many hidden layers . The hidAfter the success of the AlexNet  in imageThe state-of-the-art CNN architectures are going deeper such as the very deep CNN for large-scale visual recognition (VGG) network , GoogleNA deep learning method has been employed to non-invasively detect chemically treated collagenous tissue nonlinear anisotropic stress-strain responses in the microscopic images . VGG16 iavatar. Three first bases make three channels representing the entire thermal set as an input to the ResNet-50 model and extracted deep-thermomic features, 2048 size vector, as output.In this paper, a pre-trained residual deep convolutional network for large-scale image recognition (ResNet-50) ,86 was uSince the input of the ResNet-50 model requires an RGB squared image, we leverage this property to embed three first bases obtained by sparse PCT as three channels of the input image, showed by β2β3 see . ApplyinLet Radiomics, high-throughput features, refer to sub-visual/quantitative feature extraction and consider a vital part of medical image analysis and radiology which strive to exploit the amount of quantitative minable features extract from imaging data . Every fcurse of dimensionality problem. This creates a wrong outcome of the model due to overfitting the decision-making unit. Traditional feature selection might not the best solution for such an issue because the low-level informative features provided by the network might translate as collinearity among the descriptors and lead to the elimination of valuable information. Here, we propose an autoencoder trained specifically for such high-dimensional throughput features to reduce the dimensionality hierarchically to the lower dimension. Autoencoders are data compression algorithms that make of hierarchical compression and decompression units cascade to each other. They are data-specific, automatically learn from training input data instead of being obtained by human interference, and lossy. Autoencoders can compress data like what they have been trained on and cannot be generalized for other dissimilar data, while they are different from lossless arithmetic compression [Having sufficed features from the medical images leverage better diagnostic/prognostic decisions whereas high-dimensional feature space can impede computation and enervates the performance of feature selection known as the pression . An autoAutoencoder architecture. Several dense layers with different sizes were employed to reduce the dimensionality from 2048 to 16 compressed descriptors, in the latent space. Eight dense (8D) layers, including 4 dense layers in each of encoder and decoder, were used. The intermediate representation of feature dimensionality was varied from the size of 1024, 256, and then 64, to latent space with size 16. Each layer has a ReLu activation function and the last layer has a Sigmoid activation function, with sparse constraints in the initial layer  of data which is very valuable considering the sensitivity of the infrared to noise. Learning a dictionary fitted to a training set with the sparse latent code is formulated by the optimization below ,90:(8)miThis is a convex objective in every variable . Here, tst noise . Having The proposed method for thermal pattern detection was examined by thermal breast cancer screening datasets. The results of the low-rank approximation using sparse PCT were then compared to PCT thermal low-rank matrix approximation algorithm, as commonly used in infrared diagnostic systems.We used 208 participants from Database for Mastology Research (DMR) infrared breast screening dataset , who werThree low-rank matrices were extracted from the 23 initially thermal sequences by using Sparse PCT. Some representative results of the low-rank approximation manually selected for our study cohort are shown in We extracted 2048 deep thermomic features from the targeted ROI in the thermal imaging (solely breasts area) using the latest layer of the ResNet-50 pre-trained model. The ResNet-50 pre-trained model contained five identical blocks having a convolutional layer, max-pooling, ReLu, and many repetitive identity connections between each layer. Convolutional blocks consisted of three convolution layers like identity block. The ResNet-50 model had 25,583,592 trainable parameters and 53,120 non-trainable parameters. The preferred input image to ResNet-50 was an RGB image with a dimension of Adam optimizer with the learning −5 and for 500 epochs. The batch size was 128 for the model network. We used 2048 deep features extracted from the ResNet-50 pre-trained model as the input of the proposed autoencoder. The autoencoder consisted of seven layers  and reduFrom 2048 initially extracted deep thermomic features, the extracted features from the battle-neck layer of autoencoder resulted in 16 deep-thermomic features . SubsequWe stratified the participants based on the 16 sparse latent deep thermomic descriptors and compared them with the ground truth data based on mammography information. To examine the hypothesis that the thermal heterogeneity extracted by the deep learning model can be used as a biomarker to stratify among participants, a random forest classifier was fitted for multivariate covariates with leave-one-out cross-validation. The best multivariate model resulted accuracy of 75.24% (72.33–77.67%) for Sparse PCT, which was challenged by other matrix approximation technique PCT (73.27% (71.84–76.21%)). A multivariate model contains clinical information and demographics  gave an accuracy of 71.36% (69.42–73.3%). A full multivariate model having all clinical and demographic information with the extracted features resulted in 78.16% (73.3–81.07%) for Sparse PCT and 73.79% (72.33–76.7%) for PCT see . The recIn this study, we proposed a system to reduce the dimensionality of deep-thermomic features to extract thermal patterns for infrared diagnostic systems for thermography imaging. This study was designed based on the general trend of dimensionality reduction and to alleviate the possibility of over-fitting but used sparse multiple low-rank matrix approximations. This study showed a possibility to identify potential patients with breast cancer along with other clinical throughputs (such as CBE) using non-invasive, faster, and more cost-efficient thermography imaging.The application of deep sparse autoencoder not only reduced the initial high-dimensional deep-thermomics but also added sparsity to the initial sparse representative of the thermal stream, which theoretically increases the robustness of the system against noise. It also showed significant improvements in stratifying symptomatic patients from healthy participants . Moreovecurse of dimensionality. The proposed sparse autoencoder reduced the dimensionality by removing the redundancy among the features by spanning thermomics to lower-dimensional space, while increasing the robustness of feature selection due to rigorous training of the model . Since Thermal and infrared imagery has been used to determine breast abnormality, as the first medical application of thermography . There aOne limitation to applying the presented models is related to data, and even with a considerable number of cases there is a need to increase the cohort to confirm the accuracy of the system. Having a larger cohort of patients increases the statistical power of such analysis by increasing the possibility of independently validating the system . The other limitation may be using limited deep thermomic features. Having more deep-thermomics helps to assess the strength of the sparse autoencoder approach to select better compressing features that lead to capturing better thermal characteristics. There is an inherent limitation of using infrared thermography for detecting cancerous tissues once they are deeper into the tissues, as despite tracking the vasodilatory effects in the skin subsurface, deeper lesions might not be easy to detect. This might require further investigation using multimodal imaging analyses. There are also discussions on using a single thermal frame or multiple frames for selecting variability of thermal patterns across the acquisition time using different infrared-based approaches ,95,96,97avatars during imaging acquisition provides a significant projection of thermal heterogeneity leading to better diagnosis of abnormal patients. Second, a sparse autoencoder eliminates the manual selection or human-engineering feature selection for reducing the dimensionality of the deep thermomics. Third, the proposed method considerably alleviates the effect of motion artifacts and imaging acquisition noise, which can be substantial improvements in infrared thermography applications. To the best of our knowledge, this is the first study which performs such analyses.The presented technique offers some advantages. First, applying low-rank matrix approximation to extract thermal This study addressed one of the biggest challenges in high-dimensional deep feature selection, which selected the best representative deep thermomics from high-dimensional features extracted from a pre-trained deep neural networks model. The method performed multilayer dimensionality reduction using Sparse PCT to select the low-rank approximation of the thermal sequence. They extracted high-dimensional features from the ResNet-50 pre-trained model. Then, it used a trained sparse autoencoder to hierarchically reduce the size of the feature to 16 thermomic descriptors. We tested our method for 208 thermal breast cancer screening cases. We compared the appropriateness of these approaches with similar state-of-the-art thermographic methods, i.e., PCT. The results indicated the significant performance of the full multivariate model using Sparse PCT in preserving thermal heterogeneity to discriminate between symptomatic and healthy participants (accuracy of 78.16% (73.3–81.07%)).Future works should involve more thermomics extracted from the different low-rank approximations to increase the potential of assessing the entire thermal characteristics of cancerous parenchymal tissues. Moreover, an expansion of the validation set to a larger infrared imaging cohort can further confirm the strength and limitations of this approach.


We first describe the initial diffusion of the new confirmed cases per week across the state, which remained under 2,000 cases until Memorial Day weekend (epi week 23) then dramatically increased, peaking in mid-July (epi week 29), and slowly declining thereafter. Second, we found significant differences in cases and deaths between urban and rural counties, partially related to the timing of the number of confirmed cases and deaths and the implementation of state and local mitigations. Third, we found that the case rates and mortality rates positively correlated with pre-existing social vulnerability. There was also a negative correlation between mortality rates and county resilience patterns, as expected, suggesting that counties with higher levels of inherent resilience had fewer deaths per 100,000 population.As the COVID-19 pandemic moved beyond the initial heavily impacted and urbanized Northeast region of the United States, hotspots of cases in other urban areas ensued across the country in early 2020. In South Carolina, the spatial and temporal patterns were different, initially concentrating in small towns within metro counties, then diffusing to centralized urban areas and rural areas. When mitigation restrictions were relaxed, hotspots reappeared in the major cities. This paper examines the county-scale spatial and temporal patterns of confirmed cases of COVID-19 for South Carolina from March 1 Coronavirus disease 2019 (COVID-19) appeared in late December 2019 in Wuhan, Hubei Province, China. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) arrived in the United States in January 2020 with the first known COVID-19 case in the state of Washington  and on Mst to September 5th, 2020 and compares the initial temporal and spatial spread (March 1st—May 30th) to the cumulative impact covering March 1st—September 5th, 2020. The two time frames specifically compare and contrast the spatial patterns of cases (exposures) and outcomes  prior to Memorial Day when mitigation actions were in full force, and from Memorial Day to Labor Day when state mitigation actions were relaxed. First, we investigated the COVID-19 diffusion process and timing related to mitigations in the state. Then we examined how the confirmed cases  and deaths  related to pre-existing county conditions of social vulnerability ) and resilience (Baseline Resilience Indicators for Communities (BRIC)) and their variability between urban-rural geographies. Different covariates are tested as to their relationship to the exposures and outcomes.This paper examines the diffusion of COVID-19 cases in South Carolina from March 1Research confirms health disparities between urban and rural areas not only in terms of risk factors and life expectancy  but alsoDocumentation of race-based health disparities is extensive . For exaRural Americans face a unique combination of factors that create disparities in access to health care –22. For Transportation presents another obstacle to accessing health care. Patients are less likely to travel to see a doctor if they live far from one . ResearcThe disparities between urban and rural places also exist in the cultural perceptions of health and health care. Rural residents often are reluctant to seek health care or engage in preventive health behaviors than urban populations. For instance, rural residents are less likely to use sunscreen to prevent skin cancer ; and undLastly, rural residents are encountering health disparities regarding infectious disease prevention and treatment, especially with limited testing and recovery. According to one study , deaths The social determinants of health provide useful information on underlying health conditions affecting population vulnerability especially to COVID-19 , 29. SocOne well-known tool is the Social Vulnerability Index (SoVI), an empirical place-based composite metric that compares social vulnerability among places—counties or census tracts. Social vulnerability is a multi-dimensional construct, where the underlying factors intersect to spatially highlight areas with more socially vulnerable populations. To construct the index, 29 input variables known to influence the ability of populations to prepare for, respond to, and recover from adverse events were culled from the U.S. Census American Community Survey (ACS) 5- year data (2014–2018) for all U.S. counties. Using principal components analysis (PCA), eight factors were generated and then summed using equal weighting to produce the overall score for each county. In the most recent version of SoVI (2014–2018), these eight factors explained 77.9% of the variance in the data . Given oCommunity resilience is another perspective on a community’s pre-existing capacity to cope with natural hazards and disasters and several instruments have been proposed for measuring and tracking resilience , 34. TheThe New York Times GitHub for COVID-19 confirmed cases and fatalities ) initially provided baseline correlations between case rates and death rates, respectively, with SoVI scores, BRIC scores, government mandates, and location  used as the correlates. COVID-19 case rates and death rates in each county over the entire study were processed by log10(x) transformation to meet the assumption of normal distribution in OLS. An α = 0.05 was considered as statistically significant in the regression analysis. The model residuals were submitted to spatial dependence analysis by global Moran’s I statistics to assess the need to incorporate a spatial component of the regression model, according to the decision model proposed by Luc Anselin . Once prTo first explore the differences between urban and rural counties we conducted the Mann-Whitney U two sample t-test against case and mortality rate, SoVI, and BRIC. This non-parametric test allows us to identify significant differences in the mean ranks between the case and mortality rates of COVID-19 in urban and rural counties, as well as the underlying social vulnerability and community resilience in those places. A type-1 error rate of .05 was used to identify statistically significant results in the analysis. However, there were no additional formal statistical procedures (e.g. Bonferroni correction) done to reduce the likelihood of a type-1 error  in the comparisons between urban and rural counties in their case rates or mortality rates.th, 2020 (epi week 10), when two women tested positive—one from Kershaw County and one from Charleston County ) and the correlates of social vulnerability and community resilience (recorded at census tract or ZCTA enumeration units). Finally, this study only examined the data for South Carolina, so caution should be exercised in generalizing these findings to other regions especially considering the differences in population structure, socio-economic status, transportation, culture, physical environment, and scale of interventions. If a policy goal is to prevent and prepare for infectious disease, a one-size-fits-all strategy for disaster reduction or mitigation policy actions is inappropriate, since it ignores the inherent variability in capabilities among counties based on the rural-urban character of places. Our findings suggest that the COVID-19 response should have locally customized actions to ensure the greatest success in controlling the disease.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.